Every finding on record at Careone at Wellington

Based on observation, interview and record review, it was determined that the facility failed to a) consistently ensure accountability and reconciliation of the controlled dangerous substances (CDS) - narcotic medications with high potential for abuse and drug diversion - for 1 of 3 medication carts inspected, and b) provide pharmaceutical services in accordance with professional standards to ensure appropriate administration of a medications for 1 of 5 residents (Resident #37) observed during medication administration.The 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 6/12/26 at 9:54 AM, in the presence of the Licensed Practical Nurse (LPN#1), the surveyor began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart (narcotic box) on the third-floor cart #2. At that time, the surveyor and LPN #1 reviewed the June 2026 shift-to-shift log which revealed signatures from two nurses daily, attesting that the amounts of each medication checked for the dates signed were in agreement with the Controlled Drug Record (reconciliation form used to document each narcotic removed from each resident's designated inventory). On 6/12/26 at 9:58 AM, the surveyor and LPN #1 reviewed Resident #56's Controlled Drug Administration Record (CDAR - a declining inventory log) for 50 milligrams (mg) of Tramadol (narcotic medication). The CDAR reflected the following: -on 2/1/26 one (1) Tramadol was removed, then wasted. Under reason: reflected, fell on the floor; a succeeding removal was not documented. -on 5/13/26 one (1) Tramadol was removed, then wasted. Under reason: reflected fell on the floor. A succeeding removal for administration was not documented. -on 5/14/26 one (1) Tramadol was removed, then wasted. Under reason: reflected fell on the floor. A succeeding removal for administration was not documented. -on 6/1/26 one (1) Tramadol was removed, then wasted. Under reason: reflected fell on the floor. A succeeding removal for administration was not documented. The counts on Resident #56's CDAR for Tramadol matched the corresponding bingo card (a multidose card containing individually packaged medications). A review of Resident #56's February 2026, electronic Medication Administration Record (eMAR) revealed a physician's order (PO) for Tramadol 50 mg, give 1 tablet by mouth every 12 hours as needed for moderate to severe pain. The PO started on 1/8/26. The eMAR did not reveal administration of Tramadol on 2/1/26. Resident #56's May 2026, eMAR did not reveal administration of Tramadol on 5/13/26 and 5/14/26 at 6:00 PM. Resident #56's June 2026, eMAR did not reveal administration of Tramadol on 5/13/26 and 5/14/26 at 6:00 PM. 2.) On 6/12/26 at 10:05 AM, the surveyor and LPN #1 reviewed Resident #74's CDAR for 1 mg of Lorazepam (narcotic medication, used for anxiety). The CDAR reflected the following: -on 5/21/26 at 10:00 PM, one (1) Lorazepam was removed, then wasted. Under reason: reflected D/A. A review of the Reason Wasted Key (explanation of the abbreviation) reflected D, for accidentally punched [removed] and A, for dropped. -on 5/21/26 at 10:00 PM, one (1) Lorazepam was removed again, then wasted. Under reason: reflected A. The Reason Wasted Key reflected A for dropped. Further review of the CDAR reflected that Resident #74's Lorazepam was received on 4/29/26, with a quantity of 14 tablets. The counts on Resident #74's CDAR for Lorazepam matched the corresponding bingo card. A review of Resident #74's April 2026 and May 2026 eMAR did not reveal an order for Lorazepam. At that time, the surveyor continued the inspection in the presence of LPN #1, reviewing Resident #74's CDAR for 1 mg of Alprazolam (narcotic medication). The CDAR reflected the following: -on 6/6/26 at 8:10 PM, one (1) Alprazolam was removed, then wasted. Under reason: reflected wasted fell on the floor. -on 6/6/26 at 8:10 PM, one (1) Alprazolam was removed again, then wasted. Under reason: reflected A. The Reason Wasted Key reflected A, for dropped. A succeeding removal for administration was not documented. The counts on Resident #74's CDAR for Alprazolam matched the corresponding bingo card. A review of Resident #74's June 2026, eMAR revealed a PO for Alprazolam 1mg, give 1 tablet by mouth at bedtime for anxiety. The PO started on 4/9/26. The eMAR revealed a one-time administration of Alprazolam on 6/6/26 that was not documented on the CDAR as administered. 4.) On 6/12/26 at 10:05 AM, the surveyor and LPN #1 reviewed Resident #139's CDAR for 0.5 mg of Lorazepam (narcotic medication, used for anxiety). The CDAR revealed the following: -on 6/11/26 at 11:54 PM, reflected a removal of 1 tablet without the nurse's signature The counts on Resident #139's CDAR for Lorazepam matched the corresponding bingo card. A review of Resident #139's June 2026, eMAR revealed a PO for Lorazepam 0.5 mg, give 1 tablet every 12 hours as needed for anxiety for 14 days, may cause drowsiness, avoid alcohol. The PO was started on 6/3/26. The eMAR did not reveal an administration on 6/11/26. On 6/12/26 at 10:13 AM, in the presence of a surveyor, the LPN, and the Director of Nursing (DON), the surveyor discussed the discrepancies found for Residents #56, 74 and 139 during the medication and labeling observation. On 6/12/26 at 12:04 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), and the DON, the surveyor discussed the concerns with the CDAR that reflected fell on the floor for Residents #56, and #74 and one removal without a signature for Resident #139. On 6/15/26 at 9:56 AM, in the presence of the survey team and the LNHA, the DON stated that the CDS [narcotic] discrepancies were called into the Department of Health on 6/14/26 at 1:01 PM and the investigation was on-going. On 6/16/26 at 10:30 AM, the surveyor, in the presence of another surveyor, the Assistant Director of Nursing and LPN #3, reviewed the contents of the electronic back-up machine (EBM; automated dispensing system that contains emergency backup medications) for June 2026. The contents of the EBM included Tramadol, Lorazepam and Alprazolam. At that time, the DON stated that the nurses took the resident's supply of Tramadol and administered it to another resident. The DON stated that the three (3) nurses involved were all suspended pending full investigation results. At that time, when the surveyor asked why the EBM was not used, the DON could not explain the reason and reiterated that it is part of the on-going investigation. At that time the DON stated that Resident #74's Lorazepam had a loose backing, the pills fell out while pulling another resident's medication. The DON also stated that education was provided to the nurse to inform the pharmacy and the supervisor when this occurred. The DON stated that Resident 74's Alprazolam was administered on 6/6/26 and the nurse had documented incorrectly. Education was provided to the administering nurse. At that time, the DON stated that Resident #139's removal of Lorazepam was documented as administered on the eMAR on 6/12/26 at 12:03 AM. The nurse was educated to sign the CDAR upon removal of a narcotic. At that time, the DON stated that the managers and supervisors audited narcotics for discrepancies at least once a day and could not state how the discrepancies remained undetected. The DON stated that an investigation was initiated and on-going. On 6/16/26 at 12:28 PM, during a follow-up interview with the surveyor, the DON stated that she was working with the pharmacy, continued to investigate Resident #74's Lorazepam and found that there was no order for April 2026 and May 2026. The DON stated that the investigation was on-going. A review of the facility provided policy titled Controlled Substance, dated 11/2022, reflected that the facility complied with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimized the time between loss/diversion/follow-up. 2. On 6/11/26 at 8:24 AM, the surveyor observed Licensed Practical Nurse (LPN) #2, administer medication to Resident #37. Resident #37 was due to receive a lidocaine patch 4% to the left hip and the lumbar region. LPN #2 lifted the resident's shirt to apply the lidocaine patches onto the resident. The surveyor with the LPN observed the resident had a lidocaine patch to their upper back and their mid lower back. The LPN stated the patches should have been removed last night. The LPN removed the old patches and stated she would apply the new patches while trying to avoid the same areas. The LPN applied one patch to the resident's left flank and left upper-mid back. After exiting the resident's room, the surveyor interviewed LPN #2 about the patch placements in comparison to the orders which indicated left hip and lumbar region. The LPN reviewed the Medication Administration Record (MAR) and confirmed the orders and areas for application of the patches. LPN #2 stated Resident #37 complained of pains to the areas where the patches were placed and that's why it was applied to those areas. The LPN added that she should have asked the resident to confirm pain locations while at the bedside with the surveyor. On 6/11/26 at 10:30 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #37. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to osteoarthritis (a degenerative disease affecting the entire joint), and dementia. A quarterly Minimum Data Set (MDS) assessment, an assessment tool to facilitate the management of care, dated 5/12/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #4 scored 4 out of 15, which indicated the resident had severe cognitive impairment. A physician's order dated 3/17/26 indicated to apply lidocaine patch 4 % to left hip topically one time a day for pain management. Apply for 8 Hours in a 24-hour period; remove as per schedule. A physician's order dated 3/17/26 indicated to apply lidocaine patch 4 % to lumbar region topically one time a day for pain management. Apply for 8 Hours in a 24-hour period; remove as per schedule. A review of the June 2026 Medication Administration Record (MAR) revealed the Lidocaine patch orders were scheduled to be applied at 9 AM and to be removed at 4:59 PM. On 6/11/26 at 1:02 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the above concerns. On 6/12/26 at 9:32 AM, the LNHA and the DON met with the survey team. The DON stated the resident was re-assessed for pain location and the lidocaine orders were adjusted to reflect the specified areas. The DON further explained education was provided to the LPN about medication administration and with the nurse from the previous day who was supposed to remove the patches. A review of the facility provided policy titled, Administering Medications with a last revised date of April 2019 under Policy revealed: Medications are administered in a safe and timely manner, and as prescribed. NJAC 8:39-11.2(b), 27.1(a), 29.7(c), 29.2(a)(d)

Repeat Deficiency Based on interviews and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines, for 1 of 24 residents (Resident #37), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 6/11/26 at 11:10 AM, the surveyor observed Resident #37 in the room awake, alert, and oriented, able to answer the surveyor in simple English. The surveyor and a Certified Nurse Assistant (CNA) who spoke Spanish interviewed Resident #37, who said that they are Spanish and Italian and can only speak either language, and they want an interpreter, if possible so they can understand better and answer the question appropriately. On 6/10/26 at 2:29 PM, the surveyor reviewed the electronic medical record (eMR) of Resident #37, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #37 was admitted with diagnoses that included, but were not limited to, hypertensive heart disease without heart failure. A review of the recent quarterly MDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated that the residents had severely impaired cognition. Further review of the MDS reflected in section A - Identification Information, revealed that the MDS assessment did not code the Social Security Number (SSN), ethnicity, preferred language, or interpreter used in the following assessments: - Entry MDS dated [DATE]- admission MDS dated [DATE]- QMDS dated [DATE]- QMDS dated [DATE]- QMDS dated [DATE]- Annual MDS 1/5/26- QMDS dated [DATE] A review of the monthly summary report for the months of March, April, and May 2026, revealed that Resident #37's preferred language was Spanish. A review of the care plan report, initiated on 3/17/26, included interventions, but were not limited to, providing Resident #37 with a Spanish communication booklet to help employees understand the resident's needs. On 6/11/26 at 11:15 AM, the surveyor interviewed the CNA assigned to the resident who stated that the resident can answer simple questions and would call an interpreter or use a media translator for more detailed communication. On 6/11/26 at 11:30 PM, the surveyor interviewed a Licensed Practical Nurse (LPN), who stated that she speaks a little Spanish, but if the resident cannot understand her, there is a number they can call for an interpreter if there is no one in the facility. She added that the resident does not speak much English. On 6/11/26 at 12:10 PM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN), who stated that she wanted to make sure that the resident's SSN is correct before adding it to the assessment. She added that she left the SSN blank since they will accept the MDS assessment anyway, compared to before, when you could not submit the assessment if the SSN was missing. The MDSC/RN did not provide further information regarding Resident #37's ethnicity, preferred language, and interpreter used. On 6/11/26 at 1:01 PM, the team of surveyors met with the Licensed Nursing Home Administrator and the Director of Nursing but did not receive further information from facility administration. NJAC 8:39-33.2 (c)13

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to apply the principals of antibiotic stewardship during the treatment 1 of 5 residents reviewed for infections (Resident #12).The deficient practice was evidenced by the following: On 6/10/26 at 11:10 AM, during the initial tour of the facility, the surveyor observed Resident #12 receiving intravenous (IV) therapy from an electronic pump next to the resident's bed.On 6/10/26 at 11:45, the surveyor reviewed Resident 12's electronic health record (EHR). The review of the EHR reflected the resident was receiving care for diagnoses that included but were not limited to; leukocytosis (elevated white blood cell count), vascular wounds of the left dorsal foot and left heel and anemia.A review of resident #12's progress notes reflected the resident had a left upper arm midline vascular access device inserted on 6/6/26.A review of Resident #12's physician orders reflected the following order:Zosyn solution [an antibiotic] 3/375grams in 100 milliliters of dextrose, administer 100 milliliters every 8 hours by IV with a start date of 6/4/26 and an end date of 6/11/26 to treat leukocytosis (an elevated white blood cell count).On 6/10/26 at 12:17 PM, the surveyor interviewed the IP and she acknowledged the resident was receiving intravenous antibioticsOn 6/11/26 at 10:18 AM, the surveyor interviewed the facility's Infection Preventionist (IP). The IP stated she is responsible for oversight of the antibiotic stewardship for the facility's residents. The IP stated that she gathered resident information from direct nursing reports, from a digital report of antibiotics in use and reviewed new admissions through the facility's electronic medical record (EMR). The IP stated that she used the surveillance tool in the EMR to create reports on infection surveillance and antibiotic stewardship. The IP verbalized an Infection Screening Tool in the EHR was completed for residents identified in the surveillance report to assure that antibiotics were administered.On 6/11/26 at 1:00 PM the surveyor reviewed policies provided by the Licensed Nursing Home Administrator (LNHA). An undated policy titled Antibiotic Stewardship- Staff and Clinical Training and Roles, reflects the IP will have clinical oversight responsibilities for antibiotic stewardship and receive initial orientation and ongoing training on . the facility's antibiotic stewardship program. An undated policy titled Antibiotic Stewardship- Orders for Antibiotics reflected Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program On 6/12/26 at 11:50 AM, the surveyor interviewed the director of nursing (DON) and the IP to discuss antibiotic stewardship efforts for Resident#12, Both confirmed that Resident #12 was not on the current Infection Surveillance Report, dated 6/11/26 and both acknowledged that resident was started on antibiotics on 6/4/26 and should have been on the report. The IP acknowledged the original diagnosis for the antibiotics was leukocytosis and no cultures or testing had occurred since 6/4/26 to identify the type of organism that caused the leukocytosis or the recommended type of antibiotic. Both agreed that the facility used the Infection Screening Tool in the EMR to determine the appropriateness and effectiveness of antibiotics as part of the facility's antibiotic stewardship, and the screening tool was not completed for Resident #12. The IP acknowledged that antibiotic stewardship was part of her primary responsibility and was not conducted according to the facility's policy or documented in the EHR for Resident #12. The IP and the DON provided no further information or documentation.On 6/11/26 at 1:00 PM, the surveyor and survey team met with The DON and LNHA to discuss the observed concern with lack of documentation of antibiotic stewardship for Resident #12. Both acknowledged the concern and agreed antibiotic stewardship, and documentation of the effort was required for all residents on antibiotics. No further information provided. NJAC 8:39-19.4(d)

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices for 1 of 5 residents reviewed for infections (Resident #12).The deficient practice was evidenced by the following:On 6/10/26 at 11:10 AM, the surveyor observed Resident #12 receiving intravenous (IV) therapy from an electronic pump next to the bed. The surveyor observed there was no enhanced barrier precaution (EBP) signage or indicators at the entrance of the room.A review of Resident #12's electronic health record reflected the resident was receiving care for diagnoses that included but were not limited to leukocytosis (elevated white blood cell count), anemia, and vascular wounds of the left dorsal foot and left heel.A review of resident #12's progress notes revealed the resident had a left upper arm midline vascular access device inserted on 6/6/26.A review of Resident #12's physician orders included the following:Ferriecit intravenous solution 12.5 milligram per milliliter solution give 125 mg 1 x daily by IV with a start date of6/6/26 and a discontinue date of 6/11/26 for anemia.Zosyn solution 3/375grams in 100 milliliters of dextrose. Administer 100 milliliters every 8 hours by IV with a start date of 6/4/26 and an end date of 6/11/26 to treat leukocytosis.On 6/10/26 at 12:12 PM, the surveyor made a second observation of no EBP signage at the entrance to the resident's room. The surveyor interviewed the Licensed Practical Nurse Unit Manager (LPNUM) and she acknowledged the resident had active wounds of the left foot and was receiving IV therapy with an IV access in his upper left arm and should be on EBP. The LPNUM acknowledged there was no EBP signage or personal protective equipment (PPE) bin at the entrance to the room.On 6/10/26 at 12:17 PM, the facility Infection Preventionist (IP) arrived on the unit and posted EBP signage and a PPE bin at the resident's doorway. The surveyor interviewed the IP and she acknowledged the resident has an active IV antibiotic and should have been on EBP and there should have been signage and a PPE bin at the doorway to the resident's room.06/11/2026 10:44 AM, the surveyor interviewed the Director of Nursing (DON). The DON acknowledged that Resident#12 should have been on EBP for wounds and for the IV access and antibiotic therapy and that signage and additional PPE should have been in place at the entrance to the resident's room.A review of a facility provided, undated policy titled Enhanced Barrier Precautions reflected .enhanced barrier precautions are utilized to prevent the spread of multi-drug resistant organisms to residents.Enhanced barrier precautions apply when a resident is not known to be infected or colonized with any MDRO, but has a wound or an indwelling medical device. indwelling medical devices include central lines and peripheral IV access devices.On 6/11/26 at 1:00 PM, the surveyor and survey team met with the DON and Licensed Nursing Home Administrator to discuss the observed issue with missing EBP signage. Both acknowledged the concern and agreed the signage and precautions should have been in place. No further information provided. NJ 8:39-19.1; 19.2; 19;4; 19.5; 21.1

Based on observation, interview, and record review, it was determined that the facility failed to ensure a medication was labeled in accordance with acceptable professional standards that identified the beyond used date (expiration date). This deficient practice was identified for 1 of 3 medication carts inspected during the medication and storage observation and was evidenced by the following:Reference: According to the manufacturer's specifications for Latanoprost, section 16 How Supplied/Storage and Handling included: Once a bottle is opened for use, it may be stored at room temperature 25 degrees Celsius (77-degree Fahrenheit) for 6 weeks. On 6/12/26 at 10:18 AM, during the inspection of the third-floor cart 2, the surveyors and the Licensed Practical Nurse (LPN) observed the following:- opened and undated Latanoprost eye drops (used to treat open-angle glaucoma).At that time, the LPN confirmed with the surveyors the observation and stated that the Latanoprost should have been dated after it was opened so that the expiration date could be calculated. The LPN also stated she did not know when the eye drop was opened or who opened the eye drop container. On 6/12/26 at 12:36 PM, the survey team met with the Licensed Nursing Home Administrator and the Director of Nursing to discuss the concern of the opened and undated eye drop container.On 6/15/26 at 9:56 AM, during a meeting with the survey team, no further information was provided regarding the opened and undated eye drop.A review of the facility policy titled, Medication Labeling and Storage, revised 2/2023, included that labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirement and currently accepted pharmaceutical practices. The medication label at a minimum, should include the following: medication name, prescribed dose strength, expiration date, when applicable. N.J.A.C. 8:39-29.4 (a)8(g)(h)

Based on observation, interview, and record review it was determined that facility nurses failed to consistently perform an accurate assessment of the resident's vascular access site for hemodialysis for 1 resident (#91) of 2 reviewed for dialysis care and services. The deficient practice is evidenced by the following. On 6/9/26 at 10:32 AM, the surveyor observed the resident in bed receiving morning care and again on 6/10/26 at 11:18 AM in bed with eyes closed.A review of the electronic medical record revealed the following information.The admission Record indicated the resident was admitted with end stage renal disease and was dependent on hemodialysis.The 4/29/26 admission Minimum Data Set (MDS) assessment tool, revealed the resident had no cognitive deficits (Section C) and received hemodialysis at the time of admission (Section O).The physician's Order Summary Report included a hemodialysis order for Mondays, Wednesdays, and Fridays with a pickup time of 4:15 AM.The comprehensive care plan for hemodialysis, initiated 4/28/26, instructed nurses to assess the inguinal permacath (a permanent catheter inserted into a large vein to provide direct access to the bloodstream) for signs and symptoms of infection, swelling, or excessive bleeding.Nursing/Clinical progress notes written during May and June 2026 revealed the resident left the facility for the dialysis clinic on Monday, Wednesday, and Friday between 4:30 AM and 4:45 AM on the night shift. The Licensed Practical Nurse (LPN #1) consistently assessed the resident's permacath as intact, no bleeding, or infection noted. During this time frame Nursing/Clinical progress notes revealed the resident returned to the facility from the dialysis clinic at approximately 10:30 AM on the day shift. LPN #2 consistently documented assessment of the dialysis access site as having a bruit and thrill (physical signs used to evaluate blood flow in a surgically altered blood vessel). Bruit and thrill would be present in a arteriovenous (AV) fistula, a type of surgically a created vessel used for a hemodialysis access site. Bruit and thrill would not be assessed in the type of catheter the resident had (a permacath). On 6/10/26 at 1:03 PM, the surveyor interviewed LPN #2 inquiring how she assessed the resident's permacath. LPN #2 replied she checked for a bruit and thrill.On 6/11/26 at 1:22 PM, the surveyor discussed the concern regarding the permacath assessment with the Director of Nursing and the Licensed Nursing Home Administrator.The facility's policy titled Hemodialysis Catheters - Access and Care of, revised June 2025, did not address the procedure for assessing a central venous catheter (permacath).The facility's policy titled Hemodialysis Pre and Post Care, March 2010, did not differentiate between AV fistula and central venous catheter access sites, except to state central venous catheters are not to be used for blood draws or medication administration. The policy instructed nursing staff to assess dialysis access sites for bleeding, swelling, redness, odor, hardness, or drainage at the site.NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to update and/or revise care plans for 1 of 27 residents reviewed, Resident # 9.The deficient practice was evidenced by the following: The surveyor reviewed an investigation for a fall Resident #9 had. The fall was on 4/28/26. The resident did not sustain any injuries. The investigation determined that the resident slipped and fell as the resident forgot to lock the wheelchair when attempting to transfer self.The investigation of the fall indicated that the Interdisciplinary Team agreed to add the following interventions to the care plan to prevent future falls; Provide assistance to transfer and ambulate as needed.The surveyor asked the Director of Nursing (DON) for all of the active care plans for the resident. The DON confirmed that all of the care plans she provided were all of the resident's active care plans. There was a care plan in place for at risk of falls and it included interventions from prior falls yet, it did not include the intervention put in place for Provide assistance to transfer and ambulate as needed.On 6/11/26 at 11:57 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who cared for the resident. The LPN stated that she created the care plans along with other staff, and that the care plan should show all of the actual fall interventions yet, the LPN acknowledged that the intervention for this fall was not there.The surveyor reviewed the Care plan policy, revised on 5/7/2, which revealed that the comprehensive, person-centered care plan should include measurable objectives and timeframes. On 6/11/26 at 12:38 PM, the surveyor discussed the above concerns with DON and the Administrator.NJAC 8:39-11.2 ,2, (i)

Based on interviews and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure that newly hired staff underwent a criminal background investigation prior to their date of hire. The deficient practice was observed for 2 of 118 employees hired after 1/7/25.The deficient practice was evidenced by the following:A review of the facility provided employee records reflected:Employee #11, a physical therapist was hired on 4/17/26 and had a no background check on file. Employee #67, a Certified Nursing Assistant was hired on 8/22/25 and the background check on file was dated 12/20/23 (1 year and 8 months prior to employment).On 6/15/26 at 10:10 AM, the surveyor and the survey team met with the Director of Nursing and the Licensed Nursing Home Administrator and discussed the background checks review of the facility's employee records. A background check dated 6/10/26 was provided for Resident #11 dated 6/12/2025 (performed after surveyor inquiry). A background check was provided for Employee #67 dated 6/12/26 (performed after surveyor inquiry). No further information provided on the 1 year and 8 month discrepancy for Employee #67's background check, both confirmed the employees' hire date was 8/22/25.A review of the facility provided, undated policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reflected .The resident Abuse, Neglect, Exploitation program consists of a facility-wide commitment and resource allocation to support the following objectives: .4. Conduct employee background checks and not knowingly employ or otherwise engage any individual Who has been found guilty of abuse, neglect , exploitation, misappropriation of property, or mistreatment by a court of law.NJAC 8:39-4.1(a)5; 43.15

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 of 3 residents, Resident #135, reviewed for wound care. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 6/9/26 at 10:44 AM, the surveyor observed Resident #135 seated in a wheelchair at their bedside. Resident #135 was alert, verbally responsive, and reported no concerns. The resident was observed with bilateral (B/L) lower extremity (LE) dressings.On 6/12/26 at 9:13 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #135. The admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, cellulitis of right lower limb, cellulitis of unspecified part of limb, and congestive heart failure. The facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) evaluation which was dated 6/8/26. Resident #135 scored 6 out of 15, which indicated the resident had severe cognitive impairment.A Resident Evaluation dated 6/5/26 included a skin assessment which revealed right (front) lower leg and left (front) lower leg skin conditions. Under Description for both sites was documented wound. There was no additional documentation which indicated wound description such as wound type, size of wounds, depth, tissue characteristics, or surrounding skin area.A wound consultant (WC) note dated 6/9/26 revealed an initial assessment of Resident #135's wounds which included B/L LE wounds. The WC documented an assessment of chronic vascular wounds to the left posterior lower leg, the right posterior lower leg, and the left anterior lower leg. The assessment included measurement of the wounds, tissue characteristics, and exudate (e.g. drainage or secretions).The left posterior lower leg was assessed as being 1 centimeter (cm) x 0.8 cm in size with no odor and a small amount of serous drainage. The right posterior lower leg was assessed as being 3 cm x 4.5 cm x 0.1 cm in size with no odor and a small amount of serous drainage. The left anterior lower leg was assessed as being 3 cm x 4.5 cm x 0.1 cm in size with no odor and a small amount of serous drainage. The WC made recommendations for dressing treatments to each site and to monitor for changes.A review of physician's orders for included the following:A physician's order dated 6/9/26 indicated to cleanse the left posterior lower leg with saline and wrap with kerlix dressing as needed (PRN).A physician's order dated 6/9/26 indicated to cleanse the left posterior lower leg with saline and wrap with kerlix dressing every day shift.A physician's order dated 6/10/26 indicated to cleanse the right anterior lower leg with saline, apply xeroform petroleum patch and wrap wth kerlix dressing every day shift.A physician's order dated 6/10/26 indicated to cleanse the right posterior lower leg with saline, apply xeroform petroleum patch and wrap with kerlix dressing PRN.A physician's order dated 6/10/26 indicated to cleanse the right posterior lower leg with saline, apply xeroform petroleum patch and wrap with kerlix dressing every day shift.A physician's order dated 6/10/26 indicated to cleanse the right posterior lower leg with saline, apply xeroform petroleum patch and wrap with kerlix dressing PRN.There were no treatment orders found for the B/L LE wound sites prior to 6/9/26.On 6/12/26 at 11:42 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) who stated that as soon as a resident was admitted a skin assessment would be completed with a Registered Nurse (RN), at least within the first 8 hours. The LPN explained findings would be documented in the Resident Evaluation under the skin assessment section; and the description of any wound found would be documented. The LPN stated the description included details of how the wound looked like and its measurements.The LPN stated that hospital records were reviewed to see if the resident had previous treatment orders to be continued at the facility and the nurse would contact the physician for treatment orders for any wound the resident was assessed to have. On 6/12/26 at 12:40 PM, the surveyor informed the LNHA and the DON of the concern that there was no detailed documentation of B/L LE wound assessment upon the resident's initial evaluation by the nurse, and no documentation regarding treatment for B/L LE wounds prior to the WC's examination. The DON stated she would follow up to provide any information.On 6/15/26 at 9:56 AM, the LNHA and the DON met with the survey team. The DON stated at the time of admission the resident's B/L LE were dry scabbed areas with edema (swelling caused by too much fluid trapped in the body's tissues) present. The surveyor asked the DON if there was any documentation at the time of the wounds' description. The DON stated there was no additional documentation and acknowledged that the nurse did not adequately describe the wound upon completion of the assessment. The surveyor reviewed the facility policy titled admission Assessment and Follow Up: Role of the Nurse with a last revised date of September 2012. Under Purpose revealed: The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS.The surveyor reviewed the facility policy titled Pressure Ulcers/Skin Breakdown with a last revised date of April 2018. Under Assessment and Recognition revealed: 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions.The policy did not further address documentation of a wound's assessment by nursing staff. There was no other policy related to skin assessment provided by the facility.N.J.A.C. 8:39-27.1 (a)

Complaint #: NJ186848 Based on observation, interviews, and review of pertinent facility documents on 6/2/25, it was determined that the facility failed to provide adequate supervision to a cognitively impaired resident (Resident #1) with a known history of elopement which resulted in the resident eloping on 5/26/25. This deficient practice was identified for 1 of 4 residents reviewed for risk for elopement (Resident #1). Resident #1, a cognitively impaired resident who wore a wander guard to alert staff of possible elopement, was last seen by staff on 5/26/25 at 3:45 PM. The Licensed Practical Nurse (LPN #1) reported that the resident wanted to go downstairs for dinner, and she disarmed the elevator's wander guard system to allow the resident to self-propel themselves in their wheelchair downstairs. Observation of video footage revealed that the Receptionist (R#2) disengaged the lobby's rear exit door's wander guard alarm, and Resident #1 exited the facility through that door at 3:48 PM. At 6:45 PM, during rounds, the Registered Nurse (RN) Supervisor noted that Resident #1 did not eat their dinner tray, and asked LPN #1 to find the resident. At 6:50 PM, LPN #1 could not locate the resident and the facility initiated their elopement protocol. The resident was located at 9:45 PM in a parking lot of a tire shop in a nearby town, and was brought back to the facility by staff at 10:13 PM. The facility's failure to provide adequate supervision to a cognitively impaired resident who was at risk for elopement and eloped posed a likelihood of serious harm, injury, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation which ran from 5/26/25 at 3:45 PM, when LPN #1 allowed Resident #1 to leave the unit unescorted, until 5/26/25 at 10:13 PM, when the resident was found in a nearby town and brought them back to the facility by staff. The IJ was Past Non-Compliance (PNC). The facility's Licensed Nursing Home Administrator was notified of the IJ on 6/2/25 at 6:35 PM. The facility submitted an acceptable Removal Plan on 6/3/25 at 12:40 PM. The facility was back in compliance when the facility addressed the situation by locating the resident and immediately assessing the resident upon return to the facility; the Director of Nursing (DON) provided in-servicing to LPN #1 on the policies on elopement risk, wandering residents, accidents and incidents, and routine resident checks; the vendor assessed and repositioned the wander guard alarms on the rear entrance door and confirmed the system was fully functioning; and a facility wide in-service and re-education on resident rounding and the escorting of residents at high risk of elopement, elopement drill, transporting of residents at high risk for elopement, monitoring of the facility entrance and exits with the proper use of wander guard alarming system deactivation. The surveyor verified the completion of the Removal Plan was 5/30/25, during an on-site survey on 6/10/25, and determined the IJ was PNC. The evidence was as follows: A review of the facility's Wandering and Elopements policy dated revised March 2019, included under Policy Interpretation and Implementation: 1) If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . A review of the Facility Reportable Event (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 5/27/25, included an Investigation Summary and Conclusion (ISC) with date of incident: 5/26/25. The ISC indicated that Resident #1 was assessed as cognitively impaired and at risk for elopement with a security bracelet (wander guard) applied. The resident utilized a wheelchair for mobility, and on 5/26/25, at approximately 3:45 PM, LPN #1, their primary nurse, reported that the resident wanted to go downstairs in preparation for dinner, which was their usual behavior. At approximately 6:45 PM, the RN Supervisor was rounding on the third-floor unit and noticed the resident's dinner tray in their room was untouched. The RN Supervisor immediately reached out to LPN #1 and inquired why the tray was still in the room. LPN #1 thought the resident was downstairs in the main dining room having their dinner. Staff went downstairs, but the resident was not in the dining room which prompted the RN Supervisor to start searching for the resident thinking they may have completed their meal and was wheeling themselves around the unit as per their normal activity after dinner. When the RN Supervisor was unable to locate the resident, the RN Supervisor immediately initiated the missing person protocol and notified the DON, Assistant Director of Nursing (ADON), and the Licensed Nursing Home Administrator (LNHA). The ISC also included a conclusion which indicated that the resident exited from the unit when they went in the elevator. Their wander guard alarmed and held the elevator on the third-floor, and LPN #1 put in the code to disengage the elevator hold which allowed the resident to head down to the lobby in elevator alone. Once the resident arrived at lobby, they went toward the rear exit door. At rear exit door, the wander guard system alarmed and R#2 entered the code to disable the alarm as visitors and residents were gathered at the front of the building. Resident #1 was then able to continue out of the rear exit door. Both the front and rear exit doors were equipped with the wander guard system, and the exits and wander guards were inspected and operating properly prior to the event with no malfunctions noted. The wander guard company was called in immediately after the event and tested the system and verified it was functioning properly. The ISC indicated in the conclusion, the point of egress was the rear exit door. The wander guard system was in place and functioning. The resident was assessed with no injury. The ISC further included the following timeline of events on 5/26/25: - At 3:45 PM, the resident was noted entering the elevator. - At 3:48 PM, the resident arrived from elevator to the lobby and exited through the back door exit. - At 6:45 PM, the RN Supervisor noted Resident #1's dinner tray was untouched and requested LPN #1 go to the first floor to retrieve the resident. - At 6:50 PM, LPN #1 notified the RN Supervisor that the resident was not on the first floor. The RN Supervisor immediately initiated the missing person protocol and continued to search for the resident. - At 7:39 PM, the DON, ADON, and LNHA were notified of the missing resident. The DON notified authorities and the NJDOH. The DON and LNHA immediately headed to the facility. - At 8:03 PM, the DON and LNHA arrived at facility along with the department heads to increase search. - At 8:05 PM, the Police Officer [name redacted] arrived at the facility. - At 9:45 PM, the resident was visually located outside of the facility. - At 9:51 PM, the resident was met in person by facility staff, picked up, and driven back to the facility. - At 10:13 PM, the resident safely arrived back to the facility escorted by facility staff with the Police Officer present at arrival. A review of the admission Record face sheet (admission summary), revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to; dementia, difficulty walking, muscle weakness, hyperlipidemia, hypertensive heart disease, and chronic pain. A review of the Minimum Data Set (MDS), an assessment tool dated 5/2/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition. The MDS further revealed that the resident required assistance from staff in their completion of activities of daily living (ADLs). A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 4/27/25, that the resident was at risk for elopement due to change in environment and had a history of wandering with an actual missing person incident per spouse. Interventions included for staff to accompany to meals and scheduled activities with date initiated 4/27/25. On 6/2/25 at 2:07 PM, the surveyor requested and reviewed the video footage of the incident on 5/26/25. The surveyor noted the camera monitors showed the lobby areas, but there was no video footage by the third-floor nursing unit. The camera monitors in the lobby revealed the following: - At 3:47:57 PM, the resident was seen coming out from Elevator #1 in front of the reception area by themselves. The resident was seen self-propelling in their wheelchair wearing a dark sweatshirt, gray pants, and black sneakers. No distress was noted. - At 3:48:03 PM, the resident was seen in their wheelchair near the right side of the reception area towards the rear exit sliding doors. - At 3:48:21 PM, Receptionist (R#1) was seen coming out from the left side of the reception area and went around the reception desk. - At 3:48:32 PM, the resident was in their wheelchair near the rear exit sliding doors and started propelling towards the exit. - At 3:48:36 PM, the resident, in their wheelchair, was seen propelling towards the rear sliding doors. - At 3:48:39 PM, R#2 was seen with her left hand on the keypad on the wall. It was also noted that R#2's back was towards the rear exit sliding doors. - At 3:48:52 PM, the resident was seen in their wheelchair exiting the opened sliding doors and turned left. - At 3:49:41 PM, the resident was seen in their wheelchair passing by the left side of the outside of the building at the rear. - At 3:49:59 PM, the resident was seen self-propelling in their wheelchair towards the fenced gate on the left side area of the parking lot at the back of the facility. - At 3:50:19 PM, the resident was seen in their wheelchair through the fenced gate and made a left towards the street side and was then out of camera view. On 6/2/25 at 2:37 PM, the surveyor interviewed R#1, who stated that on 5/26/25 at around 3:45 PM, when R#2 came in, she went to the restroom before endorsing (discussing pertinent information from shift) to her. When she came back to the reception area, she went around the desk to sit and called staff regarding some issues and started giving the report to R#2 after that. R#1 stated that she heard the alarm, and she saw R#2 pressing the keypad while they were endorsing. R#1 further said she did not see the rear doors because R#2 was on her right side blocking her view. R#1 did not recall seeing the resident in their wheelchair exiting the rear exit sliding doors. On 6/2/25 at 3:14 PM, the surveyor conducted a telephone interview with R#2, who stated on 5/26/25 at around 3:45 PM, the morning receptionist (R#1) went to the restroom as her shift was about to end, and while waiting for R#1 at the reception desk, she saw Resident #1 coming out from the elevator in front of the reception area. R#2 further stated that she greeted the resident and was speaking to them when R#1 came back from the restroom. R#2 then got up while R#1 went around the desk and had their endorsement. R#1 was giving the report to R#2. R#2 said she was facing R#1 and the entrance sliding doors (left side in the camera) during the report and had her back towards the resident and the rear sliding doors. The surveyor asked R#2 if she entered the code on the keypad or pressed the button, and R#2 stated she could not remember as she was talking to R#1. The surveyor then asked if she heard the alarm sound, and she said she did and that she was facing the entrance doors and she thought there were no residents or family members. R#2 could not remember pressing the code. The surveyor informed R#2 that in the video footage she was seen pressing the keypad, and R#2 provided no further information. On 6/2/25 at 3:48 PM, the surveyor interviewed LPN #1, who stated that she saw the resident in their wheelchair going in the elevator. LPN #1 confirmed she was aware the resident had a wander guard and it alarmed. LPN #1 said she deactivated the code because she knew the resident always went down for dinner at 4:00 PM. LPN #1 also said she was aware that the resident was supposed to be accompanied by staff. LPN #1 further said the resident usually went downstairs, and she did not think something would happen to them because the lobby and dining room downstairs were secured. LPN #1 stated she knew the resident was not seen when the RN Supervisor came up and asked her if she saw the resident. LPN #1 said the resident was usually administered their medication after their dinner when the resident came up at around 6:00 PM to 6:15 PM. LPN #1 further said it never occurred to her that the resident would leave as they went down to dinner every day. On 6/2/25 at 4:28 PM, the surveyor interviewed the LNHA and DON. The DON stated they had protocols on missing persons and elopement and staff were educated before and after the incident. The DON and LNHA stated that they implemented measures right away after the incident and educated all staff right away that night. The facility submitted an acceptable Removal Plan on 6/3/25 at 12:40 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice to include: the facility located the resident and was immediately assessed upon return to the facility; the DON provided in-servicing to LPN #1 on the policies on elopement risk, wandering residents, accidents and incidents, and routine resident checks; the vendor assessed and repositioned the wander guard alarms on the rear entrance door and confirmed the system was fully functioning; and a facility wide in-service and re-education on resident rounding and the escorting of residents at high risk of elopement, elopement drill, transporting of residents at high risk for elopement, monitoring of the facility entrance and exits with proper use of the wander guard alarming system deactivation. The facility self-corrected the deficient practice and it was determined that the IJ was Past Non-Compliance (PNC), and the facility corrected their non-compliance on 5/30/25. The surveyor verified the implementation of the Removal Plan on-site on 6/10/25. NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices specifically for: a) Nursing not wearing the required Personal Protective Equipment (PPE) when entering the room of a resident on Transmission-Based Precautions (TBP) (LPN #1); b) Houskeeping (H) staff not removing soiled PPE when exiting the room of a resident on TBP (H #1, #2, #3); c) a Unit Secretary (US) wearing her surgical mask inappropriately below her nose and mouth while on the unit hallway; and d) Certified Nursing Assistants (CNA) not following appropriate hand hygiene during meal service (CNA #1, #2, #3, #4). The deficient practice was evidenced by the following: Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html Reference: Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; after contact with blood, body fluids, or contaminated surfaces. CDC recommendations for Hand Hygiene: Updated February 27, 2024: https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html#cdc_clinical_safety_best_practices_recomm-recommendations 1. On 12/30/24 at 10:20 AM the surveyor observed Resident #25 from the hallway as they were in their room in the window side bed. The resident called out to the Licensed Practical Nurse #1 (LPN #1) who was at the doorway to the room preparing the resident's morning medication. A bin was located outside the entrance to the room containing PPE. Signage at the doorway indicated the resident was on TBP. The surveyor observed LPN #1 enter the room and walk across the room to the resident's bedside. LPN #1 wore a blue surgical mask and was putting on disposable gloves as she approached the resident's bedside. LPN #1 wore no other PPE. She spoke to the resident and exited the room back to her medication cart. The surveyor approached LPN #1 and confirmed with her that Resident #25 was COVID-19 positive. The surveyor asked LPN #1 what PPE was required for COVID-19 infected residents. She responded an N-95 respirator mask, gown, and gloves was required. She stated she heard the resident call out and went in to respond to her call. She stated she did not follow the facility's policy. 2. On 12/30/24 at 10:25 AM the surveyor observed a housekeeper in the hallway outside Resident #25's room with an N-95 respirator mask in place and a blue surgical mask hanging below her chin. H #1 also wore a disposable gown and gloves. The surveyor asked H #1 if she should be wearing PPE in the hallway. She did not seem to understand the surveyor, however, she stated she did speak English. At that time, LPN #1 overheard the conversation and stated to H #1 when you come out of a COVID positive room you must remove the PPE before exiting the room. On 12/30/24 at 10:30 AM the surveyor interviewed the Unit Manager and described the surveyor's observations of LPN #1 and H #1. The Unit Manager stated a surgical mask is required in the hallways and full PPE with an N-95 mask, gown, and gloves in rooms of COVID-19 positive residents. He stated Resident #25 was COVID-19 positive. He stated he would re-educate LPN #1 and H #1. On 12/30/24 at 11:21 AM the surveyor interviewed the Infection Preventionist (IP). The IP stated the current COVID-19 outbreak began on 12/27/24. The IP stated all departments were re-inserviced on COVID-19 infection control prevention practices on 12/27/24. A review of inservice sign-in sheets revealed LPN #1 received education on 12/27/24. However, H #1 who was not working on 12/27/24, was not re-inserviced prior to beginning the 12/30/24 shift. The IP inserviced her after the surveyor's observations. 3. On 12/31/24 at 10:36 AM the surveyor observed the US on unit 2 wearing her surgical mask down under her chin in the unit hallway. She told the surveyor she should be wearing the surgical mask up over her nose and mouth. She stated it was the first day back to work since her vacation and had not been re-inserviced. The surveyor discussed the 3 infection control breaches with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) on 12/31/24 at 12:42 PM . On 01/02/25 at 10:08 AM the DON stated that facility-wide education had been completed regarding infection control, including the proper use of PPE and will be repeated on an on-going basis. 36419 4. On 12/31/24 at 10:20 AM, the surveyor observed H #2 in the hallway outside of room [ROOM NUMBER] with signage at the doorway that indicated the resident was on TBP. H #2 was wearing a surgical mask, a disposable gown, and gloves. The surveyor asked H #2 if she should be wearing PPE in the hallway. The H#2 did not seem to understand the surveyor. At that time, the CNA overheard the conversation and explained to H#2 that she needed to remove the PPE inside of the Resident's room. On 12/31/24 at 10:35 AM, the surveyor interviewed the LPN/UM on the 3rd floor who stated that there were bins inside all TBP rooms where the PPE should be doffed and that all staff were educated on the proper use of PPE. On 12/31/24 at 10:40 AM, the surveyor observed H #2 in room [ROOM NUMBER]. The surveyor observed signage at the doorway that indicated the resident was on TBP. The LPN/UM confirmed that the resident was Covid +. The H #2 was wearing a disposable gown, gloves, an N-95 mask and face shield. The surveyor observed that H #2 exited room [ROOM NUMBER] without doffing the PPE. H #2 wearing the same soiled gloves removed cleaning supplies from the housekeeping cart and went back into room [ROOM NUMBER]. H #2 then went back into the hallway and with the same soiled gloves removed the soiled mop head and placed it in the bin on the housekeeping cart. At that time,the LPN/UM observed H #2 in the hallway wearing full PPE and informed her that she needed to remove PPE inside the room. 5. On 1/3/25 at 11:00 AM, the surveyor observed H #3 in the hallway in front of room [ROOM NUMBER]. The surveyor observed signage at the doorway that indicated the resident was on Enhanced Barrier Precautions (EBP). The surveyor observed that H #3 was wearing a surgical mask, disposable gown, and gloves. The surveyor and the ADON observed H #3 removed her disposable gown and gloves in the hallway. At that time, the ADON told H #3 that she should have removed her PPE inside the room. The H #3 put the gown in a plastic bag and discarded it in the housekeeping supply cart, not in the bins inside the room as instructed by the ADON. The H #3 then entered room [ROOM NUMBER] and washed her hands for 3 seconds. The surveyor asked H#3 how long she should wash her hands. The HK replied 20 seconds. The Infection Prevention Nurse (IPN) overheard the conversation and told the surveyor she believed that H#3 understood English and that there was no language barrier. The surveyor accompanied H #3 back into the room and observed that H #3 applied soap to her hands and immediately placed them under the stream of water without first lathering outside of the water for 20 seconds. On 1/3/25 at 11:10 AM, the surveyor interviewed the IPN who stated that she had in-serviced the staff on the proper use of PPE and proper hand hygiene. On 1/3/25 at 11:15 AM, the surveyor interviewed the Director of Housekeeping (DHK) who stated that he had educated H#2 and H#3 several times and that they had each demonstrated knowledge of PPE donning and doffing and proper hand hygiene techniques. On 1/3/25 at 1:06 PM, the survey team met with the LNHA and DON to discuss the above observations and concerns. 34421 6. On 12/31/24 at 12:08 PM, during a lunch meal dining observation on the 2nd floor in the main dining room, the surveyor observed the lunch trays being distributed to the residents by four CNA's. There was no observed hand hygiene done by the four CNA's prior to passing out trays. There was also no observed hand hygiene done by the four CNA's while assisting the residents with meal set up. On 12/31/24 at 1:00 PM, the above concerns were discussed with the Director of Nursing (DON) and Administrator, who stated they will investigate this concern. On 1/02/25 at 10:17 AM, the DON and Administrator stated that it was expected that the staff use hand hygiene prior to assisting resident's with their meals. NJAC 8:39-19.4 (a)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] at 9:19 AM, the surveyor, in the presence of the Culinary Service Director (CSD) observed the following during the kitchen tour: 1. On the dry rack storage shelf, there were a stack of three half sheet pans. The surveyor observed 1 of the 3 stacked half sheet pans was soiled with white solid debris on the inside of the pan. The CSD was able to scratch the debris off and acknowledged that the pan was soiled. The surveyor observed 1 of the 3 stacked half sheet pans was wet on the inside portion. The CSD acknowledged it was wet and that it should have been dried before stacking with the other pans. The CSD took the half sheet pans to be re-washed. 2. On another dry rack storage shelf, there was a stack of two full size pans. The CSD lifted the top pan, which on the inside was observed wet. The CSD acknowledged that the pan should have been dry and took the pan to be re-washed. 3. On a countertop next to the cooking range area, there was an 8- ounce (oz) paper cup with a plastic lid which was undated and unlabeled. The surveyor asked the CSD about the item. The CSD opened the cup and stated it contained oatmeal. The CSD explained he believed it may be a staff item. The CSD acknowledged it should not be kept there and staff items should be in the staff break room. The CSD removed the item. On [DATE] at 11:46 AM, the surveyor interviewed the CSD about the refrigerators used to store outside food for residents in the facility. The CSD stated there were nutrition refrigerators on the second and third floor units. The CSD further explained that either he, dietary staff, or the manager on duty would check the refrigerator every morning. The CSD stated that when he rounded in the morning, he would check to ensure items were dated, labeled, and not expired. On [DATE] at 11:57 AM, the surveyor inspected the second-floor unit nutrition refrigerator with the registered nurse unit manager and observed the following: 4. In the freezer, there were 3 tubs of sea salt caramel ice cream, with dates of [DATE] which indicated that the ice cream was placed in the freezer and had a manufacturer's expiration date in 2025. The ice cream containers' label did not indicate who the ice cream belonged to. The RN/UM did not know who the items belonged to and acknowledged the items should have been labeled to show the resident's name. 5. In the freezer, there was a jar containing an unknown food item wrapped in foil paper stored in a clear plastic bag. The container and bag were not labeled with a resident name or a date. The RN/UM did not know who the item belonged to and acknowledged it should have been labeled. On [DATE] at 12:06 PM, the surveyor inspected the 2nd floor unit refrigerator with the CSD. The CSD checked the sea salt ice cream containers, confirming it was not a facility stocked item, and that it should have been labeled to indicate which resident it belonged to. The CSD stated he would follow up with nursing staff to try to identify who it belonged to and would dispose of if unable to determine. The CSD acknowledged the jar wrapped in foil paper should have been labeled with a resident's name and dated. The CSD did not know who the item belonged to, did not know when item was placed in the refrigerator, and would dispose the item. On [DATE] at 12:10 PM, the surveyor inspected the 3rd floor unit nutrition refrigerator with a Licensed Practical Nurse (LPN) and observed the following: 6. There was a half-gallon carton of eggnog which was labeled with a date of [DATE] and had an expiration date of [DATE]. The carton of eggnog did not have a resident name or room number to indicate who they belonged to. On [DATE] at 12:12 PM, the surveyor interviewed the LPN unit manager (LPN/UM) about items going into the unit refrigerator. The LPN/UM stated items should be labeled with a date, resident name and/or room number. The surveyor showed the LPN/UM the carton of eggnog in the refrigerator. The LPN/UM stated it should have the resident's name or resident room number besides the dates. The LPN/UM did not know who it belonged to and would have to follow up. On [DATE] at 12:15 PM, the surveyor informed the CSD about the concern of the eggnog container found in the 3rd floor refrigerator which was not labeled with a resident name. The CSD stated it was not a facility stocked item and would follow up about who it belonged to. On [DATE] at 1:16 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) about the above concerns observed in the kitchen and the nutrition refrigerators. The LNHA acknowledged it was expected for personal food items going into the refrigerators to be labeled with the resident name, room number and dated. The LNHA stated that it was a team effort among the staff to ensure items were appropriately labeled and routine checks of the refrigerators were conducted. The LNHA further explained it did not meet expectations as the team routinely checked the refrigerators. On [DATE] at 11:12 AM, the LNHA, CSD, and regional CSD met with the surveyor. The CSD stated in-service education was provided to staff about where staff items should be stored and ensuring clean dishware was dried appropriately to prevent wet nesting (stacking of wet dishes and pans, which prevents them from drying and can lead to bacteria growth). The CSD further explained that the chef who the cup of oatmeal belonged to was going on break, left it there and we happened to see it there during the tour. The surveyor asked about the items in the nutrition refrigerators. The CSD stated the items were disposed and they were unable to determine who the items belonged to. The LNHA added that a QAPI would be initiated and the CSD or designee would be doing audits to monitor and prevent reoccurrence of concerns. The surveyor reviewed the facility's policy titled, Sanitization with a last revised date of [DATE]. Under the Policy Statement revealed: The food services area is maintained in a clean and sanitary manner. Under Policy Interpretation and Implementation, it revealed: . 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions . Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical . The policy did not further address drying protocols for dishware and cookware. The surveyor reviewed the facility's policy titled, Food Brought by Family/Visitor with a last revised date of [DATE]. Under Policy Interpretation and Implementation, it revealed: 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility prepared food. 5b. Perishable foods are stored in re-sealable containers with tightly fitted lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. NJAC 8:,d+[DATE].2(g)

Based on interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate documentation of a) the receipt of a controlled substance for three (3) of three (3) Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on one (1) Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) reviewed and b) two (2) of two (2) controlled substances were accurately accounted for on two (2) of two (2) Controlled Drug Administration Records (CDAR) observed in one (1) of three (3) medication carts. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 12/31/24 at 7:56 AM, the surveyor reviewed a binder provided by the facility Licensed Nursing Home Administrator (LNHA), containing, but not limited to, facility DEA 222 Forms, copies of medical director state and federal controlled substance registration certificates, and packing slips associated with the DEA 222 Forms for controlled substance deliveries. A review of the facility DEA 222 Forms that were filled out and used to order controlled substances (CDS) revealed the following: a) DEA 222 Form with order form # 240326293 dated 3/12/24 for one (1) package of 50 oxycodone 5mg tablets (a schedule II-CDS used for pain), one (1) package of 68 oxycodone/apap 5-325mg tablets (a schedule II-CDS used for pain), and one (1) package of 21 oxycodone 15mg tablets (a schedule II-CDS used for pain) with the section Part 5: to be filled in by purchaser, number received, date received, not filled in. b) On 12/31/24, the surveyor conducted the medication storage and labeling task. The surveyor observed medication cart #1 located on the 2nd floor. The observation revealed two (2) CDAR forms for an unsampled resident where the total doses of CDS documented as available on the CDAR did not match the physical quantity located in the medication cart. The surveyor asked the Licensed Practical Nurse (LPN) assigned to the medication cart about the discrepancy. The LPN stated that the resident who got those medications was in a rush, and I forgot to sign the sheets. The surveyor reviewed the electronic medication administration record (eMAR) for that resident which revealed that the LPN did indicate the resident received the medications. The surveyor asked the LPN what the policy and procedure was for administering CDS. The LPN stated that the CDAR should be signed as soon as the medication is removed from the packaging for administration. On 1/02/25, the surveyor met with the LNHA and the Director of Nursing (DON) to discuss the concerns with the CDS documentation and DEA form. The surveyor asked the DON how the staff should document CDS use. The DON stated the staff should document on the CDAR when the medication is removed from the packaging. On 1/3/25, the surveyor met with the LNHA and DON for responses to the CDAR and DEA form concerns. The DON provided a packing slip that coincided with the DEA 222 form that was not filled out that reflected the CDS were received by the facility. The surveyor asked the DON if the DEA 222 form should be filled in when the medications are delivered. The DON stated, yes, the form should be properly filled out at the time of receipt. No other pertinent information was provided by the DON or LNHA. The surveyor reviewed the instructions for completing the DEA 222 Forms located in the Code of Federal Regulations at 21 CFR1305.13. The CFR 1305.13 revealed at section (e) The purchaser must record on its copy of the DEA Form 222 the number of commercial or bulk containers furnished on each item and the dates on which the containers are received by the purchaser. The surveyor reviewed the facility policies titled Medication Labeling and Storage with a revision date of February 2023. And the policy titled Administering Medications with a revision date of April 2019. The policies did not reflect any pertinent information relating DEA 222 forms or CDAR documentation. NJAC 8:39-29.3(a)6, 29.4(g), 29.7(c) 21 CFR 1305.13(e)

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to ensure that all medications (meds) were administered with an error rate of less than 5%. During the medication administration observation conducted on 12/311/24, the surveyor observed three (3) nurses administer meds to six (6) residents. There were twenty-six (26) opportunities, and three (3) errors were observed which resulted in a medication error rate of 15.38%. This deficient practice was identified for two (2) of six (6) residents observed (Resident #15 and an unsampled resident), which was administered by one (1) of three (3) nurses. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 12/31/24 at 9:36 AM, the surveyor observed the Registered Nurse (RN) prepare meds for an unsampled Resident. The meds included an active physician's orders (PO) dated 2/22/22 for the following: Docusate Sodium capsule 100mg give one capsule by mouth two times a day for constipation. The surveyor observed the RN remove Docusate Sodium tablet 100mg from the bottle and place in a medication dose cup. The surveyor asked the RN to see the bottle for Docusate. The surveyor observed that the label reflected the tablet dose form. The surveyor showed the RN the label and asked if the this was the medication they wanted to give. The RN stated that the resident needed medication crushed and uses the tablets. The surveyor observed the RN crush the tablet and administer to the resident. At 9:51 AM, the surveyor observed the same RN prepare meds for Resident #15. The meds included active PO's for: Docusate Sodium Capsule 100mg give 1 capsule by mouth two times a day for constipation. 9/15/23. Phenytoin Sodium Extended Capsule 100mg give 2 capsule by mouth two times a day for seizure Do not crush, open. Separate from calcium by at least 2 hours.10/23/24. Budesonide Suspension 0.5 MG/2ML 1 vial inhale orally via nebulizer two times a day for COPD-Start D 9/17/23. The surveyor observed the RN remove Docusate Sodium tablet 100mg from the bottle and place in a medication dose cup. The surveyor asked the RN to see the bottle for Docusate. The surveyor observed that the label reflected the tablet dose form. The surveyor showed the RN the label and asked if the this was the medication they wanted to give. The RN stated that the resident needed medication crushed and uses the tablets. The surveyor observed the RN remove an individually wrapped Budesonide Suspension vial from the bottom drawer of the medication cart and place on the top of the cart. The RN stated that she could not find the resident's other medications and they may be in another cart. The surveyor observed the RN move to a different med cart and leave the Budesonide on top of the first cart. The RN then proceeded to access Resident #15's meds from the 2nd cart. The surveyor observed the RN remove a vial of Budesonide from the 2nd cart. The surveyor asked the RN about the previous vial. The RN responded that the other vial must have been another resident's medication. The surveyor observed the RN remove the Phenytoin from the packaging and start to open the capsules for administration. The surveyor stopped the RN at that time and asked if that was appropriate for that medication and resident. The RN stated the resident has difficulty swallowing and gets the med in apple sauce. The surveyor asked the RN to read the medication order including any cautionary or administration notes. The RN did so and stated that it was OK to open the capsule as the resident needs it this way. The surveyor observed the RN administer due medications to the resident. The surveyor completed the medication pass observation. On 1/2/25 at 1:47 PM, the surveyor met with Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) to discuss the concerns with the medication pass observation. The surveyor asked the DON if the nursing staff should give resident's only medications that were ordered for them and the proper dosage form ordered. The DON stated, yes. The surveyor asked the DON if the staff should follow medication cautions or warnings. The DON stated, yes, and they should call the physician or pharmacy if there is a problem or question. On 1/3/24, the surveyor met with the DON and LNHA for any responses to the medication pass concern. The DON provided attendance sheets for education that was provided to the nursing staff after surveyor inquiry. The surveyor reviewed the facility policy titled Administering Medications with a revision date of April 2019. The policy reflected: 4. Medications are administered in accordance with prescriber orders . 8. If a dosage is believed to be inappropriate or excessive for a resident .contact the prescriber. 10. The individual administering the medication checks the label THREE (3) times to verify the .right dosage . 26. Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing services. The facility did not provide any further pertinent documentation. N.J.A.C 8:39-29.2 (d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication for 2 of 3 medication carts inspected according to facility's policy and standard of clinical practice. 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 1/2/25 at 10:57 AM, the surveyor began to inspect selected medication (med) storage areas in the facility. The surveyor observed the following: The surveyor in the presence of the Unit Manager/Licensed Practical Nurse (UM/LPN), the surveyor inspected the med cart identified as Cart 2 located on the 2nd floor. The surveyor observed one (1) foil package of budesonide inhalant suspension (a medication that is inhaled to reduce lung inflammation) that did not reflect a date when the foil was originally opened. The surveyor also observed one (1) foil package of albuterol/ipratropium inhalant solution (DuoNeb) (a medication used to treat lung or breathing disorders) that did not reflect a date when the foil was originally opened. The budesonide foil package label reflected once the foil envelope is opened, use the vials within 2 weeks. The DuoNeb foil package reflected once removed from the foil pouch, the individual vials should be used within one week. The surveyor verified with the UM/LPN that there was no date on either foil package. The surveyor asked the UM/LPN if either of those medications should have a date when opened. The UM/LPN stated, yes, they should be dated. The surveyor in the presence of the LPN/med nurse on duty (LPN), inspected the med cart identified as cart 1 located on the 2nd floor. The surveyor observed one (1) foil package of DuoNeb solution that did not reflect a date when the foil was originally opened. The surveyor asked the LPN if the vial should have a date when opened. The LPN stated, yes, there should be one written on it. On 1/2/25, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss the concerns with medication storage. On 1/3/25 the surveyor met with the LNHA and DON for responses related to concerns with medication storage. The DON provided sign in attendance sheets reflecting staff education that was done after surveyor inquiry. The facility did not provide any further pertinent information. The surveyor reviewed the manufacturer packaging information for DuoNeb and budesonide. The manufacturer label for DuoNeb reflected: Once removed from the foil pouch, the individual vials should be used within one week. The packaging information for budesonide, under storage and handling, reflected: When an envelope has been opened, the shelf life of the unused ampules is 2 weeks when protected. The surveyor reviewed the facility policy titled Medication Labeling and Storage with a revision date of February 2023. The policy did not reflect any pertinent information in relation to dating opened packaging of nebulizer solutions. NJAC 8:39-29.4(d)(g)

Complaint NJ00170288 Based on interview, medical record review, and review of other pertinent documentation it was determined that the facility failed to ensure that residents who receive hemodialysis (HD) receive such services consistent with professional standards of practice for 1 of 2 residents (Resident #191) reviewed for dialysis services. The deficient practice was evidenced by the following: On 1/2/25 the surveyor reviewed a Reportable Event Record/Report submitted by the facility Director of Nursing (DON) to the NJ Department of Health (DOH) on 11/29/23. The Report summarized an event which occurred on 11/26/23. Resident #191 returned from the HD clinic on the evening of 11/25/23. On 11/26/23 at 5:30 PM, the resident's family member observed the resident's dialysis access site (a permanent intravenous catheter inserted into a blood vessel in the upper chest) with 2 empty syringes connected to the catheter. The syringes were used during the HD treatment at the clinic to flush the intravenous catheter with normal saline solution after the treatment was completed. The syringes should have been removed immediately after use while the resident was in the dialysis clinic. A review of the medical record and other pertinent records revealed the following information. The Admission Record indicated the resident was admitted with diagnoses including but not limited to end stage renal disease, dependence on hemodialysis, anemia in chronic kidney disease, and acute appendicitis. The 11/24/23 Admission Minimum Data Set (MDS) assessment tool indicated the resident had moderate cognitive impairment (Brief Interview for Mental Status, Section C) and received hemodialysis while a resident in the facility (Section O). The November 2023 Order Summary Report (physician's orders) included the following HD-related orders. 11/18/23 assess dialysis site for signs and symptoms of infection/bleeding every shift for monitoring. 11/20/23 dialysis Tuesday/Thursday/Saturday pick-up time 3 pm. 11/17/23 permacath to right chest every shift for dialysis site. 11/24/23 assess right chest wall permacath dialysis site for signs and symptoms of infection/bleeding every shift for monitoring. The November 2023 Treatment Administration Record (TAR) indicated Resident #191's permacath was assessed by LPN #1 on the 11 pm to 7 am shift on 11/25/23 when the resident returned from HD. The dialysis communication report (a 3-part form which indicated the facility nurse's pre-treatment assessment, the HD clinic nurse's assessment during treatment, and the facility nurse's post-treatment assessment) accompanies the resident to the HD clinic and back with the resident to the facility. An un-named nurse documented on the 11/25/23 post-treatment section of the communication report R chest permacath - patient refuse for site to be checked. Electronic nurse progress notes on 11/25/23 did not contain an entry indicating a pre- or post-HD treatment assessment was performed. LPN #1 documented in a 12/1/23 Individual Statement Form (part of the facility's investigation of the incident) when the resident returned from dialysis at 11:30 pm there were no visible signs of bleeding (permacath) through nightclothes noted. An 11/26/23 late entry nursing progress note indicated Resident #191's family member alerted the Certified Nursing Assistant (CNA) the resident had 2 empty syringes left connected to the resident's permacath from HD the previous day. The CNA alerted the nurse, who confirmed their presence. The nurse removed the syringes and assessed the permacath. The nurse documented the site was intact with no bleeding. An 11/27/23 Care Conference Note reflected a family meeting was held with the interdisciplinary team. The note read, family requested despite if patient refuses assistance with ADLs [activities of daily living], family to be contacted to assist as needed. Family expressed concern for patient to be frequently checked on. On 1/2/25 at 10:13 AM the surveyor interviewed the DON who stated the nurse should evaluate and assess the resident's vital signs and monitor the access site and the resident's mental acuity when the resident returns from HD. The DON stated, ideally I would have them document the assessment in [the electronic record] and secondarily on the post dialysis sheet when they return. Additionally, the DON stated nursing documents each shift in the TAR the assessment of the dialysis site. However, she did confirm this is not specifically related to the timeframe of when the resident returns from an HD treatment. On 1/2/25 at 12:28 PM the surveyor conducted a telephone interview with LPN #1, the nurse who received the resident back from HD on the 11 pm to 7 am shift on 11/25/23 at 11:30 pm. LPN #1 stated the resident had on a sweater and LPN #1 only looked at the top of the permacath. She stated there was no bleeding at the top of the permacath. She stated she did not see the syringes attached to the catheter. LPN #1 stated the dialysis communication report often did not come back to her when the resident returned to the facility on the night shift. She stated she would document the post-treatment assessment in electronic nurse progress notes if she did not have the dialysis communication report. She did not explain why there was no electronic progress note for the 11/25/23 post-treatment assessment. On 1/6/25 the surveyor discussed with the Licensed Nursing Home Administrator (LNHA) and the DON the presence of 2 syringes attached to the HD access site for 18 hours without nursing intervention and the discrepancies in LPN #1's interview with the facility, the surveyor, and the documentation on the HD communication sheet. The LNHA provided the surveyor with the following dialysis-related facility policies. Hemodialysis Catheters - Access and Care of, revised February 2023, section titled Documentation instructed nurses to document in the medical record if dialysis was done during the shift, any part of report from dialysis nurse post-dialysis being given, and observations post-dialysis. Hemodialysis Pre and Post Care, revised March 2010, section titled General Information instructed nurses to assessment treatment site regularly including pre and post hemodialysis treatment. The section titled Post-Dialysis Care instructed nurses to access the dialysis access site upon return to the facility for patency, any unusual redness or swelling or bleeding. NJAC 8:39-27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 18 residents (Resident #67 and #70), reviewed for MDS coding accuracy. On 1/10/25 at 10:20 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #67. The Admission Record (a summary of important information about the resident) revealed that Resident #67 was male. An entry record for the MDS assessment dated [DATE] revealed under Section A (Identification Information), A0800-Gender, the resident was coded as female. A comprehensive MDS assessment dated [DATE] revealed under section A (Identification Information), A0800-Gender, the resident was coded as female. The surveyor reviewed the EMR of Resident #70. The Admission Record revealed that Resident #70 was female. An entry record for the MDS assessment dated [DATE] revealed under Section A, A0800-Gender, the resident was coded as male. A comprehensive MDS assessment dated [DATE] revealed under section A, A0800-Gender, the resident was coded as male. On 1/3/25 at 10:29 AM, the surveyor interviewed the Registered Nurse (RN) MDS coordinator regarding MDS assessment submission. The MDS coordinator stated the guidance of the MDS 3.0 Manual [Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual] was followed. She stated MDS coordinator responsibilities included completing and ensuring the accuracy of MDS assessments. The surveyor reviewed with the MDS coordinator the MDS assessments of Residents #67 and #70. The MDS coordinator acknowledged the inaccuracies of the coding of the residents' genders on the MDS assessments. The MDS coordinator stated she would review and submit a corrected MDS assessment for the residents. On 1/3/25 at 1:09 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about the concerns with the MDS accuracy of Resident #67 and #70. A review of the latest version of the MDS 3.0 Manual (updated October 2023), Chapter 3-page A-14, under A0800 revealed .Resident gender on the MDS must match what is in the Social Security system . NJAC 8:39-33.2 (d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to change respiratory nasal cannula (NC) tubing according to infection control standards of practice and failed to ensure that it was stored in accordance with infection control measures for one of one resident reviewed for Respiratory therapy, Resident #24. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 12/30/24 at 11:50 AM, the surveyor observed Resident #24 with Oxygen (O2) delivered via a nasal cannula (NC) tubing attached to the O2 concentrator at 2 liters per minute (LPM). The surveyor observed that the NC tubing was dated 12/18/24. On 1/3/25 at 10:48 AM, the surveyor entered Resident #24's room and observed that the resident was not in the room. The surveyor observed that the NC tubing was on the floor and not contained in a bag. The surveyor reviewed the medical record for Resident #24. A review of Resident #24's Admission Record indicated that the resident was admitted to the facility with diagnoses that included but were not limited to congestive heart failure, schizophrenia, and major depressive disorder. A review of Resident #24's Admission Minimum Data Set (MDS), an assessment tool, dated 12/10/24 included; a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated the resident's cognition was intact. Section O documented that the resident was receiving respiratory treatment which included O2 therapy. A review of the Care Plan documented a focus area effective 12/9/24 which included the resident was at risk for Respiratory Impairment related to shortness of breath (SOB). Interventions included but were not limited to: Administer Oxygen therapy as per physician order. A review of the January 2025 Order Summary Report revealed an active physician order (PO) with an order date of 12/9/24 for: O2 at 2LPM (liters per minute) per NC every shift for SOB and a PO: change all disposable oxygen supplies every Tuesday on night shift and as needed, label and date all supplies. On 1/3/25 at 10:50 AM, the surveyor interviewed the Assistant Director of Nursing (ADON). The surveyor showed the ADON the NC tubing; the ADON acknowledged that the NC tubing should not be on the floor but stored in a plastic bag for Infection Control Prevention. The surveyor informed the ADON that she observed that the NC tubing was dated 12/18/24 when observed by the surveyor on 12/30/24. The ADON acknowledged that the NC tubing should have been changed and dated on 12/24/24 as it was the facility policy to change it every Tuesday on the night shift. On 1/3/25 at 11:05 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) assigned to Resident #24's care. The CNA confirmed that she should have stored the NC tubing in a plastic bag for infection control prevention. On 1/3/25 at 1:10 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The DON stated the facility policy was that the NC tubing should be changed every 7 days and stored in a bag when not in use. A review of the facility provided, Oxygen Administration policy and procedure dated/revised 10/2010, included the following: The purpose of this procedure is to provide guidelines for safe oxygen administration. N.J.A.C. 8:39- 19.4(a); 27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to maintain the dignity of an unsampled residents. This deficient practice was found with 4 of 4 Certified Nursing Aides (CNA) observed during a dining observation on the third floor. The deficient practice was evidenced by the following: On 12/31/24 at 12:08 PM, during a lunch meal dining observation on the 2nd floor in the main dining room, the surveyor observed the lunch trays being distributed to the residents by four CNA's. The four CNA's passed out the trays to each resident and left the trays on the table underneath each of the resident's plates. There were three insulated lids left in the middle of the tables and the CNA's were observed placing wrappers and garbage inside those lids. The lids remained on the tables throughout the entire meal. At 12:18 PM, the surveyor observed CNA # 1 standing while feeding an unsampled resident. At 12:23 PM, the surveyor interviewed the CNA # 1, who stated she should have been seated while feeding the resident. On 12/31/24 at 1:00PM, the above concerns were discussed with the Director of Nursing (DON) and Administrator, who stated they will investigate this concern. On 1/02/25 at 10:17 AM, the DON and Administrator stated that there should have been dignity provided during the resident's lunch meal and that they educated the CNA's regarding these concerns. No further information was provided. NJAC 8:39-4.1(a)12

Based on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to ensure accurate documentation and review of a resident's advance directives for 1 of 2 residents (Resident #21) reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the paper chart and electronic medical records of Resident #21. The Admission Record (a summary of important information about the resident) documented Resident #21 had diagnoses that included but were not limited to, Alzheimer's disease, heart failure, and atrial fibrillation (an irregular, often rapid heart rate). A comprehensive Minimum Data Set (MDS) assessment, a tool to facilitate the management of care, dated 10/28/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #21 scored a 3 out of 15, which indicated the resident had severe cognitive impairment. The resident's paper chart included a New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, dated 12/13/24, which revealed the resident had advance directives that they desired DNR, DNI, Do Not Hospitalize [DNH]. The form was signed by the resident's representative and an advance practice provider. A physician's order dated 12/12/2024 documented, DNI (Do Not Intubate). A physician's order dated 12/12/2024 documented, DNR (Do Not Resuscitate). A review of care plans revealed there was no care plan related to advance directives. On 12/31/24 at 10:07 AM, the surveyor interviewed a licensed practical nurse unit manager (LPN/UM) about advance directives. The LPN/UM stated upon admission were assessed for advance directives and as needed advance directives could be updated. He stated social services also followed up on advance directives. The LPN/UM further explained when a POLST was completed, the form would be placed in the paper chart and scanned into the EMR. The LPN/UM stated the resident's code status would be documented under the physician's orders and on the resident's dashboard (top of the screen) of the EMR. The surveyor reviewed with the LPN/UM Resident #21's POLST in the paper chart. The LPN/UM reviewed the EMR with the surveyor. The LPN/UM confirmed the physician's orders and the code status in the EMR did not include DNH. The LPN/UM could not speak to the follow up of Resident #21's POLST and stated nursing staff present when the POLST was completed should have ensured the EMR was updated. On 1/2/25 at 11:19 AM, the surveyor interviewed the Assistant Director of Social Services (ADSS) about advance directives and POLST completion. The ADSS stated social services would assess residents to determine if the resident had advance directives and if they wished to have advance directives. The ADSS stated a completed POLST would be followed up by the unit manager and nursing who would be responsible for ensuring the wishes made on the POLST were carried out. On 1/2/25 at 1:40 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about the above concerns for Resident #21's advance directives. The DON stated that once a POLST was completed it should be completed as soon as possible. The facility was to review and provide further information. On 1/3/25 at 10:19 AM, the DON and LNHA met with the survey team. The DON confirmed the EMR was updated to reflect the POLST and code status for DNH. The DON stated in-service education was provided to staff. She further explained it was a team effort, social services were to help keep team on track with following up on advance directives, and ultimately nursing was responsible to ensure they were carried out. A review of the facility provided policy titled, Advance Directives with a revised date of September 2022 revealed under Policy Interpretation and Implementation: Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff. The residents' wishes are communicated to the residents' direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the residents' wishes in care planning meetings. N.J.A.C. 8:39-9.6

Complaint #: NJ00179638 Based on interviews, record review and review of pertinent facility documents on 11/18/2024 and 11/19/2024, it was determined that the facility failed to ensure the safety of a resident (Resident #1) when: (a) the Resident took his/her p.o. [by mouth] medication with a clear liquid which was given by Registered Nurse (RN) #1. Resident #1 drank the liquid and reported a burning sensation when swallowing and notified RN #1. It was revealed the clear liquid was a Dakin's solution [a wound cleanser solution] half-strength (Sodium Hypochlorite 0.25%); (b) RN #1 did not follow facility's proper procedure in preparing liquid solutions for wound care, and (c) RN #1 did not follow facility's procedure in accordance to professional standards of nursing practice in administration of medication in a safe and timely manner. Resident #1 did not require hospitalization after this incident. The deficient practice was evidenced by the following: According to the FRE (facility reported event), submitted to the New Jersey Department of Health (NJ DOH) on 10/29/2024 by the facility, under the Type of Incident: Other, Specify: accidental ingestion of substance and Narrative: [Name of Resident #1] .admitted on .with Dx: Aftercare following joint replacement surgery, acute and subacute endocarditis, rt [right] femur FX [fracture], ex iv [intravenous] drug use and a BIMS [Brief Interview of Mental Status] of 15. At 2:50 pm [afternoon] on 10/28/24, [initials of Resident #1] took P.O. [by mouth] medications with approximately 30-60 mls ( millimeters) of clear liquid. [Initials of Resident #1] reportedly swallowed the liquid and reported a burning sensation when swallowing. He/she notified the nurse, [ initials of RN #1] and threw the cup with the remaining liquid in the garbage. Investigation revealed the clear liquid was Dakin's solution 1/2 strength (Sodium Hypochlorite 0.25%). NP [nurse practitioner in house], primary care physician and poison control immediately notified . The FRE further indicated under the Narrative .3) .After a thorough investigation it has been determined the Dakins solution 1/2 strength (approx. 30-60 mls) was poured in the 7oz cup by [initials of RN #1 at the treatment cart. [Initials of Resident #1] interrupted the nurse and asked for the pain medication. [RN #1] carried the cup and the wound care supplies over to the medication cart to review the MAR [medication administration record] and placed the cup on top of the cart. The cup was inadvertently handed to [Resident #1] instead of water when [RN #1] administered [Resident #1]'s medication. On 11/18/2024, a review of the Resident's Admission Record (AR), Resident #1 was admitted to the facility with the following diagnoses that included but not limited to: Fracture of Unspecified Part of Neck of Right Femur, Hypertensive Heart Disease without Heart Failure, Bacteremia, and Repeated Falls. A review of Resident #1's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities, dated 11/03/2024, indicated Resident #1's Cognitive Skills for Daily Decision Making was independent. The MDS further revealed in Section GG-Functional Abilities, Resident #1 required supervision or touching assistance in his/her completion of Activities of Daily Living (ADLs). A review of Resident #1's Progress Notes (PN) dated 11/03/2024 and documented electronically by Licensed Practical Nurse (LPN) #1, pt educated by primary nurse and this undersign regarding risk of going out on pass without assistance .pt agitated and requested to go AMA [against medical advice] .pt gathered belongings and took personal rolling walker outside facility .pt aware he cannot return upon AMA. On 11/18/2024, the Surveyor was notified by the Director of Nursing (DON) and License Nursing Home Administrator (LNHA) that RN #1 no longer worked in the facility and was terminated effective 11/08/2024. The DON further stated RN #1 stopped communicating with them and never answered their phone calls after the incident. On 11/18/2024, the Surveyor made call to RN#1 and call was not returned. On 11/18/2024 at 10:30 a.m. [morning], the Surveyor in the presence of RN #2 Unit Manager (UM), made a tour of nursing unit [3rd floor Sub Acute]. RN #2 UM stated there were three medications carts and one treatment cart. The Surveyor checked the treatment cart in the presence of the RN #2 UM and observed treatment and wound supplies in the cart and no residents' medications identified. The surveyor didn't observe any residents on the floor wandering near the carts. The Surveyor furthermore checked the medication carts and observed the following findings: At 10:46 a.m., [Med Cart B] - no treatment and wound supplies identified in the cart. At 10:50 a.m., [Med Cart C] - no treatment and wound supplies identified in the cart. At 10:52 a.m., [Med Cart A] - no treatment and wound supplies identified in the cart. On 11/18/2024 at 1:18 p.m. [afternoon], the Surveyor observed LPN #2, the regular nurse with medication cart [Med Cart C], performed wound care to a non-sampled resident [SR]. In an interview with the Surveyor on 11/18/2024 at 1:44 p.m. [afternoon], RN #2 Unit Manager (UM) stated medication cart is only for medications, treatment cart used for doing treatments, there should not be any treatment supplies on top of medication cart and take the treatment cart when doing the wound care. In an interview with the Surveyor on 11/18/2024 at 3:36 p.m. [afternoon], the DON in the presence of the Licensed Nursing Home Administrator (LNHA), stated, when asked regarding wound care specifically with use of liquid wound solution such as Dakin's, not normal to pour solution in drinking cup, RN did not follow proper procedure in wound care. RN made a mistake in giving the cup with Dakin's. I tried to reach out to RN to get more information after her initial statement but she never picked up or returned our calls. In an interview with the Surveyor on 11/19/2024 at 6:54 a.m., Resident #1's attending physician (AP), stated he was made aware right away of the Resident's incident and gave orders immediately. He further stated he gave orders based on the poison control recommendations and I went to see and checked [Resident's name] right away. A review of facility's policy on Wound Care, its Purpose .is to provide guidelines for the care of wounds .; under Preparation: .3. Assemble the equipment and supplies as needed . (Note: This may be performed at the treatment cart.); under Steps in the Procedure: 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field .8. Pour liquid solutions directly on gauze sponges on their papers; 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound . A review of facility's policy on Administering Medications, its Policy Statement: Medications are administered in a safe and timely manner, and as .; under Policy Interpretation and Implementation: .19. During administration of medications, the medication cart is kept closed .No medications are kept on top of the cart . N.J.A.C. 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to prevent a fall from the bed by following the resident's plan of care during bed mobility which resulted in leg fractures and hospitalization . This deficient practice was identified for 1 of 4 residents reviewed for accidents (Resident #11). The evidence was as follows: On 7/20/22 at 12:24 PM, the surveyor observed Resident #11 sitting up in a bariatric bed (a bed designed to accommodate a higher weight capacity than standard beds) wearing a hospital gown. The resident who appeared morbidly obese stated to the surveyor that he/she had a fall in the facility a few months ago when the Certified Nursing Aide (CNA #1) attempted to change his/her incontinence brief independently. The resident stated he/she had told CNA #1 she could not do it on her own and needed another CNA to assist her, but CNA #1 continued to independently perform bed mobility anyway, and it caused him/her to fall out of the bed. The resident stated he/she spent weeks in the hospital and had injured both their right and left leg, resulting also in pain. The surveyor reviewed the medical record for Resident #11. A review of the Admission Record face sheet (an admission summary) reflected the resident was readmitted to the facility in January 2022 with diagnoses that included a history of falls, multiple sclerosis (a chronic disease where the immune system attacks nerve fibers in the brain and spinal cord causing inflammation which then alters the electrical messages to the brain), morbid obesity, unspecified fracture (break) of lower end left femur (thigh bone), and fracture of right tibial tuberosity (shin bone). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/21/21 reflected that the resident had a brief interview for mental status score of 10 out of 15, which indicated that the resident had a moderately impaired cognition. It further reflected that the resident had exhibited no behaviors in the last seven days of the assessment. Section G used to assess the resident's functional status for activities of daily living (ADL), included that the resident required extensive assistance with a two-person physical assist for toileting and bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). It further included that the resident had a functional range of motion limitation to one upper extremity and functional range of motion limitations to the bilateral lower extremities. A review of the individualized comprehensive care plan reflected a focused area that Resident #11 had a risk for falls that was initiated on 1/24/18. Interventions included to provide assistance, and to transfer as needed. The care plan was updated on 1/25/19 after a noted actual fall, and the care plan specified to include a two-person assist at all times with ADL's and bed mobility. The surveyor reviewed the progress notes for Resident #11 and identified that the resident had an actual fall from the bed on 1/14/22. A review of the Progress Notes reflected a Nurses Note dated 1/14/22 at 1:40 PM. The note indicated, Notified by staff, resident sustained fall inside bedroom. CNA was present in the room and witnessed fall. CNA states that fall occurred while she was performing a diaper change. Resident found kneeling on the floor while hanging on to the bed railing. [Resident #11] then was lowered to the ground by staff and kept comfortable. Upon assessment, resident states [he/she] was in pain but did not identify exact location of pain. Noted laceration to left lower abdomen, first aid administered. Resident has difficulty raising [his/her] lower extremities. Patient kept comfortable on the floor with pillow under [his/her] head until Emergency Medical Technician [EMT] arrived. Medical Doctor [MD] made aware, and family notified. Order received to send to emergency room [ER] for evaluation. The surveyor requested the incident/accident investigative report for Resident #11's fall that occurred on 1/14/22. A review of the Incident Report dated 1/14/22, included the CNA #1 staff statement As per CNA. While changing the resident, I turned [him/her] to [his/her] side and [his/her] legs began to slide out of bed. I eased [him/her] out of bed and went to get help. A review of the most recent annual MDS dated [DATE], reflected a brief interview for mental status (BIMS) score of 10 out of 15, which indicated a moderately impaired cognition. On 7/26/22 at 10:08 AM, the surveyor requested the corresponding hospital records for Resident #11. A review of the hospital records revealed Resident #11 was hospitalized from 1/14/22 until 1/28/22. The report further revealed Resident #11 was seen by the orthopedic surgeon on 1/16/22 whose impression was resident sustained .a right, non-displaced tibial plateau fracture and a left, minimally displaced distal femur fracture after a fall out of bed . On 7/26/22 at 11:11 AM, the surveyor conducted a telephone interview with the Registered Nurse/Unit Manager (RN/UM) who worked on 1/14/22. The RN/UM stated he remembered CNA #1 had called him into the room and told him Resident #11 had sustained a fall out of bed. The RN/UM stated he went into the room and assisted Resident #11 to the ground, and assessed the resident and he/she had no apparent injuries at the time except a skin tear on his/her thigh, and no sign of hip fracture or hip displacement. The RN/UM also stated Resident #11 did complain of localized pain around the skin tear but complained of generalized pain, so the resident remained on the floor until Emergency Medical Services (EMS) could transfer them to the hospital for further assessment and treatment. The RN/UM stated he believed CNA #1 was in the room alone at the time of the fall, and that CNA #1 should have called someone into the room to assist her in moving the resident during care especially with a resident that big in size. He added that you would need an extra hand to ensure the resident's safety. The RN/UM stated he did not believe the resident had a history of falls, but knew resident required a mechanical lift to get them out of bed. When the surveyor asked the RN/UM if there were any circumstances when one staff would be sufficient when a resident was assessed to require a two-person extensive assistance, and the RN/UM responded, No. He continued that staff must get someone to come help them with that resident's care. He added that in general, if they were a two-person assist, we instructed staff to get someone to ensure nothing happens to the resident or staff member such as falls or injury. The RN/UM stated prior to this incident, he had never had any concerns with CNA #1's transfers but he spoke to CNA #1 about having a second staff member when there is a two-person assistance required. On 7/26/22 at 12:13 PM, the surveyor observed Resident #11 in bed on an air mattress with their head elevated. There was lunch on the resident's bedside table. The resident informed the surveyor he/she was afraid now of another fall from the bed. The resident added that since the fall, their left leg was so sore. On 7/26/22 at 12:52 PM, the surveyor interviewed the Director of Rehabilitation Services (DRS) who stated since Resident #11 could not get out of bed or perform bed mobility (rolling side to side), the resident required an extensive, two-person physical assist. One staff member would perform the care while the other staff member maintained the resident's position, for safety. The DRS stated Resident #11 was not on therapy services before the hospitalization , but once they returned from the hospital, Resident #11 was placed on both Physical Therapy (PT) and Occupational Therapy (OT) from 1/29/22- 2/24/22. The DRS stated that per the hospital records, Resident #11 had a fall which resulted in a minimal displacement (slight shift in position) of the left distal femur (the area of the leg just above the knee joint) and a non-displaced (bone did not shift) right proximal tibia fracture (a break in the shinbone just below the knee). The RDS stated there were no circumstances when a two-person assist should be performed alone, as it could cause injury to staff as well as the resident. On 7/27/22 at 10:33 AM, the surveyor interviewed CNA #1 who was assigned to Resident #11 on 1/14/22. The CNA #1 stated she has worked at the facility for about a year and three months. She stated that she starts her shift in the morning with gathering her supplies and checking on her residents based on the assignment she was given that day. She stated that there are many ways in which she can find out what kind of care or level of assistance a resident needs, such as asking the resident directly, reviewing the Kardex or care plan for the resident, look on the resident's chart, or ask the nurse. CNA #1 stated that she was familiar with Resident #11 and that the resident required extensive assistance because he/she had a weak right arm. The CNA #1 stated that at the time she cared for the resident, she had only been working at the facility for about six months and didn't know about a Kardex (CNA care plan) system as she was still trying to learn things. The CNA #1 stated that she believed that the resident required one person to assist. The surveyor inquired about the fall incident that occurred on 1/14/22. The CNA #1 stated after washing the front of the resident, she needed to turn the resident to their side to perform washing to the back, so she independently pulled the sheet that was under Resident #11 and crossed their legs. CNA #1 stated she had one hand on the resident holding them and the other hand she held a washcloth, when Resident #11's left leg had begun to slip off the bed, she immediately grabbed the bed controller and lowered the bed to the floor, because she said she knew she could not independently hold the resident's weight. Once the bed was lowered, she tried to ease the resident down to the floor and onto their knees and she called out to the Housekeeper who called the RN/UM. She stated that the resident was not complaining of pain, but was more so in shock and panic from falling out of the bed and was more so scared than in pain. The CNA #1 told the surveyor that she had the resident on her assignment once more when the resident returned to the facility, and another male CNA assisted her that day. The surveyor asked CNA #1 how many residents were on her assignment that day and CNA #1 stated she believed 11 or 12, but usually it was 13 residents. CNA #1 stated she was sure there were only four CNA's that day because if there had been five CNA's, she would not have had Resident #11's room on her assignment. On 7/27/22 at 12:15 PM, the surveyor reviewed the Daily Assignment Sheet provided by the Assistant Director of Nursing (ADON) which revealed on 1/14/22 during the 7:00 AM to 3:00 PM day shift, they had four CNA's assigned to work on the third floor. At that same time, the surveyor reviewed the facility provided census for the third floor on 1/14/22 which revealed there were a total of 54 residents residing on the third floor that day, making the ratio one CNA to every 13 residents. On 7/27/22 at 12:20 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON acknowledged that according to the fall investigation CNA #1 independently turned Resident #11 during care, but according to the resident's care plan and quarterly MDS dated [DATE] prior to the fall, the resident required a two-person physical assist for bed mobility and toileting. Together the surveyor and the DON reviewed the facility provided Incident Report for Resident #11's fall investigation's conclusion which revealed In conclusion resident sustained a witnessed fall when CNA #1 turned [him/her] and [he/she] was lowered to the floor. The DON acknowledged there was no mention of cause regarding the one-person assist when two-person assistance was required. The DON further acknowledged there was no documented re-education provided to CNA #1 directly after the fall incident and no competencies were immediately performed. The DON stated it was important that CNA #1 should have been re-educated regarding safe care for Resident #11 regarding bed mobility to prevent future accidents. The DON was able to provide the surveyor a copy of the CNA Kardex at the time of the the fall that occurred on 1/14/22. The Kardex revealed that the resident required one person for bathing. (This did not correspond with the care plan that was updated on 1/25/19 that indicated the resident required a two person assistance for ADL care and bed mobility). The DON stated that the resident was one person for bathing, but confirmed if the resident was going to be turned during the bathing process, it would require two people to turn the resident. At that time also, the surveyor and the DON reviewed the facility provided census for 1/14/22 as well as the Daily Assignment Sheet for the CNA's for 1/14/22. The DON acknowledged there were four CNA's assigned to the 7:00 AM to 3:00 PM day shift for the third floor and that the resident census for that day was 54, a ratio of one CNA to every 13 residents. The DON acknowledged that the resident had leg fractures and an unplanned hospitalization . There were no other incidents regarding the CNA #1 or Resident #11. A review of the facility's Bath, Bed policy revised 2018, included under General Guidelines 1. Review the care plan to determine any special needs of the resident .a. Instruct the resident to turn on his/her side with his/her back toward you. (Note: Be sure the side rail is up on the opposite side of the bed to prevent the resident from rolling out of bed.) b. If the resident cannot turn by himself or herself, assist as needed . A review of the facility's Identifying Neglect policy dated 2/10/22, included preventing resident neglect is a priority throughout all levels of this organization .neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress; any situation in which the resident's care needs are known (or should be known) by staff (based on assessment and care planning), and those needs are not met due to other circumstances, can be defined as neglect; circumstances that lead to neglect: .lack of sufficient staffing .poor staff oversight and/or performance evaluations NJAC 8:39-27.1 (a)

COMPLAINT # NJ 579 Part A: Based on observation, interview, and record review, it was determined that the facility failed to clarify a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident became symptomatic and was hospitalized due to critical elevated potassium laboratory values which were directly related to receiving the incorrect medication administration. This deficient practice resulted in a Past Non-Compliance Immediate Jeopardy (IJ) situation for 1 of 29 residents reviewed (Resident #33) for accuracy of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], Resident #33's physician hand wrote a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Licensed Practical Nurse (LPN), LPN#1 then transcribed this physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a pharmacy E-RX New Prescription sheet, a pharmacy staff worker sent an electronic message to this LPN (LPN#1) on [DATE] at 8:22:17 a.m., PLS [please] CLARIFY 20MEQ [milliequivalent] ? Per the same pharmacy, the E-RX New Prescription sheet dated [DATE] at 10:21:37 a.m., reflected AS PER NURSE PLEASE SEND 20MEQ (15ML) and a subsequent entry dated [DATE] at 10:23:06 a.m., indicated S/W [name redacted] SHE WILL UPDATE THE ORDER. This resulted in the resident receiving a total of 66 doses of Potassium Chloride for 17 days until [DATE]. There were five different nurses Licensed Practical Nurse (LPN)#1, LPN#3, LPN #4 and Registered Nurses (RN)#1, and RN#2 who had administered the incorrect medication Potassium Chloride to Resident #33 from [DATE] until [DATE], when Resident #33 exhibited increased confusion and was identified with symptoms of [CONDITION(S)] (increased Potassium level). There was a multi-system failure when the five nurses continuously administered the wrong medication (Potassium Chloride), in the absence of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], the Pharmacy Consultant requested clarification of the dosage and the dosage formulation for Potassium. The Unit Manager then discovered the transcription error late that evening. The following actions were immediately taken: 1. The Physician was notified and Potassium immediately discontinued. 2. The family was notified on [DATE] at 7:26 p.m. 3. Stat [immediate] Electrocardiogram (EKG) and Comprehensive Metabolic Panel (CMP) Lab [laboratory] values were ordered. Resident #33 was found to have a Potassium level of 7.1 (critical level) and was sent to the emergency room at 12:50 a.m., on [DATE]. The Administrator was notified of the Past Non-Compliance Immediate Jeopardy on [DATE] at 1:50 p.m. The survey team received the Immediate Jeopardy Removal Plan from the facility Administrator on [DATE] at 3:45 p.m. A facility plan of correction had been implemented on [DATE] after the facility became aware of the medication error. The facility completed their plan of correction on [DATE]. The survey team verified the plan's implementation during the standard survey period. The 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 state: 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 regimen 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 state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On [DATE] at 9:45 a.m., the surveyor observed Resident #33 seated in a wheelchair at the bedside. The resident was confused and slow to respond to the surveyor's questions. The resident's demeanor was pleasant. A review of the Admission Record revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] quarterly Minimum Data Set (MDS), an assessment tool, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderate cognitive impairment. A review of the Interdisciplinary Progress Notes dated [DATE] at 22:09 [10:09 p.m.], revealed that Resident #33 was received in wheelchair alert confusion noted at times and was offered a shower (that day) but stated, I'm tired, not today. Further review, reflected that on [DATE] at 19:26 [7:26 p.m], the Unit Manager Registered Nurse (UM/RN) documented Medication review was done by Pharmacy consultant and an order needed clarification by [primary physician]. Patient was receiving Potassium po qid [by mouth four times a day]. MD [medical doctor] order discontinue medication with stat lab and EKG. On [DATE] at 22:13 [10:13 p.m.] LPN #1 documented, Hourly checks in place. New orders received for STAT EKG and CMP [comprehensive metabolic panel including level of potassium]. LPN #2 documented on [DATE] at 01:19 [1:19 a.m.], MD notified of abnormal lab results. A new order to transfer Pt [patient] out to [hospital] made by MD. LPN #2 documented on [DATE] at 18:50 [6:50 p.m.], a follow up call was made to the hospital to check on the resident's status. LPN #2 documented, Pt. is admitted for [CONDITION(S)] (an increased serum potassium level). A review of the New Jersey Universal Transfer Form dated [DATE] and timed at 12:55 a.m., revealed the resident was transferred from the facility to the hospital due to [CONDITION(S)]. A review of emergency room Hospital records dated [DATE] at 1:42 a.m., revealed Resident #33 had a potassium level of 6.7 (normal 3.,d+[DATE].2) and documented the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the electronic medication order revealed LPN #1 transcribed the order directly into the facility's electronic system which was integrated with the provider pharmacy's electronic system. LPN #1 entered an incorrect order for Potassium Tablet 15 ml by mouth four times a day for low potassium. A review of the provider pharmacy Long-Term Care Pharmacy Shipping Manifest dated [DATE], revealed that 473 mls of Potassium Chloride 10% (20 milliequivalent/15 ml) was delivered to the facility. A review of the ,d+[DATE] and ,d+[DATE] electronic Medication Administration Records (e-MAR) revealed the incorrect order for Potassium tablet (Potassium) give 15 ml by mouth four times a day for low Potassium-Start Date- [DATE] 0900. The resident received a total of 66 doses of Potassium Chloride for 17 days from [DATE] through [DATE] (17 days, 66 doses). The surveyor reviewed laboratory (lab) reports on [DATE] which were located in the resident's paper medical record. A review of lab result reports revealed the resident's potassium level was 5.2 millimoles/Liter (mmol/L) on [DATE], 2 days after initial dose of potassium. The reference or normal range was 3.,d+[DATE].1 mmol/L. The [DATE] lab report was flagged by the lab as H [high]. On [DATE], the potassium level was 7.1 mmol/L and flagged as HH [critical]. On [DATE], the potassium level was 5.5 mmol/L and flagged as H. On [DATE], the potassium level was 4.4 mmol/L. This was noted to be in the normal range. The potassium level prior to the [DATE], initiation of potassium supplementation, was in the normal range of 4.5 mmol/L on [DATE]. Each of the lab reports failed to contain a notation by the nurse indicating that the nurse reviewed the lab values and alerted the physician of values outside of the normal range. On [DATE], the DON provided the surveyor with the facility Clinical Protocol for Lab and Diagnostic Test Results, revised ,d+[DATE] and unsigned. The protocol indicated if a lab value has high or toxic serum levels, the nurse would notify the physician promptly and would not give the next dose until the situation has been reviewed by the physician. There was no evidence provided that the protocol was followed when labs were received with high or critically high potassium levels on [DATE], [DATE], and [DATE]. On [DATE] at 12:17 p.m., the Senior DON provided the surveyor with a statement which she had typed. The statement indicated she had spoken with the physician regarding Resident #33's [DATE] high potassium level report. The physician stated he had initialed the report and indicated no new recommendations were made. The surveyor again reviewed the lab reports in the paper medical record on [DATE]. The reports which were identified as unsigned by the resident's physician during the surveyor's review on [DATE], were signed (but not dated) by the physician during the surveyor's review on [DATE]. A review of a Radiology Results Report of a 12-lead electrocardiogram, with an examination date of [DATE] at 00:41 [12:41 a.m.], revealed normal sinus rhythm, first degree A-V block, right bundle branch block, left anterior fascicular block, clinical correlation is advised. There was no nurse documentation on the report to indicate it was reviewed and reported to the physician. The surveyor interviewed the UM/RN on [DATE] at 11:23 a.m. The UM/RN stated she discovered the [DATE] incorrect transcription of Robitussin on [DATE]. The UM/RN stated the physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM/RN stated she immediately called the physician. The physician discontinued the order for potassium, an electrocardiogram and blood work were ordered immediately. The surveyor interviewed an account manager for the provider pharmacy on [DATE] at 12:00 p.m. via telephone. The account manager stated a pharmacy data entry clerk called the facility on [DATE] at 10:23 a.m. to clarify the order for Potassium 15 ml four times daily. At that time, a facility nurse [unidentified] clarified the order as Potassium 20 milliequivalents (Meq) four times daily for low potassium. The accompanying handwritten Incident/Accident Report was dated [DATE] a.m. No actual time was documented; a.m. was checked off. The investigation summary indicated the order for potassium was discontinued immediately after the error was discovered. The Incident/Accident Report was alleged to have been written on the morning of [DATE]. The electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .m]. The resident received the first 3 doses of potassium on [DATE] at 9:00 a.m., 1:00 p.m., and 5:00 p.m. The order was discontinued before the final dose scheduled for 9:00 p.m. The investigation indicated the nurse transcribed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The investigation did not include interviews with LPN #1 who incorrectly transcribed the order, the nurse assigned to perform the [DATE] 24-hour chart review for clarification of the day's physician orders, and/or the 5 nurses who documented administration of the order 4 times a day for 17 days. The surveyor interviewed the DON on [DATE] at 10:00 a.m., inquiring about the omission of nurse interviews during the investigation. The DON stated she interviewed LPN #1 at the time of the investigation on [DATE]. The DON stated she did not document the interview. The DON later presented a typewritten interview of LPN #1 to the surveyor. The DON stated she typed the statement on [DATE]. On [DATE] at 11:50 a.m., the DON provided the surveyor with an undated Testament of Statement signed by the DON. The statement contained a narrative of the interviews conducted with each of the 5 nurses who administered the incorrect medication and the nurse who was assigned to perform the 24 hour chart check. The narrative indicated the nurses were educated individually by the DON on [DATE]. The aforementioned statement reflected that the DON and RN/UM met with LPN #1 regarding the medication transcription error. Proper protocols on medication transcription were reviewed with LPN #1. Standard dosing for potassium was also reviewed with LPN #1. The statement did not include an interview with and/or explanation from LPN #1 on the sequence of events involved in the transcription error. The surveyor interviewed LPN #1 on [DATE] at 3:01 p.m. LPN #1 stated the doctor wrote the order and she transcribed the order into the electronic medication ordering system which was integrated with the provider pharmacy electronic system. LPN #1 stated she did not question the order. She stated the resident had low Potassium levels. LPN #1 stated, After learning what I know now, I should have asked for a stop date, I should have checked the labs to see if the potassium was low, and I should have questioned the dosage. The timing of 4 times a day did not alarm me. The surveyor interviewed the consultant pharmacist (CP) on [DATE] at 11:37 a.m. via telephone. The CP stated she identified an irregularity with the dose and formula of potassium on [DATE], and reported the irregularity to the Director of Nursing (DON) and the UM/RN. The CP also documented the irregularity in a type written report and provided the report to the facility. The CP stated the facility needed to clarify the dose and whether a tablet or liquid was ordered. The surveyor reviewed the [DATE] Consultant Pharmacist's Medication Regimen Review. The CP documented the concern as an incomplete prescription order. The CP requested the facility to review and clarify dosage formulation and dosage for potassium with MD. Order is for potassium tablet, but directions of use says to give 15 ml 4 times a day. The surveyor interviewed LPN #3 on [DATE] at 12:31 p.m. LPN #3 was 1 of 5 nurses who administered the incorrect medication. LPN #3 explained the electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #3 stated, that she did not read the notice on the bottom of the highlighted area in small print which included full order information. LPN #3 further stated she did not recognize that potassium was ordered four times daily. She stated the facility, does not usually order potassium that many times a day. On [DATE] at 9:40 a.m., the surveyor attempted to conduct a telephone interview with RN #1 who was 1 of 5 nurses who administered the incorrect medication to Resident #33. The surveyor was unable to conduct the telephone interview. On [DATE] at 9:50 a.m., the surveyor conducted a telephone interview with RN #2, who was 1 of 5 nurses who administered the incorrect medication to Resident #33. RN #2 stated she did not recall administering the potassium to the resident. She further stated, that she didn't question the potassium order because only the one dose that she would be administering populates on the eMAR, so she wasn't aware potassium was being administered four times a day. On [DATE] at 10:27 a.m., the surveyor attempted to conduct a telephone interview with LPN #4 who was 1 of 5 nurses who administered the incorrect medication to Resident #33. The surveyor was unable to conduct the telephone interview with LPN #4. On [DATE], the DON provided the surveyor with the facility policy for Physician Orders: Obtaining and Transcribing, effective [DATE], revised [DATE]. The policy indicated medication orders should include the strength and dosage of medication. The policy also indicated a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], the DON provided the surveyor with the facility policy for Daily Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy indicated each nurse taking a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy also indicated all charts would be reviewed for new orders and transcription accuracy validated. The third shift (11 p.m.- 7 a.m.) nurse will review all Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If the order is incomplete or incorrectly noted, the nurse should attempt to correct or complete the notation at the time of discovery. If the order cannot be completed on the night shift, the nurse must communicate the finding to the Unit Manager at morning report. On [DATE], the DON provided the surveyor with LPN #1's employee file. LPN #1 was noted to have several disciplinary actions regarding physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], LPN #1 received disciplinary action for failure to complete an assigned task of completing monthly notes timely. LPN #1 received a documented verbal warning which was signed (checked off) as agreed. On [DATE], LPN #1 received a notice of disciplinary action for failure to pass evening snacks and for documenting the task as done. The notice was signed as agreed however, the disciplinary action to be taken was left blank. On [DATE], LPN #1 received disciplinary action for failure to document a post fall note of the assigned resident. LPN #1 received a documented verbal notice. LPN #1 refused to sign the notice. On [DATE], LPN #1 received disciplinary action for a failure to enter a medication order correctly; LPN #1 omitted supplementary data to an ordered medication. LPN #1 received another documented verbal notice, no other action was taken. LPN #1 signed the notice, agreed. Part B This deficiency continues at a scope and severity of D based on the evidence in Part B. Based on observation, interview, and record review during an extended survey of [DATE], it was determined that the facility failed to a.) clarify a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) transcribe the complete physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. The surveyor observed Resident #70A on [DATE] at 9:10 a.m. seated in a wheelchair at the bedside. The resident was alert and oriented. The resident stated he/she was going home later that day after a short term stay for rehabilitation. The [DATE], the Admission MDS indicated the resident had no long or short memory impairment. The resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed a [DATE] a 16:30 [4:30 p.m.] handwritten physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Potassium 20 MEQ po daily x 5 days, [DATE] - [DATE]. The surveyor reviewed the ,d+[DATE] electronic MAR. The order for one dose of Potassium 40 MEQ to be given on [DATE] was plotted for the following day, [DATE]. The subsequent dose of Potassium 20 MEQ daily was plotted to begin on [DATE]. The resident did not receive the 1 time dose of 40 MEQ Potassium on [DATE], but received it on [DATE] in addition to the 20 MEQ for a total of 60 MEQ that day. The surveyor reviewed reports of Potassium blood levels taken on [DATE] and [DATE]. On [DATE] the value was 3.2 mmol/L, outside of the therapeutic range of 3.,d+[DATE].1. On [DATE], the level was in the normal range at 3.8 mmol/L. The DON provided the surveyor with LPN #4's employee file on [DATE]. LPN #4 received a Notice of Disciplinary Action on [DATE] at 5:00 p.m. The nurse's supervisor described the issue as follows: The nurse transcribed the order for Potassium, incorrectly plotting the days. It should have read to give 40 MEQ x 1 dose and then 20 MEQ daily through [DATE]. The nurse plotted both orders (40 MEQ and 20 MEQ) on the same day, [DATE], and gave 60 MEQ of Potassium on [DATE]. LPN #4 documented on the Notice of Disciplinary Action that she disagreed with the statement, stating she gave the 40 MEQ dose the first day and the 20 MEQ dose the second day despite how it was written and signed for. The nurse received one on one education and a verbal warning regarding transcription of medication orders and plotting orders on the eMAR. On [DATE], the DON provided the surveyor with an unsigned typewritten document, dated [DATE], describing the incident. The document indicated during a routine, random audit of orders it was noted that the nurse had miss-entered the dates for the [DATE] Potassium order. The DON provided the surveyor with the facility policy for Daily Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy was unsigned. Step 1 of the process indicated that each nurse taking a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Noting the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On [DATE], the surveyor reviewed the closed record of Resident #19. The Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN/UM stated the resident expired on [DATE]. The surveyor reviewed the quarterly MDS dated [DATE], which indicated the resident had severe cognitive impairment. The surveyor reviewed the ,d+[DATE] Order Summary Report which contained a [DATE] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . three times a day for [CONDITION(S)] (low blood pressure). Hold for systolic blood pressure greater than 140. On [DATE], the DON provided the surveyor with LPN #1's employee file. The file contained an undated typewritten statement by the RN/UM. The file indicated that on [DATE], LPN #1 received a disciplinary action due to failure to add supplementary data to an ordered medication. The supplementary data should have included space for the plotting of the resident's blood pressure, since the blood pressure was to be taken prior to administering the blood pressure lowering medication. The nurse was educated on how to add supplementary data into the eMAR. The file also contained a [DATE] unsigned typewritten statement indicating a random audit of supplemental documentation was done for Resident #19. It was discovered that the supplemental data for blood pressure review was omitted; one to one education was provided. The statement further indicated the medication was administered without measuring the blood pressure from [DATE] through [DATE] prior to the 1:00 p.m. dose, and from [DATE] through [DATE] prior to the 1 p.m. dose. On [DATE], the medication was given for the 9:00 a.m. dose when the blood pressure was over 140. NJAC 8:,d+[DATE].2 (b)

Complaint # NJ 1. Based on interviews, review of Medical Records (MRs) and other facility documentation, it was determined that the facility's licensed nurses failed to administer Cardio [MEDICAL CONDITION] Resuscitation (CPR) according to Healthcare Provider Basic Life support (BLS) standards of practice in a timely manner for 1 of 3 Residents (Resident #3) causing a delay in medical intervention. On [DATE] at approximately 2:20 AM, Resident #3 was observed without respirations and facility staff (Registered Nurse) RN #1 initiated chest compressions, without ventilation/breaths, stopped chest compressions after approximately 3 minutes, and left the resident's bedside to call for help from facility staff (RN#2). In addition, staff members did not bring to the resident's bedside or initiate the use of the Automated External Defibrillator (AED), the facility Emergency Code Cart, which contained the ambu bag and/or non rebreather mask (used to assist with ventilation/breaths) or the back board (used to place under a resident on a soft surface during administration of chest compressions). The facility staff members decision to not provide ventilation/breaths, to stop CPR created an Immediate Jeopardy (IJ) situation for Resident #3 and the potential for all other Residents who were at risk for [MEDICAL CONDITION] that would require CPR initiation and calling 911 according to BLS Protocol. Subsequently, Resident #3 expired at the facility. The deficiency is considered past non compliance because the facility identified the immediate jeopardy on [DATE] and corrected it the same day by the implementation of an acceptable plan of correction. Reference #1: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statues 45:,[DATE]. Definitions b. 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 casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. 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 of licensed or otherwise legally authorized physician or dentist. Reference #2: AMERICAN HEART ASSOCIATION Reference: http://www.heart.org/idc/groups/heart-public/wcm@ecc/documents/downloadable/ucm_ 0.pdfme Health Provider Basic Life Support: Component Adults Recognition: Unresponsive (for all ages), No breathing or no normal breathing (i.e., only gasping), No breathing or only gasping, No pulse palpated within 10 seconds for all ages (HCP only) (Health Care Providers). CPR sequence: C-A-B (Compressions-Airway-Breathing) Compression rate: At least 100/min (minute) Compression depth: At least 2 inches (5 cm) Chest wall recoil: Allow complete recoil between compressions, HCPs (Health Care Providers) rotate compressors every 2 minutes Compression interruptions: Minimize interruptions in chest compressions, Attempt to limit interruptions to <10 seconds Airway: Head tilt-chin lift (HCP suspected trauma: jaw thrust) Compression-to-ventilation ratio (until advanced airway placed): 30:2, 1 or 2 rescuers Ventilations: when rescuer untrained or trained and not proficient: Compressions only Ventilations with advanced airway (HCP): 1 breath every ,[DATE] seconds (,[DATE] breaths/min), Asynchronous with chest compressions, About 1 second per breath, Visible chest rise Defibrillation: Attach and use AED as soon as available. Minimize interruptions in chest compressions before and after shock; resume CPR beginning with compressions immediately after each shock. Abbreviations: AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; HCP, healthcare provider. Reference #3: American Heart Association http://circ.ahajournals.org/content/early/[DATE]/CIR.0b013e d8654.full.pdf 1. .Ensure a Firm, Hard Surface. The 2010 AHA Guidelines for CPR and ECC (Emergency Cardiovascular Care), recommend performing CPR on a firm, hard surface. Backboards are commonly used to achieve target depths and reduce rescuer exertion, but their placement interrupts CPR. For this reason, the expert panel recommends placement of a backboard or firm, hard surface as soon as possible and in coordination with other mandatory pauses in compressions to minimize interruption time . Reference #4: Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation an Emergency Cardiovascular Care. The American Heart Association states: Withholding and Withdrawing Referencing CPR (Termination of Resuscitative Efforts) Related to Out-of Hospital [MEDICAL CONDITION] (OHCA) Criteria for Not Starting CPR in All OHCA Basic life support (BLS) training urges all potential rescuers to immediately begin CPR without seeking consent, because any delay in care dramatically decreases the chances of survival. While the general rule is to provide emergency treatment to a victim of [MEDICAL CONDITION], there are a few exceptions where withholding CPR might be appropriate, as follows: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril, Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection or decomposition), a valid, signed and dated advance directive indicating that resuscitation is not desired, or a valid, signed and dated DNAR (do not attempt resuscitation) order. This deficient practice was evidenced by the following: According to the Admission Record Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#3 was not a DNR (Do Not Resuscitate). The surveyor reviewed the physician progress notes [REDACTED]. The surveyor reviewed the Progress Notes documented by the Registered Nurse (RN) #1 on [DATE] at 08:13 a.m. According to the RN #1's documentation: Pt (patient) received in bed resting, HOB (head of bed) elevated, O2 (oxygen) flowing well, compressor on, peg tube flowing well, breathing easy and unlabored. Foley draining well, frequent rounds made. At 2:20 am on bedside rounds pt observed not breathing, no palpable pulses felt, pupils fixed and dilated. Chest compressions done, no successful response received. Doctor (Dr) notified, family notified as per Dr. The surveyor interviewed RN #1 on [DATE] at 12:50 p.m. According to the RN #1, he/she was on duty on the ,[DATE] shift on [DATE]. RN #1 stated that rounds are done every hour and are alternated with the CNA (Certified Nursing Assistant). During rounds at 2:20 a.m., I found Resident (#3's) face turned to the wall and not breathing. I realized that Resident (#3) was a full code and I started the chest compressions and continued for 3 minutes. The Resident (#3) was not responding. I called the nurse (RN #2) on duty. The resident was dead. The nurse (RN #2) confirmed that the resident was dead. I stopped the CPR and called the doctor. I did not call 911 because the resident was dead. The doctor told me to pronounce and I did. I told the MD (Medical Doctor), I stopped the CPR and he told me to call the family. The body was a little warm when we found (Resident #3) unresponsive. She was not breathing and did not respond. The AED was not used. The husband came in at 4 AM. He called 911 from his home. 911 came before the husband came. (Resident #3) was dead, but the husband said I killed (Resident #3) because of negligence. On [DATE] at 1:20 p.m., the surveyor interviewed RN #2. As per RN #2, The nurse (RN #1) called for me to come into the room at 2:20 a.m We assessed the patient and we realized that the patient was already expired. We used the pulse ox machine and it showed no pulse. We did not use an AED. We palpated for a pulse and there was no pulse. I touched (Resident #3) and the resident wasn't warm. (Resident #3) had no response of pupils. No one started CPR. (Resident #3) was already expired with no signs of life. I did not observe CPR by the other nurse but (she/he) was in the room before me. We would not call 911 if we determine that the Pt (patient) is already expired. We would call the physician and the nurse (RN#1) called the MD. The MD told (him/her) to pronounce and inform the family. The 911 called and told me the husband called them and told them that (Resident #3) was in [MEDICAL CONDITION]. They were dispatched to our facility. The husband was furious and angry, said we killed (Resident #3). The surveyor interviewed the ADON (Assistant Director of Nursing)/Clinical Services Coordinator on [DATE] at 12:31 p.m According to the ADON, The MD told the nurse to stop CPR secondary to the patient being in a vegetative/comatose state. That is what the nurse told me. The husband was not realistic. He called the 911. Our policy is, if a patient is found unresponsive, call supervisor and code blue. Check the chart for DNR status, start CPR and continue, call 911 and MD. Our corporate policy is, if nurse assesses that there is no life and could not be resuscitated, call MD to inform. (However the ADON could not provide a copy of the policy.) If we follow the CPR policy, would use AED, but ordinarily I don't think they would. Based on our policy, 911 should have been called. We took statements from both nurses and I spoke with the MD, who said there was nothing we could do for the Resident (#3). The investigation is not finalized, but we in-serviced the nurses and the whole house staff. The surveyor interviewed MD #1 on [DATE] at 3:10 p.m. According to the MD #1, Resident #3 was flaccid with Anasarca (Extreme generalized [MEDICAL CONDITION]) on Saturday; there was nothing in his/her body that was working. The nurse called me on [DATE] at around 3 a.m. crying that she found him/her breathless, unresponsive. I called the husband on [DATE]. The husband started shouting, 'this is negligence. Why was CPR not started. Why was 911 not called. I don't care I already called the ambulance.' The 911 came and refused to take him/her because he/she was dead. The Medical Examiner called me informing me that the husband complained. He, (Medical Examiner) said that this is not a case for the Medical Examiner. (Resident #3) should have been sent to a hospice facility, not here. The nurse did start CPR, but his/her judgement was good and he/she stopped. The surveyor reviewed the statements that were obtained from the two nurses by the facility. According to the statement provided by RN #1, I observed the patient and realized the patient was not breathing, was unresponsive with no palpable pulses and had fixed dilated pupils. I tried to initiate a response from patient with chest compression without success and then I immediately called for help from my co-worker. We both confirmed that the patient had expired. The statement from RN #2 indicated the following: I assisted the nurse in assessing the status of the patient. Patient presented unresponsive with no signs of life, no palpable pulses, pupils fixed bilaterally. The physician was immediately called. The surveyor reviewed CNA #1's statement. CNA #1 indicated the following: On [DATE] at the beginning of my shift 11 p.m. - 7 a.m., I checked Pt in room [ROOM NUMBER] D and checked patients Foley bag at 11:20 p.m On [DATE] at 1:20 a.m., I again checked the Pt in room [ROOM NUMBER] D and emptied the Foley containing approximately 700 cc of urine and Pt was alive. The surveyor reviewed the Unwitnessed [MEDICAL CONDITION] Policy dated 2009 with revision date of ,[DATE] and effective date [DATE]. According to the policy: A nurse may withhold CPR when there is a valid DNR order in place OR when there are signs of irreversible death, defined as: decapitation, decomposition, rigor mortis and dependent lividity. In the absence of a DNR order and in the absence of signs of irreversible death, the nurse is required to initiate CPR when a patient or resident has a [MEDICAL CONDITION]. The purpose of this policy is to: Ensure that the decision to initiate or withhold CPR reflects the standard of nursing practice when there is an unwitnessed [MEDICAL CONDITION] in the skilled setting. In the event of an unwitnessed [MEDICAL CONDITION], the nurse is expected to conduct a sequential evaluation of the resident and initiate CPR without delay unless all of the following clinical signs are present: There is no response when the patient or resident is tapped on the shoulder and asked, 'Are you alright? ' AND There are no respirations as determined by opening the airway using the head tilt-chin lift maneuver (or jaw thrust if a cervical spine injury is suspected) and observing for the rise and fall of the chest wall while listening and feeling for breath for at least 30 seconds (the use of pulse oximetry is not appropriate for this observation); AND There is no pulse as determined by palpation of the carotid artery or auscultation of the apical pulse for at least 30 seconds; AND The pupils are dilated bilaterally (if observable) and are unresponsive to bright light; AND There is dependent lividity. If rigor mortis is present, as determined by the presence of hardening of the muscles or rigidity of the jaw, shoulders, elbows or knees, then a finding of dependent lividity is not required. These observations must be conducted by the nurse to support the withholding of CPR. Each nurse is responsible and accountable for his or her judgements, actions, and competency with regard to the initiation or withholding of CPR. Documentation must be complete, accurate and legible; entries in the resident record and must include: Patient or resident DNR status (or absence of); Findings from the nurse's sequential observation of the patient or resident including responsiveness, respiratory status, cardiac status, pupillary responsiveness, and the presence of dependent lividity and/or rigor mortis that substantiates the nurse's determination of irreversible death. Judgements and interventions made by the nurse based on his or her sequential evaluation of the patient or resident including, the decision to initiate or withhold CPR; Collaboration and communication with other health care providers to ensure quality and continuity of care including dates and times of notifications of primary care providers; Collaboration and communication with the patient or resident's family or significant others including dates and times of notification. The deficiency is considered to be past non-compliance. The facility identified the immediate jeopardy which began on [DATE] and corrected it on the same day. The Immediate Jeopardy was corrected on [DATE] based on the implementation of the following Plan of Correction: 1. The Resident no longer resides in the facility. 2. Audit current residents to evaluate physician orders [REDACTED]. 3. Inservice licensed nurses regarding the procedure for initiating CPR on [DATE]. 4. Audits residents who receive CPR to evaluate procedure used during the code for three months. Submit results of the audits to the QAPI committee for review and further plan of action. The facility in-serviced RN #1 regarding the unwitnessed [MEDICAL CONDITION] policy and procedure. According to the Employee Education Attendance Record, in the content section of the form the surveyor observed the following: Do not stop CPR once chest compressions are initiated. Unwitnessed [MEDICAL CONDITION] form reviewed, proper CPR protocol reviewed and the signs of irreversible death. In the Objective section, At the completion of this training session the participant will: RN (#1) will have a full understanding of the P&P (Practice and Protocol) on Unwitnessed [MEDICAL CONDITION], CPR protocol. Can identify signs of irreversible death. The facility in-serviced staff on [DATE] as observed on the Employee Education Attendance record on the following: Check Code status, unresponsive Pt and start BLS. Once compressions are initiated they can not be stopped until paramedics come to take over, Unwitnessed [MEDICAL CONDITION], dependent lividity and rigor mortis. In the objective section, At the completion of this training session the participant(s) will: Staff will understand protocol of [MEDICAL CONDITION] (Unwitnessed). Ensure the decision to initiate or withhold CPR reflects standard of nursing practice when there is an unwitnessed [MEDICAL CONDITION] in the skilled setting. NJAC 8:39 - 27.1 Complaint # NJ The deficient practice continues at a lower scope and severity of E. 2. Based on observation, interview and record review, it was determined that the facility staff failed to sign the Medication Administration Records (MAR) to indicate that medications were administered and failed to administer eye drop medication according to a physician order. This deficient practice was evident for 3 of 5 medical records (Resident #4, Resident #2, and Resident #5) reviewed for routine medication administration. This was evidenced by the following: A) The surveyor reviewed the medical record of Resident #4 on [DATE] at 11:45 a.m. The Admission Record indicated that Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The Resident required extensive assist in activities of daily living. The surveyor reviewed the facility Medication Administration Policy. The policy failed to indicate an established date, but did document a revision in [DATE]. According to the policy: If a drug is withheld, refused or given at a time other than a scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dosage. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next one. A review on Resident #4's MAR dated [DATE], indicated the following: [MEDICATION NAME] 30 milligrams, (mg)/0.3 milliliter (ml) ( generic for [MEDICATION NAME]) 0.3 ml ( 30 mg), administered subcutaneous was ordered every day for [DIAGNOSES REDACTED]. There were no initials present on Resident #4 MAR to indicate that the medication was administered on [DATE] for the 5 p.m. dose. [MEDICATION NAME] tablet 25 mg, 1 tablet by mouth every 12 hours was ordered for a [DIAGNOSES REDACTED]. Carvedilol 3.125 mg 1 tablet by mouth was ordered to be administered with meals twice daily at 8:00 a.m. and 5:00 p.m. There were no initials present on the MAR for [DATE] for the 5:00 p.m. dose. [MEDICATION NAME] 325 mg supplement 1 tablet by mouth was to be administered everyday at 5:00 p.m. There were no nurse's initials on the MAR on [DATE] and 2, 2015 that indicated that the [MEDICATION NAME] was administered. [MEDICATION NAME] 3 mg tablet 1 tablet by mouth at bedtime timed for 9:00 p.m. There were no initials on [DATE] and 2, 2015 MAR that indicate that the [MEDICATION NAME] was administered. House Supplement was ordered by mouth was ordered to be administered three times daily at 10:00 a.m., 2:00 p.m., and 7:00 p.m. There were no initials present on the MAR for [DATE] and 2 at 7:00 p.m. that would indicated that the supplement was administered. B). The surveyor reviewed the medical record of Resident #2 on [DATE]. The admission record indicated that Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS revealed on [DATE] that Resident #2 has a BIMS score of 99 which indicated that the Resident was unable to complete one or more questions for the interview. Resident #2 required extensive assist in Activities of daily living. According to Resident #2's MAR, dated [DATE], the resident was ordered Artificial Tears 2 drops in both eyes three times per day for dry eyes to be administered at 9:00 a.m., 5:00 p.m., and 9:00 p.m. There were no initials on the MAR for [DATE] at 5:00 p.m. and 9:00 p.m. that indicated that Artificial Tears was administered. On [DATE] at approximate 4:00 p.m., the surveyor received a second copy of Resident #2's MAR from the facility. The MAR dated [DATE] revealed a nurse's initials for Artificial Tears, 2 drops in both eyes, for 5:00 p.m. and 9:00 p.m. These nurse's initials were not present on the first copy of the MAR that was provided to the surveyor. On [DATE] at 11:53 a.m., the surveyor interviewed Registered Nurse (RN) #3. RN #3 stated that if any medications were not given by the nurse, the nurse must circle the MAR and explain on the back of the MAR why the medication was not given. RN #3 was unable to explain why there were blanks on the MAR for the dates indicated. On [DATE] at 12:19 p.m., the surveyor interviewed License Practical Nurse #1 who stated that if any medications were not given for any reasons, the nurse must initial, circle and write on the back of the MAR and the reason why it was not given. LPN #1 was unable to explain why there were blanks on the MAR for the dates indicated. C). According to the Resident Face Sheet, Resident #5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS revealed no BIMS score available at this time. On [DATE] at 10:40 a.m., during the medication pass, the surveyor observed RN #3 administer the [MEDICATION NAME] ophthalmic solution 0.5% 1 drop to Resident #5's left eye. When RN #3 was about to administer the second drop, Resident #5 stated I'm supposed to be getting only 1 drop. RN #3 stated: You get 2 drops. RN #3 then administered another 1 drop into the left eye of Resident #5. On [DATE] at 10:43 a.m., the surveyor reviewed the facility Physician order [REDACTED].#5. The order read for : [MEDICATION NAME] 0.5% ophthalmic solution apply 1 drop to left eye daily for [MEDICAL CONDITION]. On [DATE] at 10:45 a.m., the surveyor in the presence of RN #3 reviewed the facility record titled Medication Administration Record (MAR) for [DATE] which indicated an entry for [MEDICATION NAME] 0.5% ophthalmic solution, apply 1 drop to left eye daily and timed for 9 a.m. On [DATE] at 11 a.m., the surveyor reviewed the facility record titled Patient Discharge Summary, (acute care hospital name), which indicated an entry for [MEDICATION NAME] (commonly known as [MEDICATION NAME]) 0.5 % ophthalmic solution place 1 drop into the left eye daily. A review of a facility form located in Resident #5's medical record titled My Pocket List on [DATE] at 11 a.m., revealed an entry for [MEDICATION NAME] ([MEDICATION NAME]) 0.5% ophthalmic solution 1 drop into the left eye daily. On [DATE] at 11:53 a.m., the surveyor interviewed RN #3 who stated I thought I saw 2 drops but then further looking, I realized it was only 1 drop. On [DATE] at 4:00 p.m., the surveyor reviewed the facility policy titled Administering Medications under Policy Interpretation and Implementation #3: Medications must be administered in accordance with the orders, including any required time frame. N.J.A.C. 8:,[DATE].2(d)

Complaint # NJ Based on interviews, review of Medical Records (MRs) and other facility documentation, it was determined that the facility's licensed nurses failed to administer Cardio [MEDICAL CONDITION] Resuscitation (CPR) according to Healthcare Provider Basic Life support (BLS) standards of practice in a timely manner for 1 of 3 Residents (Resident #3) causing a delay in medical intervention. On [DATE] at approximately 2:20 AM, Resident #3 was observed without respirations and facility staff (Registered Nurse) RN #1 initiated chest compressions, without ventilation/breaths, stopped chest compressions after approximately 3 minutes, and left the resident's bedside to call for help from facility staff (RN#2). In addition, staff members did not bring to the resident's bedside or initiate the use of the Automated External Defibrillator (AED), the facility Emergency Code Cart, which contained the ambu bag and/or non rebreather mask (used to assist with ventilation/breaths) or the back board (used to place under a resident on a soft surface during administration of chest compressions). The facility staff members decision to not provide ventilation/breaths, to stop CPR created an Immediate Jeopardy (IJ) situation for Resident #3 and the potential for all other Residents who were at risk for [MEDICAL CONDITION] that would require CPR initiation and calling 911 according to BLS Protocol. Subsequently, Resident #3 expired at the facility. The deficiency is considered past non compliance because the facility identified the immediate jeopardy on [DATE] and corrected it the same day by the implementation of an acceptable plan of correction. Reference #1: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statues 45:,[DATE]. Definitions b. 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 casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. 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 of licensed or otherwise legally authorized physician or dentist. Reference #2: AMERICAN HEART ASSOCIATION Reference: http://www.heart.org/idc/groups/heart-public/wcm@ecc/documents/downloadable/ucm_ 0.pdfme Health Provider Basic Life Support: Component Adults Recognition: Unresponsive (for all ages), No breathing or no normal breathing (ie, only gasping), No breathing or only gasping, No pulse palpated within 10 seconds for all ages (HCP only) (Health Care Providers). CPR sequence: C-A-B (Compressions-Airway-Breathing) Compression rate: At least 100/min (minute) Compression depth: At least 2 inches (5 cm) Chest wall recoil: Allow complete recoil between compressions, HCPs (Health Care Providers) rotate compressors every 2 minutes Compression interruptions: Minimize interruptions in chest compressions, Attempt to limit interruptions to <10 seconds Airway: Head tilt-chin lift (HCP suspected trauma: jaw thrust) Compression-to-ventilation ratio (until advanced airway placed): 30:2, 1 or 2 rescuers Ventilations: when rescuer untrained or trained and not proficient: Compressions only Ventilations with advanced airway (HCP): 1 breath every ,[DATE] seconds (,[DATE] breaths/min), Asynchronous with chest compressions, About 1 second per breath, Visible chest rise Defibrillation: Attach and use AED as soon as available. Minimize interruptions in chest compressions before and after shock; resume CPR beginning with compressions immediately after each shock. Abbreviations: AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; HCP, healthcare provider. Reference #3: American Heart Association http://circ.ahajournals.org/content/early/[DATE]/CIR.0b013e d8654.full.pdf 1. .Ensure a Firm, Hard Surface. The 2010 AHA Guidelines for CPR and ECC (Emergency Cardiovascular Care) recommend performing CPR on a firm, hard surface. Backboards are commonly used to achieve target depths and reduce rescuer exertion, but their placement interrupts CPR. For this reason, the expert panel recommends placement of a backboard or firm, hard surface as soon as possible and in coordination with other mandatory pauses in compressions to minimize interruption time . Reference #4: Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation an Emergency Cardiovascular Care. The American Heart Association states: Withholding and Withdrawing Referencing CPR (Termination of Resuscitative Efforts) Related to Out-of Hospital [MEDICAL CONDITION] (OHCA) Criteria for Not Starting CPR in All OHCA Basic life support (BLS) training urges all potential rescuers to immediately begin CPR without seeking consent, because any delay in care dramatically decreases the chances of survival. While the general rule is to provide emergency treatment to a victim of [MEDICAL CONDITION], there are a few exceptions where withholding CPR might be appropriate, as follows: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril, Obvious clinical signs of irreversible death (eg, rigor mortis, dependent lividity, decapitation, transection or decomposition), a valid, signed and dated advance directive indicating that resuscitation is not desired, or a valid, signed and dated DNAR (do not attempt resuscitation) order. This deficient practice was evidenced by the following: According to the Admission Record Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. The surveyor reviewed the physician progress notes [REDACTED]. The surveyor reviewed the Progress Notes documented by the Registered Nurse (RN) #1 on [DATE] at 08:13 a.m. According to the RN #1's documentation: Pt (patient) received in bed resting, HOB (head of bed) elevated, O2 (oxygen) flowing well, compressor on, peg tube flowing well, breathing easy and unlabored. Foley draining well, frequent rounds made. At 2:20 am on bedside rounds pt observed not breathing, no palpable pulses felt, pupils fixed and dilated. Chest compressions done, no successful response received. Doctor (Dr) notified, family notified as per Dr. The surveyor interviewed RN #1 on [DATE] at 12:50 p.m. According to the RN #1, he/she was on duty on the ,[DATE] shift on [DATE]. RN #1 stated that rounds are done every hour and are alternated with the CNA (Certified Nursing Assistant). During rounds at 2:20 a.m., I found Resident (#3's) face turned to the wall and not breathing. I realized that Resident (#3) was a full code and I started the chest compressions and continued for 3 minutes. The Resident (#3) was not responding. I called the nurse (RN #2) on duty. The resident was dead. The nurse (RN #2) confirmed that the resident was dead. I stopped the CPR and called the doctor. I did not call 911 because the resident was dead. The doctor told me to pronounce and I did. I told the MD (Medical Doctor), I stopped the CPR and he told me to call the family. The body was a little warm when we found (Resident #3) unresponsive. She was not breathing and did not respond. The AED was not used. The husband came in at 4 AM. He called 911 from his home. 911 came before the husband came. (Resident #3) was dead, but the husband said I killed (Resident #3) because of negligence. On [DATE] at 1:20 p. m., the surveyor interviewed RN #2 on. As per RN #2, The nurse (RN #1) called for me to come into the room at 2:20 a.m We assessed the patient and we realized that patient was already expired. We used the pulse ox machine and it showed no pulse. We did not use an AED. We palpated for a pulse and there was no pulse. I touched (Resident #3) and the resident wasn't warm. (Resident #3) had no response of pupils. No one started CPR. (Resident #3) was already expired with no signs of life. I did not observe CPR by the other nurse but (she/he) was in the room before me. We would not call 911 if we determine that the Pt (patient) is already expired. We would call the physician and the nurse (RN#1) called the MD. The MD told (him/her) to pronounce and inform the family. The 911 called and told me the husband called them and told them that (Resident #3) was in [MEDICAL CONDITION]. They were dispatched to our facility. The husband was furious and angry, said we killed (Resident #3). The surveyor interviewed the ADON (Assistant Director of Nursing)/Clinical Services Coordinator on [DATE] at 12:31 p.m According to the ADON, The MD told the nurse to stop CPR secondary to the patient being in a vegetative/comatose state. That is what the nurse told me. The husband was not realistic. He called the 911. Our policy is, if a patient is found unresponsive, call supervisor and code blue. Check the chart for DNR status, start CPR and continue, call 911 and MD. Our corporate policy is, if nurse assesses that there is no life and could not be resuscitated, call MD to inform.( However, the ADON could not provide the policy.) If we follow the CPR policy, would use AED, but ordinarily I don't think they would. Based on our policy, 911 should have been called. We took statements from both nurses and I spoke with the MD, who said there was nothing we could do for the Resident (#3). The investigation is not finalized, but we in-serviced the nurses and the whole house staff. The surveyor interviewed MD #1 on [DATE] at 3:10 p.m. According to the MD #1, Resident #3 was flaccid with Anasarca (Extreme Generalized [MEDICAL CONDITION]) on Saturday; there was nothing in his/her body that was working. The nurse called me on [DATE] at around 3 a.m. crying that she found him/her breathless, unresponsive. I called the husband on [DATE]. The husband started shouting, 'this is negligence. Why was CPR not started. Why was 911 not called. I don't care I already called the ambulance.' The 911 came and refused to take him/her because he/she was dead. The Medical Examiner called me informing me that the husband complained. He, (Medical Examiner) said that this is not a case for the Medical Examiner. (Resident #3) should have been sent to a hospice facility, not here. The nurse did start CPR, but his/her judgement was good and he/she stopped. The surveyor reviewed the statements that were obtained from the two nurses by the facility. According to the statement provided by RN #1, I observed the patient and realized the patient was not breathing, was unresponsive with no palpable pulses and had fixed dilated pupils. I tried to initiate a response from patient with chest compression without success and then I immediately called for help from my co-worker. We both confirmed that the patient had expired. The statement from RN #2 indicated the following: I assisted the nurse in assessing the status of the patient. Patient presented unresponsive with no signs of life, no palpable pulses, pupils fixed bilaterally. The physician was immediately called. The surveyor reviewed CNA #1's statement. CNA #1 indicated the following: On [DATE] at the beginning of my shift 11 p.m. - 7 a.m., I checked Pt in room [ROOM NUMBER] D and checked patients Foley bag at 11:20 p.m On [DATE] at 1:20 a.m., I again checked the Pt in room [ROOM NUMBER] D and emptied the Foley containing approximately 700 cc of urine and Pt was alive. The surveyor reviewed the Unwitnessed [MEDICAL CONDITION] Policy dated 2009 with revision date of ,[DATE] and effective date [DATE]. According to the policy: A nurse may withhold CPR when there is a valid DNR order in place OR when there are signs of irreversible death, defined as: decapitation, decomposition, rigor mortis and dependent lividity. In the absence of a DNR order and in the absence of signs of irreversible death, the nurse is required to initiate CPR when a patient or resident has a [MEDICAL CONDITION]. The purpose of this policy is to: Ensure that the decision to initiate or withhold CPR reflects the standard of nursing practice when there is an unwitnessed [MEDICAL CONDITION] in the skilled setting. In the event of an unwitnessed [MEDICAL CONDITION], the nurse is expected to conduct a sequential evaluation of the resident and initiate CPR without delay unless all of the following clinical signs are present: There is no response when the patient or resident is tapped on the shoulder and asked, 'Are you alright? ' AND There are no respirations as determined by opening the airway using the head tilt-chin lift maneuver (or jaw thrust if a cervical spine injury is suspected) and observing for the rise and fall of the chest wall while listening and feeling for breath for at least 30 seconds (the use of pulse oximetry is not appropriate for this observation); AND There is no pulse as determined by palpation of the carotid artery or auscultation of the apical pulse for at least 30 seconds; AND The pupils are dilated bilaterally (if observable) and are unresponsive to bright light; AND There is dependent lividity. If rigor mortis is present, as determined by the presence of hardening of the muscles or rigidity of the jaw, shoulders, elbows or knees, then a finding of dependent lividity is not required. These observations must be conducted by the nurse to support the withholding of CPR. Each nurse is responsible and accountable for his or her judgements, actions, and competency with regard to the initiation or withholding of CPR. Documentation must be complete, accurate and legible; entries in the resident record and must include: Patient or resident DNR status (or absence of); Findings from the nurse's sequential observation of the patient or resident including responsiveness, respiratory status, cardiac status, pupillary responsiveness, and the presence of dependent lividity and/or rigor mortis that substantiates the nurse's determination of irreversible death. Judgements and interventions made by the nurse based on his or her sequential evaluation of the patient or resident including, the decision to initiate or withhold CPR; Collaboration and communication with other health care providers to ensure quality and continuity of care including dates and times of notifications of primary care providers; Collaboration and communication with the patient or resident's family or significant others including dates and times of notification. The deficiency is considered to be past non-compliance. The facility identified the immediate jeopardy which began on [DATE] and corrected it on the same day. The Immediate Jeopardy was corrected on [DATE] based on the implementation of the following Plan of Correction: 1. The Resident no longer resides in the facility. 2. Audit current residents to evaluate physician orders [REDACTED]. 3. Inservice licensed nurses regarding the procedure for initiating CPR on [DATE]. 4. Audits residents who receive CPR to evaluate procedure used during the code for three months. Submit results of the audits to the QAPI committee for review and further plan of action. The facility in-serviced RN #1 regarding the unwitnessed [MEDICAL CONDITION] policy and procedure. According to the Employee Education Attendance Record, in the content section of the form the surveyor observed the following: Do not stop CPR once chest compressions are initiated. Unwitnessed [MEDICAL CONDITION] form reviewed, proper CPR protocol reviewed and the signs of irreversible death. In the Objective section, At the completion of this training session the participant will: RN (#1) will have a full understanding of the P&P (Practice and Protocol) on Unwitnessed [MEDICAL CONDITION], CPR protocol. Can identify signs of irreversible death. The facility in-serviced staff on [DATE] as observed on the Employee Education Attendance record on the following: Check Code status, unresponsive Pt and start BLS. Once compressions are initiated they can not be stopped until paramedics come to take over, Unwitnessed [MEDICAL CONDITION], dependent lividity and rigor mortis. In the objective section, At the completion of this training session the participant(s) will: Staff will understand protocol of [MEDICAL CONDITION] (Unwitnessed). Ensure the decision to initiate or withhold CPR reflects standard of nursing practice when there is an unwitnessed [MEDICAL CONDITION] in the skilled setting. NJAC 8:39 - 27.1