Every finding on record at Complete Care at Barn Hill

Based on observation, interview, and record review, it was determined that the facility failed to respond to the Consultant Pharmacist's (CP) monthly recommendations in a timely manner for 1 of 27 residents (Resident #29) reviewed.The deficient practice was evidenced by the following:On 12/29/25 at 10:45 AM, the surveyor observed Resident #29 who was seated on their bed and was watching television. The resident was alert and oriented and told the surveyor in an interview that he/she received their medications every day.A review of the admission Record (an admission summary) reflected that Resident #29 was admitted to the facility with diagnoses that included peripheral vascular disease(a circulation disorder where narrowed blood vessels (usually in the legs/arms) reduce blood flow, causing pain, cramping, or fatigue), chronic diastolic (congestive) heart failure(occurs when the left ventricle stiffens and can't relax properly to fill with enough blood between beats, leading to fluid backup (congestion) in the lungs and body, causing symptoms like shortness of breath, fatigue, and swelling ), and atherosclerotic heart disease (caused by plaque buildup in arterial walls).A review of the admission Minimum Data Set, an assessment tool used to facilitate the of care, dated 09/09/25, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident was cognitively intact.A review of the December 2025 Order Summary Report (OSR) revealed the following Physician's Order (PO) dated 10/02/25 for Metoprolol Succinate ER tablet Extended Release 24 hour 25 mg, give 1 tablet by mouth one time a day for Hypertension (HTN) hold for Systolic Blood Pressure (SBP) (a top, higher number in a blood pressure reading, measuring the pressure in your arteries when your heart beats (contracts) and pushes blood out) less than or equal to 90 and/ or Heart rate (HR) (how many times your heart beats per minute) less than or equal to 60A review of the October, November, and December 2025, e-MAR revealed a PO dated 10/02/25 for Metoprolol Succinate ER tablet Extended Release 24-hour 25 mg, give 1 tablet by mouth one time a day for Hypertension (HTN) hold for SBP less than or equal to 90 and/or HR less than or equal to 60. The e-MAR further revealed that Metoprolol Succinate ER had a plotted time of 0800 (8:00 AM) and contained no dropped down to enter the resident's HR or BP (blood pressure). The e-MAR further revealed from 10/2/25 through 12/30/25 that the nurses were only documenting that the medication was being administered with no heart rate or blood pressure. The e-MAR also revealed that from 10/2/25 through 12/30/25 that the resident received Metoprolol Succinate ER 25 mg every day and was never held in that period.A review of the electronic medical record under weights and vitals revealed an entry section for blood pressure (BP) and pulse (heart rate) which showed that both the resident's BP and HR were not being monitored every day at 0800 (8:00AM).A review of the CP - Medication Regimen Review revealed the following recommendations:A CP recommendation dated 10/21/25 which revealed the following: Metoprolol has hold parameters that are not being properly followed. Please re-enter order requiring BP and pulse to be taken and inputted into the e-MAR prior to administering medication (check off supplementary documentation for BP and Pulse). The recommendation had noted under the response section.A CP recommendation dated 12/19/25 which revealed the following Metoprolol has hold parameters that are not being properly followed. Please re-enter order requiring BP and Pulse to be taken and inputted into the e-MAR prior to administering medication (check off supplementary documentation for BP and Pulse. The recommendation had completed under the response section. On 1/5/26 at 10:10 AM, the surveyor interviewed the Director of Nursing (DON) regarding who would review and sign the response section of the CP recommendation. DON stated that the unit manager would be the one who would review and sign off the CP recommendations. She stated that when the unit manager wrote complete, they are acknowledging that the recommendation is being address. the DON further stated that it was the unit managers responsibility that the recommendations are being followed through. On 1/05/26 at 10:15 AM, the surveyor discussed the above concerns with the facility administrative team which consisted of the Licensed Nursing Home Administrator, Director of Nursing, Regional Nurse, and the Director of Operations.No further information was provided. A review of the facility's policy Pharmacy Services provided by the Director of Operations with a date of 9/1/2025, did not include a section regarding a facility's response to the CP recommendations pertaining to medication irregularities. NJAC 8:39-29.3

Based on observation, interview, record review, and a review of the facility policies, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 2 of 27 residents (Resident #9 and Resident #29) observed during the medication review.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 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.1). On 12/29/2025 11:46 AM, The surveyor observed Resident #9 who was alert and oriented sitting in bed and was watching television.A review of the admission Record (an admission summary) reflected that Resident #9 was admitted to the facility with diagnoses that included malignant neoplasm of bladder (bladder cancer), gross hematuria( the visible presence of blood in the urine, making it appear pink, red, colored, or brownish), and chronic kidney disease (a progressive condition where kidneys gradually lose their ability to filter waste and fluids from the blood).A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the of care, dated 10/10/25, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident was cognitively intact.A review of a Physician order dated 12/17/25 and signed by the physician revealed an order for Macrobid 100 mg (antibiotic for a urinary tract infection) to be given twice daily for 5 days.A review of the December 2025 Order Summary Report (OSR) revealed the following Physician's Order (PO) dated 12/17/25 for Macrobid oral capsule 100 mg (Nitrofurantoin Monohydrate Macro) give 100 mg by mouth two times a day for Urinary Tract Infection (UTI) with no stop date. A review of the December 2025 and January 2026 electronic medication administration record (e-MAR) revealed a PO dated 12/17/25 for Macrobid Oral Capsule 100 mg, give 100 mg by mouth two times a day for UTI (no stop date). A further review of the resident's e-MAR revealed that the medication had an administration time of 0900 (9:00AM) and 2100 (9:00PM) and was plotted as being administered from 12/17/25 through 1/5/26.On 1/5/26 at 9:30 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN#1) reviewed Resident #9's medical records and LPN#1 acknowledged that the resident has a standing order for Macrobid 100 mg because the resident is being seen by the urologist weekly. When the surveyor asked the LPN#1 to review the PO dated 12/17/25, she acknowledges that the order was written by the physician and that the order for Macrobid was written for 5 days. Both LPN#1 and the Registered Nurse (RN)/unit manager acknowledge that the order should have been verified with the physician.2).12/29/25 at 10:45 AM, the surveyor observed Resident #29 who was seated on their bed and was watching television. The resident was alert and oriented and told the surveyor in an interview that he/she receives their medications every day.A review of the admission Record (an admission summary) reflected that Resident #29 was admitted to the facility with diagnoses that included peripheral vascular disease(a circulation disorder where narrowed blood vessels (usually in the legs/arms) reduce blood flow, causing pain, cramping, or fatigue), chronic diastolic (congestive) heart failure(occurs when the left ventricle stiffens and can't relax properly to fill with enough blood between beats, leading to fluid backup (congestion) in the lungs and body, causing symptoms like shortness of breath, fatigue, and swelling ), and atherosclerotic heart disease (caused by plaque buildup in arterial walls).A review of the admission Minimum Data Set, dated [DATE], reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident was cognitively intact.A review of the December 2025 OSR revealed the following PO dated 10/02/25 for Metoprolol Succinate ER tablet Extended Release 24 hour 25 mg, give 1 tablet by mouth one time a day for Hypertension (HTN) hold for Systolic Blood Pressure (SBP) (a top, higher number in a blood pressure reading, measuring the pressure in your arteries when your heart beats (contracts) and pushes blood out) less than or equal to 90 and/ or heart rate (HR) (how many times your heart beats per minute) less than or equal to 60A review of the October, November, and December 2025, e-MAR revealed a PO dated 10/02/25 for Metoprolol Succinate ER tablet Extended Release 24-hour 25 mg, give 1 tablet by mouth one time a day for Hypertension (HTN) hold for SBP less than or equal to 90 and/or HR less than or equal to 60. The e-MAR further revealed that Metoprolol Succinate ER had a plotted time of 0800 (8:00 AM) and contained no dropped down to enter the resident's HR or BP (blood pressure). The e-MAR further revealed from 10/2/25 through 12/30/25 that the nurses were only documenting that the medication was being administered with no heart rate or blood pressure. The e-MAR also revealed that from 10/2/25 through 12/30/25 that the resident received Metoprolol Succinate ER 25 mg every day and was never held in that period.A review of the electronic medical record under weights and vitals revealed an entry section for blood pressure (BP) and pulse (heart rate) which showed that both the resident's BP and HR were not being monitored every day at 0800 (8:00AM).On 12/30/25 at 12:25 PM, the surveyor in the presence of LPN#1 reviewed the resident's physician's orders and e-MAR. LPN#1 acknowledge that the resident had an order for Metoprolol Succinate ER to hold the medication when the resident's SBP was equal or less than 90 or when the resident's HR was equal or less than 60. LPN#1 further acknowledge after reviewing the resident's e-MAR that the resident's SBP and HR was not being documented, and that the e-MAR should have a drop down do that both the HR and BP could be monitored.On 01/2/26 at 12:30 PM and on 01/5/26 at 10:00 AM, the surveyor discussed the above concerns to the facility administration team that consisted of the Licensed Nursing Home Administrator, the Director of Nursing (DON), Regional Nurse, and the Director of Operations.There was no additional information provided.A review of the facility's policy for Following Physician Orders that was dated 10/1/25 and was provided by the Director of Operations revealed the following: 2. Medications must be administered in accordance with the orders, including any required time frame. 6. The following information must be checked/verified for each resident prior to administering medications: a. allergies to medications; and b. vital signs, if necessary.A review of the facility's policy for Medication Administration that was dated 9/1/25 and was provided by the Director of Operations revealed the following: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 21. Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR.NJAC 8:39-11.2 (b), 29.2 (d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer Oxygen therapy according to the physician's orders for 2 of 3 residents reviewed for Respiratory therapy, Resident #16 and #53. 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. 1. On 12/29/2025 at 11:00 AM, the surveyor observed Resident #16 in bed on a specialty mattress, with Oxygen (O2) delivered via a nasal cannula (NC) tubing attached to the O2 concentrator at 2.5 Liters per minute (LPM). On 12/30/25 at 11:05 AM, the surveyor observed Resident #16 in bed on a specialty mattress, with O2 delivered via a NC tubing attached to the O2 concentrator at 2.5 Lpm. The surveyor reviewed the medical record for Resident #16. A review of the admission Record reflected the Resident was admitted to the facility with diagnoses that included but were not limited to; dementia (loss of mental functioning), hypertension (high blood pressure, a condition where the force of blood against artery walls is too high, making the heart work harder) and coronary artery disease (a narrowing or blockage of coronary arteries, which supply oxygenated blood to the heart.) A review of Resident #16's quarterly MDS dated [DATE] revealed Resident #16 had a BIMS score of 00 out of 15, which indicated the resident had a severe cognitive impairment. The MDS further revealed that Resident #16 was dependent on staff for ADL care, and section O indicated that the resident received special respiratory treatments, which included O2 therapy. A review of Resident #16's Care Plan had a focus that indicated the resident exhibited or was at risk for cardiovascular symptoms or complications related to diagnoses of hypertension and coronary artery disease, with interventions that included but were not limited to; Resident uses O2 at 3 LPM via NC. A review of the current Order Summary Report reflected a Physician's Order (PO) for O2 at 3 LPM via NC tubing continuously every shift with a start date of 09/06/2023. On 12/30/25 at 11:10 AM, the surveyor showed the Licensed Practical Nurse (LPN #1) assigned to Resident #16's care the O2 flow rate. LPN #1 confirmed that the gauge was set at 2.5 LPM but should have been set at 3 LPM per the Physician's orders. LPN #1 further stated that she usually checked the O2 gauge each morning, but had not checked it that morning. 2. On 12/29/25 at 11:00 AM, the surveyor observed Resident #53 in bed with their eyes closed. Resident #53 was further observed receiving O2 via NC currently running at 3 LPM. On 12/29/25 at 11:25 AM, the surveyor reviewed Resident #53's medical record, which revealed the following:The surveyor reviewed the admission Record which revealed that the resident had been admitted to the facility with diagnoses that included chronic kidney disease (progressive damage and loss of kidney function), chronic atrial fibrillation (irregular heartbeat that may cause the heart to beat faster than usual), and cardiomyopathy (disease of the heart muscle). A review of the admission MDS, dated [DATE], revealed that the resident had a BIMS score of 8 out of 15, which indicated moderate cognitive impairment. The MDS also reflected that the resident received continuous O2 therapy. A review of Resident #153's CP had a focus that indicated respiratory therapy for improvement in pulmonary function related to poor lung expansion; the CP did not include interventions for following the physician's orders for O2 administration. A review of the December 2025 PO for Resident #53 included a PO dated 12/2/25, Oxygen at 2 L/min via Nasal Cannula every shift for hypoxia. On 1/2/26 at 9:11 AM, in the presence of LPN#2, the surveyor observed Resident #53's O2 machine set at 2.5 LPM. LPN#2 stated Resident #53 was on continuous O2 at 2 L/min; unable to state why the O2 was set at 2.5 LPM. On 1/2/26 at 11:35 AM, the Director of Nursing (DON) provided the surveyor with a facility policy titled, Oxygen Concentrator, with a reviewed date of 9/1/25 .The policy explanation section revealed, 4.a. The nurse shall verify the physician's orders for the rate of flow and route of administration of oxygen. Plug the unit in and turn the unit on to the desired flow rate. On 1/2/26 at 12:43 PM, the surveyor met with the DON, Licensed Nursing Home Administrator (LNHA), and [NAME] President of Operations (VPO) to review concerns identified during the survey. The DON stated that all O2 settings should match the PO. On 1/5/26 at 11:37 AM, the survey team met with the DON, LNHA, VPO, and Regional Director of Nursing (RDON) for the exit conference. No further pertinent information provided. NJAC 8:39- 27.1 (a)

Based on observation, interview, and review of the facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms. The deficient practice was observed on 1 of 5 units ([NAME] Unit). The deficient practice was evidenced by the following:On 12/31/25 at 9:30 AM, the surveyor toured the [NAME] nursing unit and observed the following: In room [ROOM NUMBER], the floor was discolored and had black smudge marks throughout.In room [ROOM NUMBER], the floor was discolored and soiled, with black smudge marks throughout.In room [ROOM NUMBER], the wall across from the door, by the bed, was cracked, exposing wallboard, and the floor was discolored.In room [ROOM NUMBER], the floor was stained and soiled with a brownish substance, with black smudge marks throughout.In room [ROOM NUMBER], the wall across from the door and window bed was soiled with chipped paint and exposed wallboard.In room [ROOM NUMBER], molding was missing across the entire wall, and cracks exposed the wallboard. Floor heavily stained with brown substance and black smudge marks throughout.In room [ROOM NUMBER], the wall across from the bed, near the door, had chipped paint revealing exposed wallboard, and the floor was heavily stained with a brown substance. On 12/31/25 at 9:45 AM, during an interview with the surveyor, the maintenance floor technician acknowledged that the floors needed to be cleaned, waxed, buffed, and/or replaced. On 1/2/25 at 9:00 AM, the surveyor presented the above concerns to the director of maintenance/housekeeping (DOM/H). The DOM/H confirmed that the above conditions were not conducive to a clean, homelike environment and that the floors needed to be deep-cleaned, stripped, and waxed or replaced, and the walls needed to be repaired. On 1/2/26 at 12:44 PM, the survey team met with the Director of Nursing (DON), Licensed Nursing Home Administrator ( LNHA), and [NAME] President of Operations (VPO) to discuss the above observations and concerns. A review of the facility's policy, Safe and Homelike Environment, dated as reviewed 9/1/25, reflected .In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment . On 1/5/25 at 11:30 AM, the survey team met with the DON, LNHA, VPO and Regional DON. No further information was provided. NJAC 8:39-4.1(a)11. 31.4 (a), (b), (c), (f)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 3 of 27 residents reviewed for accommodation of needs (Resident #16, 80, and 101), and was evidenced by the following: 1. On 12/29/2025 at 10:50 AM, the surveyor observed Resident #101 in bed with their eyes open and the call bell (a device used to summon the staff for assistance) on the floor, not within the resident's reach.The surveyor reviewed the medical record for Resident #101. A review of the admission Record reflected the Resident was admitted to the facility with diagnoses that included but were not limited to; dementia, (a broad term covering various brain conditions that affect thinking, memory and behavior), Parkinson's disease (a degenerative brain disorder that damages dopamine-producing neurons) and diabetes mellitus (a disease of inadequate control of blood levels of glucose). A review of Resident #101's quarterly Minimum Data Set (MDS), an assessment tool dated 10/31/25, revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident had a moderate cognitive impairment. The MDS further revealed that Resident #101 required staff assistance with activities of daily living (ADL). A review of Resident #101's Individualized Care Plan (CP) had a focus that indicated the resident had an ADL self-care performance deficit related to Parkinson's disease, with interventions that included but were not limited to; encourage the resident to use the call bell for assistance. 2. On 12/29/2025 at 11:00 AM, the surveyor observed Resident #16 in bed on a specialty mattress, with oxygen infusing at 2.5 Liters per minute via nasal cannula tubing. The surveyor observed that the call bell was behind Resident #16's privacy curtain on their roommate's table, not within the Resident's reach. The surveyor reviewed the medical record for Resident #16. A review of the admission Record reflected the Resident was admitted to the facility with diagnoses that included but were not limited to; dementia, hypertension (high blood pressure, a condition where the force of blood against artery walls is too high, making the heart work harder) and coronary artery disease (a narrowing or blockage of coronary arteries, which supply oxygenated blood to the heart.) A review of Resident #16's quarterly MDS dated [DATE] revealed Resident #16 had a BIMS score of 00 out of 15, which indicated the resident had a severe cognitive impairment. The MDS further revealed that Resident #16 was dependent on staff for ADL care. A review of Resident #16's CP had a focus that indicated the resident was at risk for falls, with interventions that included but were not limited to: ensuring that when the resident was in bed, all personal items were within their reach.3. On 12/29/25 at 11:05 AM, the surveyor observed Resident #80 in bed. The surveyor observed the call bell on the floor, under the bed frame, not within the resident's reach. The surveyor reviewed the medical record for Resident #80. A review of the admission Record reflected the Resident was admitted to the facility with diagnoses that included but were not limited to; Alzheimer's Disease (a progressive brain disease causing dementia). A review of Resident #80's annual MDS dated [DATE] revealed Resident #80 had a BIMS score of 00 out of 15, which indicated the resident had a severe cognitive impairment. The MDS further revealed that Resident #80 was dependent on staff for ADL care. A review of Resident #80's CP had a focus that indicated the resident was at risk for falls, with interventions that included but were not limited to; anticipate and meet the resident's needs and encourage the resident to participate in activities. On 12/30/25 at 11:15 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) confirmed that nurses and Certified Nursing Assistants should make frequent rounds to ensure that when residents were in bed, their call bells were placed within reach. On 12/30/25 at 11:20 AM, during an interview with the surveyor, the Program Director confirmed that all residents should have their call bells within reach. On 1/2/26 at 12:44 PM, the survey team met with the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA), and [NAME] President of Operations (VPO) to discuss the above observations and concerns. A review of the facility's Call Light: Accessibility and Timely Response dated 9/1/25 reflected.The purpose of this policy is to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. The call system will be accessible to residents while in their beds. NJAC 8:39-27.1 (a); 31.8 (c) (9)

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: On 08/01/24 at 10:29 AM in the presence of the Food Service Director (FSD) and the Regional FSD (RFSD) the surveyor observed the following: 1. Inspection of the Microwave unit revealed the interior to have multi-colored splattered food debris stuck to the interior upper wall. 2. During inspection of the oven the surveyor observed 3 cast iron grill plates that were visibly used, dirty with solidified grease in the oven. The FSD stated they had been used the night before. On 08/05/24 at 10:15 AM, the surveyor interviewed the FSD. who stated that the cooking equipment should have been removed from the oven and cleaned after use. It needs to be cleaned and maintained in a sanitary way to prevent food borne illness and contamination. The microwave should be thoroughly cleaned daily in the evening. The FSD acknowledged that the above items should have been cleaned. On 08/05/24 10:30 AM, the surveyor interviewed the RFSD. who stated that the cooking equipment should have been cleaned and maintained in a sanitary way to prevent food borne illness and contamination according to regulations. It did not meet supervisory expectations, facility policy or regulations. A review of the facilities General Kitchen Cleaning Policy, dated revision February 2024, revealed . Policy: The staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. A review of the facilities Food Borne Illness Policy, dated revision 1/2024, revealed . Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Definitions: Contamination means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. Policy Explanation and Compliance Guidelines: 1) Food safety practices shall be followed throughout the facility's entire food handling process. Elements of the process include the following: c.) Preparation of food, including thawing, cooking, cooling, holding, and reheating. 6) All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. a) Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. NJAC 8:39-17.2(g)

Complaint #NJ00174420 Based on interviews, and record reviews, it was determined that the facility failed to provide pharmaceutical services by ensuring the resident did not receive a medication not ordered by the physician. The medication, metformin, (medication used to help lower blood sugar levels in people with type two diabetes- a chronic condition that happens when you have persistently high blood sugar levels) was given to Resident #395 without a valid physician order. The deficient practice was identified for one (1) of 28 residents, (Resident #395) reviewed for medication management. The deficient practice was evidenced by the following: Resident #395 was not in the facility; the surveyor conducted interviews and investigated the closed records. A review of the electronic health records (EHR) revealed the resident with a diagnosis of but not limited to diabetes mellitus II with hyperglycemia (a condition in which the level of glucose in the blood is higher than normal). According to the order summary in the EHR revealed orders for: tradjenta 5mg one tablet a day for diabetes; insulin glargine solution 100 unit/ml, inject 22 units subcutaneously at bedtime for diabetes; Humalog injection solution 100 unit/ml (Insulin Lispro) as per sliding scale and every 4 hours insulin check x 24 hours ordered on 6/1/24. The admission minimum data set (MDS), an assessment tool, dated 5/6/24 revealed a brief interview mental status (BIMS) score of 11 out of 15 indicating moderate impaired cognition. A review of the care plan revealed care plan for diabetes, diabetes medication as ordered by doctor. According to the nurse's progress notes, a registered nurse (RN) on 6/1/24 stated, Followed up for the report by the other nurse of administering the metformin 500 mg PO @ 17:18 PM. Resident's blood sugar was checked after taking the said medication & showed a result of 131 mg/dl, rechecked again 19:35 = 162 mg/dl & @ 21:32 is 177 mg/dl. Remains alert & oriented x3, claim he/she does not feel any side effects. Blood sugar is monitored every 4 hours. A review of the progress notes from 6/1/24 through 6/4/24 revealed resident had no negative outcome or issues of low blood sugar with the incident. The surveyor reviewed documentation titled, Employee Medication Error dated 6/3/24, which revealed on 6/1/24 an agency LPN #1 nurse accidentally administered metformin 500mg to resident in room [ROOM NUMBER]-D thinking it was resident in 14-W. The resident's spouse, assistant director of nursing (ADON) and medical doctor were notified. The physician ordered to monitor blood sugar every four hours for 24 hours and the resident had no negative outcomes. The nurse who admitted to giving the metformin to the wrong resident was educated and medication pass was completed on 6/3/24. On 8/7/24 at 11:00 AM, the surveyor interviewed the unit manager (UM) in the [NAME] Unit, LPN #2, who has been working in the facility for two years. The UM stated, The patient was pleasant, I don't recall having any complaints from the resident, he/she would be smiling. I was told that the patient was given the wrong medication. The process is to contact the doctor when there is a medication error, make the Director of Nursing (DON) aware, and follow doctor's orders. Inform emergency contact if patient is not alert and oriented. The nurse stated that she went into the wrong room thinking it was another room. The patient was monitored, checking the blood sugars a few times and no abnormalities found and patient remained stable. On 8/7/24 at 11:53 AM, the surveyor interviewed the DON, who started working in the facility since last February of 2024. The DON stated, The resident had no other complains or grievances. It was reported to me that the LPN #1 went to the room and gave the medication to the wrong patient. I think the nurse realized the wrong medication was given when she signed it on the medication administration record (MAR) and realized it was the wrong patient. She's a very good nurse. Upon coming here, the agency nurse usually gets an orientation packet. They must be med pass and we have a schedule for the med pass. The nurse did not have any previous infractions. The surveyor requested for the LPN's #1 medication pass and medication administration education on policies. On 8/7/24 at 12:30 PM, the DON provided the medication pass observation for LPN #1 which was completed before this incident on 9/11/23, with no issues. On 8/7/24 at 1:30 PM, in the presence of the survey team, the surveyor discussed the concern of metformin administration to the wrong resident, to the administration: License Nursing Home Administrator (LNHA), DON, Director of Clinical Services, MDS Regional, Regional Nurse, and Administrator in Training (AIT). No additional documentations were provided. On 8/8/24 at 9:26 AM, the DON provided the most current facility policy and procedure titled, Medication Administration and reviewed on 7/1/24. The policy stated, Ensure that the rights of medication administration are followed: right resident; right drug; right dosage; right route; and right time. NJAC 8:39-29.2(b), (d); 29.3(a)6

Based on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 1 of 28 residents reviewed (Resident # 132). The deficient practice was evidenced by the following: The surveyor reviewed Resident # 132's records. The resident was discharged from the facility and according to the Discharge Return Not Anticipated MDS, an assessment tool used to facilitate the management of care, dated 5/3/24, the resident was assessed as being discharged to the hospital. A review of Resident # 132's progress notes dated 5/3/24 revealed the resident was discharged home with family. On 8/8/24 at 12:50 PM, the surveyor interviewed the MDS Coordinator, who stated that the MDS dated [DATE] should have indicated discharge to home or lesser care and that it was an error that it indicated discharge to the hospital. During an interview on 8/8/24 at 1:30 PM, the surveyor brought the above concerns to the attention of the Director of Nursing and Administrator. NJAC 8:39-11.2(e)1

Based on interview, and review of other facility documentation, it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and apply for a change in name to include Doing Business As in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services, or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing or contracting with individuals or entities that meet either of the following conditions: (i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act. (ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76 (d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes: (1) Within 30 days - (i) A change of ownership; (ii) Any adverse legal action; or (iii) A change in practice location. (2) All other changes in enrollment must be reported within 90 days. A review of the facility Admission agreement revealed under the facility name section as Complete Care at Barn Hill Center. A review of the Census Report revealed the name of the facility as Complete Care at Barn Hill Center. The Business cards provided to the surveyors upon entrance reflected the facility name as Complete Care at Barn Hill. During an interview with the surveyor on 8/6/24 at 11:04 AM, an interview with Licensed Nursing Home Administration (LNHA) stated that the Facility is called Complete Care at Barn Hill and this is according to signage outside of the facility, it is also documented on the facility's policies and procedures and printed clinical documentation. The surveyor indicated that the above noted documents do not match the documentation according to CMS Novitas, dated October 2026, whcih revealed Legal Business Name (LBN): COMPLETE CARE AT BARN HILL LLC Doing Business As Name: BARN HILL CARE AND REHAB CENTER. The surveyor asked if the facility had filed a 855 B form and the LNHA explained that they have not done the 855B form and that they would need to do one to change the DBA name to Complete Care at Barn Hill. The LNHA was only able to provide the surveyor with a LSC-9 application for a long term care facility license which revealed DBA Barn Hill Care and Rehab Center. A review of the facility license that was issued by the New Jersey Department of Health Division of Certificate of Need and Licensing with an issue date of April 1, 2024, and an expiration date of March 31, 2025 revealed under name licensed to operate Barn Hill Care and Rehab Center and not Complete Care at Barn Hill. NJAC 8:39-5.1 (a)

Complaint # NJ172653 Based on interviews, medical record review, and review of other pertinent facility documents on 04/08/2024 and 04/09/2024, it was determined that the facility failed to develop and implement a NPO (Nothing by Mouth) Care Plan (CP) for a resident (Resident #2) with a Peg Tube (a tube inserted through the wall of the abdomen directly into the stomach, it can be used to give drugs and enteral nutrition to a patient) and failed to follow its policy titled Care Plans, Comprehensive Person-Centered. This deficient practice was identified for 1 of 3 residents reviewed for CP and was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to the Admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to Dysphagia, Pneumonia, Acute Chronic Kidney Failure and Obstructive Reflux Uropathy. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 02/08/2024, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 3/15, which indicated the resident was severely cognitively impaired. The MDS also indicated the resident was admitted with a Feeding tube. A review of Resident #2's CP initiated on 02/03/2024 did not reveal evidence of a NPO CP being placed. During an interview on 04/09/2024 at 12:38 p.m. the Surveyor asked if Resident #2 should have had a NPO CP in place, The Licensed Practical Nurse (LPN) stated, Yes, there should have been a CP initiated upon admission for Resident #2's NPO status. She further stated the importance of the CP is to show how a resident care is to be provided and how the interventions should be followed. A review of Resident #2's Progress Notes (PNs) dated 02/03/2024 through 02/08/2024 revealed documentation of the resident's NPO status been maintained. During an interview on 04/08/2024 at 1:23 p.m., the Certified Nursing Aide (CNA) assigned to Resident #2 stated she was aware of Resident #2's NPO status from the shift-to-shift report given by Resident #2's Nurses. She further revealed Resident #2 had a blue dot [a system the facility used to indicate NPO status for residents] on his/her room door, name identification bracelet and at the head of their bed which was an indication of their NPO status. During an interview on 04/09/2024 at 12:51 p.m., the Assistant Director of Nursing (ADON) stated, The purpose of the CP is to ensure continuity of care for the residents and that the proper care is provided to the residents. She stated that the NPO CP should have been initiated upon admission. When presented with Resident #2's CP, the ADON stated, I don't see a CP for NPO. A review of the facility's Care Plans, Comprehensive, Person-Centered revised 10/2022 under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs developed and implemented for each resident. N.[NAME].C.: 8:39-11.2(d)(2)

Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was observed for 16 of 24 residents (Resident #81, #15, #74, #18, #70, #167, #68, #12 #57, #106, #366, #98, #7, #115, #83, and #19) reviewed and occurred over several months. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above that revealed the resident's primary physician had not hand signed the Order Summary Reports (monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident #81's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . December 2021's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident #15's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident #74's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Resident #18's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Resident #70's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/03/22 at 12:17 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated it was her understanding that the physicians come monthly. The LPNUM stated she was not aware of the process of who checks to make sure the physicians are signing their orders. 6. Resident #167's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Resident #68's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Resident #12's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 9. Resident #57's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 10. Resident #106's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/03/22 at 12:12 PM the surveyor interviewed LPN #1 regarding the process for doctors signing their resident's monthly orders. LPN #1 stated the physicians sign orders electronically, however, LPN #1 was unable to show the surveyor that physicians had signed orders in the electronic record. 11. Resident #366's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 12. Resident #98's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 13. Resident #7's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 14. Resident #115's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/4/22 at 11:30 AM, the surveyor asked LPN #2, where the physician's signed their orders. LPN #3 said they sign the medical record electronically. 15. The hybrid medical records of Resident #83 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/3/22 at 12:22 PM, the surveyor interviewed LPN #2 about where the physicians sign the orders for residents. LPN #2 stated the physicians sign in the resident's electronic chart. 16. Resident #19's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/4/22 at 1:05 PM, the surveyors discussed the above concern with the Administrator, Director of Nursing (DON), Regional Clinical Specialist and Regional Administrator. On 3/8/22 at 12 PM, the DON provided the surveyor with the facility's policy titled Physician Orders. Under Process #5 indicated the following: All orders must be signed by an authorized, credentialed physician or other authorized practitioner in accordance with state regulations regarding prescriptive privileges. NJAC 8:39-23.2

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control procedures in a manner that would decrease the possibility of spreading infection. This was found with: 1 of 2 certified nursing assistants (CNA) during urinary drainage bag changes, 1 of 5 nurses during medication administration and 1 of 3 nurses during wound care observation. The deficient practice was evidenced by the following: 1. On 3/1/22 at 10:12 AM, the surveyor observed the CNA who was assigned to Resident #83 change their large urinary drainage bag to a urinary leg bag. The resident had a urinary catheter (A flexible tube used to empty the bladder and collect urine in a drainage bag). The CNA, with gloved hands, pulled a garbage can towards her, removed her gloves, and put on a new pair of gloves. The CNA did not perform hand hygiene and continued the task of changing the urinary drainage bags. The CNA disconnected the large drainage bag from the catheter and laid the urinary catheter tubing on the inside of the resident's soiled incontinent brief. The CNA then cleansed the leg bag connection tip with an alcohol swab and connected the tube to the catheter. The CNA placed the large drainage bag on the foot of the resident's bed while she retrieved a clear plastic bag for storage. The tube attached to the large drainage bag was not capped and was touching the bed. The CNA placed the large drainage bag with uncapped tubing in a clear plastic bag and placed it in the resident's bed side table. The CNA went to the resident's bathroom, removed her gloves, and washed her hands. The CNA lathered her hands outside of running water for 9 seconds. On 3/2/22 at 1:05 PM, the surveyor interviewed the CNA, about the techniques used and observations during the change of the drainage bags for Resident #83. T he CNA stated, I should have connected the new bag immediately. The surveyor asked the CNA about the storing of the drainage bag and if there was a cap for the drainage bag. The CNA acknowledged there should have been a cap for the drainage bag and said, they go missing and there are times a new drainage bag is used or bags are stored without a cap. The CNA acknowledged the drainage bag should be stored with a cap on and said she had not reported to nurse or unit manager when a cap was missing. The surveyor asked the CNA about the facility's hand hygiene policy. The CNA stated hand hygiene should be performed at least 30 seconds or you can sing the happy birthday song. The surveyor reviewed the Resident #83's hybrid medical records (paper and electronic) which revealed the following: According to the Admission Record, Resident #83 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set assessment tool, dated 1/25/22, indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15. On 3/2/22 at 1:37 PM, the surveyor informed the Administrator, the Director of Nursing (DON), Regional Clinical Specialist and Regional Administrator of the concerns during the urinary drainage bag change observation. On 3/3/22 at 10:50 AM, the DON provided the policies and procedures for hand hygiene and changing of urinary bags. The surveyor reviewed the facility's policy and procedure revised on 12/21, titled, Policy and Procedure for Changing of Urinary Bags. Under Policy, it read It is the policy of the facility to decrease the incidences of nosocomial infections by utilizing clean techniques when a drainage bag or leg bag is disconnected. Under Procedure, it read 8. Carefully remove sterile cap over the connection tip on leg bag or bedside drainage bag being switched to. 10. Carefully apply sterile cap to drainage system being switched from. The surveyor reviewed the facility's policy and procedure updated on 3/2021, titled, Handwashing/Hand Hygiene. Under Policy Interpretation and Implementation, it read: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .m. After removing gloves . and 9. The use of gloves does not replace handwashing/hand hygiene. Under Washing Hands, it read 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds. 2. On 3/3/22 at 8:40 AM, the surveyor observed the Licensed Practical Nurse #1 (LPN #1) administer medication to Resident #116. LPN #1 administered an eye drop medication to each eye to Resident #116. The surveyor observed LPN #1 use the same tissue for each eye when giving eye drops. On 3/3/22 at 8:50 AM, the surveyor spoke with LPN #1 about observation of using same tissue for both eyes. LPN #1 said she used different corners of tissue for each eye. On 3/3/22 at 12:53 PM, the surveyor informed the Administrator, the DON, and two regional directors of the above concerns. On 3/4/22 at 9:50 AM, the DON provided policy and procedure for eye drop administration. The surveyor reviewed the facility's policy and procedure reviewed on 11/21, titled Eye-Drop Administration. Under Procedure, it read 8. Gently dry the eyelid with a tissue if dripping occurs. (Note: Use only one tissue per eye.). 3. On 3/4/22 at 10:32 AM, the surveyor observed LPN #2 perform a wound treatment to the sacrum of Resident #115. After washing her hands LPN #2 removed a wet paper towel that had fallen in the sink. The LPN then donned gloves without performing any hand hygeine after removing the wet paper towel from inside of the sink. LPN #2 prepared supplies on the overbed table after sanitizing it and establishing a clean field, removed the old dressing from the resident's sacrum, and sprayed the wound on the sacrum with saline wound wash. LPN #2 then squeezed Santyl (a [MEDICATION(S)] ointment) onto a tongue blade and wiped it into the wound, while LPN #2 was wiping the Santyl into the wound, the can of saline wound wash fell on the floor. LPN #2 picked up the can of saline wound wash with her gloved hand and placed it back onto the overbed table. Without changing gloves or performing any hand hygeine, LPN #2 picked up the calcium alginate (an absorbent dressing) and placed it into the wound, she then pressed it into the wound with a cotton swab. LPN #2 covered the wound with foam gauze and returned the can of saline wound wash to an opened zip lock bag and placed it into the treatment cart. She did not sanitize the over bed table when she was done. On 3/4/22 at 12:02 PM, the surveyor spoke to LPN #2 and asked her about the observation of her removing the wet paper towel from the sink and not performing any hand hygeine. LPN #2 said she recognized that she dropped the paper towel in the wet sink but she used another paper towel to remove it. The surveyor then asked her about the can of saline wound wash that she picked up from the floor. LPN #2 said that she should not have picked up the can of saline wound wash from the floor and continued with the treatment without any hand hygiene. The surveyor then asked about spraying the wound with the saline wound wash and then returning the can back to the treatment cart in an open ziplock bag. LPN #2 agreed with the risk of splash back onto the spray can. LPN #2 showed the surveyor the can in the treatment cart that was in an open zip lock bag. LPN #2 showed the surveyor that the zip lock bag could be closed with the can inside and that it was labeled for and dedicated to resident # 115. She said she could have used a disinfectant wipe before putting the can of saline wound wash back in the treatment cart. On 3/4/22 at 1:00 PM, the surveyor discussed the wound treatment concerns with the Director of Nursing, (DON), the Administrator, Regional Clinical Specialist and Regional Administrator. They were in agreement that the concerns were infection control issues. On 3/7/22 at 11 AM, the surveyor reviewed the facility's policy and procedure titled Dressings, Dry/Clean and updated 10/2021. Under Preparation number 4 read Wipe nozzles of wound [cleanser] with alcohol pledget or facility disinfectant wipe. (Note: this may be performed at the treatment cart). Number 22 read Clean the bedside stand. NJAC 8:39-19.4 (a)

Based on observation, interview, and record review it was determined that the facility failed to properly label and date medications in 1 of 8 medication carts and 1 of 3 medication storage rooms inspected. The deficient practice was evidenced by the following: 1. On 2/28/22 at 12:26 PM, the surveyor inspected the medication cart on the Franklin unit in the presence of the Licensed Practical Nurse (LPN) who was assigned to the cart. There was a [MEDICATION(S)] insulin vial box with a resident's last name written with a marker on the box. The [MEDICATION(S)] insulin vial removed from inside the box, had written in marker a different resident's last name. There was a second [MEDICATION(S)] insulin vial box with a pharmacy label. The [MEDICATION(S)] insulin vial removed from inside the box, had written in marker, the resident's last name which was smeared and only partially visible. There was no pharmacy label on the vial. An [MEDICATION(S)] insulin pen (A device used to inject insulin. It contains a cartridge, a dial to measure dosage, and a disposable needle), had a resident's first name written in marker on it and there was no pharmacy label. At that time, the surveyor asked the LPN about the insulin vials and pens with resident's name written in marker, she stated the pharmacy labels come off. On 2/28/22 at 12:40 PM, the surveyor inspected the medication room refrigerator on the Franklin unit with the LPN. Inside the refrigerator was a [MEDICATION(S)] insulin pen. There was a pharmacy label with the date of 2/19/22. The plastic bag containing the insulin pen read Refrigerate until opened. The LPN acknowledged unopened insulin pens should have been stored in the refrigerator and said she didn't know if the pen was unused as she was not the nurse who wrote the date on the medication. On 3/1/22 at 1:40 PM, the surveyor spoke with the Administrator, the DON, the Regional Clinical Specialist and Regional Administrator of the above concerns. On 3/2/22 at 9:55 AM, the surveyor reviewed the facility's policy and procedure titled, Storage of Medications, with the revised date of November 2021. Under Policy Interpretation and Implementation it read, 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing and 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. The surveyor reviewed the facility's policy and procedure, titled Administering Medications, updated on 10/2021. Under Policy Interpretation and Implementation it read, 14. Insulin pens will be clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse will verify that the correct pen is used for that resident. NJAC 8:39-29.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for 1 of 1 resident (Resident #15) reviewed for respiratory services. The deficient practice was evidenced by the following: On 2/25/22 at 8:22 AM, the surveyor observed Resident #15 in bed awake and alert receiving oxygen (O2) via a nasal cannula at 4 l/m (liters per minute) and a [CONDITION(S)] (continuous positive airway pressure to prevent the collapse of airway) mask on the nightstand not secured in a plastic bag. During the interview with resident, the resident stated that the nurses do not clean the mask. On 3/4/22 at 10:38 AM, the surveyor observed the resident in bed awake and alert with O2 via nasal cannula at 4 l/m O2 and the [CONDITION(S)] mask was in a plastic bag. The surveyor asked the resident if the tubing gets changed and she replied yes, they change it weekly, but they still haven't cleaned my mask. On 3/4/22 at 12:12 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPNUM) who stated that the night shift nurse takes off the [CONDITION(S)] mask and they should wash it with soap and water. The surveyor reviewed Resident #15's hybrid medical records (paper and electronic) that revealed the following: According to the Admission Record, Resident #15 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set an assessment tool dated 2/14/22, indicated that the facility performed a Brief Interview for Mental Status which the resident scored a 14 out of 15. The score of 14 indicated that the resident was cognitively intact. The March 2022 Physician's Order Summary Sheet revealed the following order [CONDITION(S)] Pressure: [CONDITION(S)] or IPAP and EPAP Back-Up Rate: 15/5 Oxygen Liter Flow (for bleed in): 4 LPM Apply at HS and remove in AM. Interface type: Nasal Pillows/Mask/ Full face mask Humidification (if appropriate) Heated or Cool Fill humidifier with sterile or distilled water. every evening and night shift. This order was initiated on 2/3/22. The March 2022 Electronic Treatment Administration Record (ETAR) reveal the above order was initiated on 2/3/22 and the nurses signed the ETAR 12 AM - 8 AM and 4 PM - 12 AM daily. The care plan titled [the resident] has oxygen therapy r/t (related to) CHF, ineffective gas exchange, respiratory illness. The interventions do not include how to care for the [CONDITION(S)] equipment. According to the manufacturer's specifications the [CONDITION(S)] mask should be cleaned every day. The mask can be cleaned with mild soap where it touches face or nose to clean the facial oils from the seal. Then rinse the mask with warm water and sit the mask on a paper towel or hang to let air dry. On 3/7/22 at 11:22 AM, the surveyor observed the resident in bed awake and alert, and the [CONDITION(S)] mask lying on the nightstand not secured in a plastic bag. The surveyor asked the resident if the [CONDITION(S)] mask was being cleaned in the morning when removed. The resident stated, they still don't clean the mask. The surveyor asked the LPNUM to come to the resident's room. The LPNUM looked at the nightstand and stated, the mask should be in a plastic bag. The LPNUM restated to the surveyor that the nurse who removes the [CONDITION(S)] mask should wash it with soap and water. The surveyor and LPNUM reviewed the physician's orders. There was no physician's order for the care of the [CONDITION(S)] equipment. There was no documentation in the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/7/22 at 12:13 PM, the surveyor returned to the resident's room and observed the [CONDITION(S)] mask was still on the nightstand not secured in a plastic bag. On 3/7/22 at 1:00 PM, the surveyor discussed with the Administrator, Director of Nursing, Regional Clinical Specialist and Regional Administrator the above concern and that the mask was still on the nightstand not secured in a plastic bag even after the LPNUM had observed it. The surveyor reviewed the facility's policy titled [CONDITION(S)] [CONDITION(S)] dated 5/2021, under Procedure #8 The machine, tubing and masks must all be cleaned according to manufacturer's instructions and facility policy. A review of the facility's policy titled B-PAP/C-PAP Cleaning Policy indicated the following Mask and filter should be cleaned weekly in warm soapy water and rinsed in warm water. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to follow physician's orders and failed to handle medication appropriately. This was found with 2 of 24 residents reviewed, Resident # 115 and Resident # 81. 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 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. 1. On 2/24/22 at 11:19 AM, the surveyor observed Resident #81 seated in the wheelchair in the activity room. During an interview with the resident, the resident informed the surveyor that he/she doesn't always get their medications and many times not on time. The surveyor asked the resident if they had received their medications today. The resident replied no. After completing the interview with the resident, the surveyor interviewed Licensed Practice Nurse #1 (LPN #1) who was assigned to the resident. The surveyor asked the nurse if she had given the resident the 9 AM medications. LPN #1 replied yes. Resident #81 had come up behind the surveyor and quickly stated no you didn't. LPN #1 stated she would check. LPN #1 opened the medication cart and went into the locked narcotic box and took out an unlabeled medicine up with pills inside and stated that these were the medications for the resident. LPN #1 stated she had poured the medications and realized the resident wasn't in the resident's room. She stated she put the medicine cup with the resident's prescribed medication in the narcotic box. LPN #1 agreed it was not best practice to store the medications in the narcotic box. The surveyor asked what time the medications are scheduled to be administered and LPN #1 stated 9 AM. She agreed that the medications should be administered at the time they are scheduled. The surveyor reviewed Resident #81's the electronic medical records (EMR) that revealed the following: According to the Admission Record, Resident #81 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) an assessment tool dated 1/23/22, the facility performed a Brief Interview for Mental Status that revealed a score of 15 out of 15 indicating the resident was cognitively intact. The February 2022 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMAR Resident Details form showed an administration history for all the medications listed above that were due at 9 AM were given between 11:47 AM and 11:55 AM. On 2/24/22 at 12:54 PM, the surveyor discussed the above concern with the Administrator, Director of Nursing (DON), Regional Clinical Specialist and Regional Administrator. The DON provided the surveyor with the Administering Medication policy. The surveyor reviewed the policy titled Administering Medication with an update dated 10/2021. Under Policy Interpretation and Implementation #3 and #4 revealed the following, Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Surveyor: [NAME], [NAME] A. 2. On 2/24/22 at 11:45 AM, the surveyor observed Resident #115 in bed. The resident was on their back asleep. On 2/28/22 at 11:35 AM, the surveyor observed Resident #115 on their back in bed asleep. On 3/1/22 at 9:41 AM, the surveyor observed Resident #115 asleep in bed on their back. On 3/1/22 at 12:34 PM, the surveyor observed Resident #115 asleep in bed on their back. On 3/2/22 at 1:21 PM, the surveyor observed Resident #115 asleep in bed on their back. The surveyor reviewed the Resident #115's medical record which revealed the following: According to the Admission Record, Resident #115 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Treatment Administration Record (TAR) with a physician's order that read Ensure resident is turned and reposition side to side q 2 hrs (every 2 hours). Resident should only be on [the] back during meals. The order date was 1/4/22. The order was initialed by a nurse every day to indicate that the order was being followed. A quarterly MDS dated [DATE] that indicated the resident had severely impaired cognition and was rarely/never understood. On 3/7/22 at 11:28 AM, the surveyor asked the LPN #2 about the resident being observed multiple times on the back when there was a physician's order for the resident to only be on the back during meal time. LPN #2 said the resident stayed on their back for about 15 minutes after eating. The surveyor informed LPN #2 that there were multiple observations of the resident on their back long after meal time. LPN #2 stated she was not aware. On 3/7/22 at 11:41 AM, the surveyor asked LPN #2 who was responsible for repositioning the resident. LPN #2 said the Certified Nursing Assistant (CNA) but that she signed for it. LPN #2 said the order should have read, turn and reposition every two hours and not that the resident should only be on their back during meals. She said she would call the doctor and have it changed. The Unit Manager/LPN was present and stated yeah, it's a funky order. She agreed that if the nurse was signing for it she was signing for the order as it was written. On 3/7/22 at 12:41 PM, the surveyor discussed the above concern with the Administrator, DON, the Regional Clinical Specialist, and Regional Administrator. The DON agreed that the nurse should have clarified the physician's order and not signed for it if it was not an accurate order. she would get NJAC 8:39-27.1 (a)

Based on interview and record review, it was determined that the facility failed to notify resident families or resdient representatives (RR), and the Ombudsman's office in writing for a facility-initiated transfer to the hospital for 6 of 6 residents (Resident #81, #15, #18, #167, #105, and #106) reviewed for hospitalization . The deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) that revealed facility-initiated hospital transfers had occurred without written notification to the families and Ombudsman's office for the following residents: 1. According to the Discharge Minimum Data Set (MDS) an assessment tool dated 11/16/21, Resident #81 was transferred to the hospital with anticipated return to the facility. There was no documentation that the facility had notified the resident's family or RR in writing regarding the reason for transfer and bed hold policy. In addition, the Ombudsman's office was not notified. 2. According to the Discharge MDSs dated 9/29/21, 11/5/21 and 1/25/22, Resident #15 was transferred to the hospital with anticipated return to the facility. There was no documentation that the facility had notified the resident's family or RR in writing regarding the reason for transfer and bed hold policy. In addition, the Ombudsman's office was not notified. 3. According to the Discharge MDSs dated 11/16/21 and 1/18/22, Resident #18 was transferred to the hospital with anticipated return to the facility. There was no documentation that the facility had notified the resident's family or RR in writing regarding the reason for transfer and bed hold policy. In addition, the Ombudsman's office was not notified. 4. The 2/2/22 MDS indicated the Resident #167 was discharged from the facility on 2/2/22 and anticipated to return to the facility. The Census tab indicated the resident was discharged to the hospital on 2/2/22 and readmitted to the facility on [DATE]. The surveyor interviewed Resident #167's resident representative (RR) on 3/2/22 at 11:30 AM. The RR stated the facility provided notification of the transfer by phone. The reason for emergency transfer and a review of the facility bed hold policy was not provided to the RR in writing. 5. The 1/18/22 MDS indicated the Resident #105 was discharged from the facility on 1/18/22 and anticipated to return to the facility. The Census tab indicated the resident was transferred to the hospital on 1/18/22 and returned to the facility on [DATE]. There was no documentation that the family or RR, and Ombudsman's office were notified in writing for the reason of the transfer. 6. The 1/19/22 MDS indicated the Resident #106 was discharged from the facility on 1/19/22 and anticipated to return to the facility. The Census tab indicated the resident was transferred to the hospital on 1/19/22 and readmitted to the facility on [DATE]. There was no documentation that the family or RR, and Ombudsman's office were notified in writing for the reason of the transfer. On 3/1/22 at 1:13 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated families or RRs had not been provided with written notification of emergency transfer or provided with the facility's bed hold policy at the time of transfer. Additionally, the facility had not provided notification of resident emergency transfers to the New Jersey Long-Term Care Ombudsman (LTCO) office. On 3/3/22 the DON provided the surveyor with the facility policy titled Transfers-Bed Hold, revised 5/2021. The policy indicated before transfer the resident or RR is to be provided with written information of the bed hold policy. The policy did not address written notification of the reason for emergency transfer to the resident or RR or written notification to the LTCO office. NJAC 8:39-5.3

Based on observation, interview, and record review it was determined that the facility failed to provide full visual privacy and maintain confidentiality when discussing the resident's pain during medication administration and a physical assessment, for 1 of 24 residents reviewed, Resident #116. The deficient practice was evidenced by the following: On 3/3/22 at 8:40 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare to administer medication to Resident #116. The surveyor observed the LPN speaking to the resident from outside the doorway of the resident's room. The LPN entered the room of Resident #116 to administer medication and examine the resident's abdomen. The door to the room was open and the resident could be seen from the hallway lying in the bed. During the physical exam, the resident's abdomen was exposed, the resident's gown raised, and blankets were below the resident's waist. The LPN returned to the medication cart outside of the resident's doorway to prepare pain medication for the resident. The LPN spoke to Resident #116 from outside the doorway of the resident's room and asked about the resident's level of pain. The LPN repeated back the resident's answers from the doorway in a loud voice. On 3/3/22 at 8:50 AM, the surveyor spoke with the LPN about the observations of speaking to Resident #116 from outside doorway of the resident's room, examining the resident with the door open and the resident being visible from the hallway. The LPN acknowledged she should have closed the door when examining the resident and should have not asked questions from outside the room's doorway for resident privacy. The surveyor reviewed the medical record of Resident #116 which revealed the following: The Minimum Data Set assessment dated [DATE], revealed the resident scored 15 out of a possible 15 when the Brief Interview for Mental Status was done which indicated the resident was cognitively intact. On 3/3/22 at 12:53 PM, the surveyor spoke with the Administrator, the Director of Nursing (DON), the Regional Clinical Specialist and Regional Administrator about the above concerns. The DON provided the surveyor with policies as requested. On 3/4/22 at 9:50 AM, the surveyor reviewed the facility's policy and procedure dated 10/2021, titled Quality of Life-Dignity. Under Policy Interpretation and Implementation it read, 9. Staff shall maintain an environment in which confidential clinical information is protected .10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The surveyor also reviewed the facility's policy and procedure, dated 10/2021, titled Administering Medications, but it did not address the need to provide privacy. NJAC 8:39-4.1(a)12,16

Based on observation, interview, and record review it was determined that the facility failed to consistently provide coordination between facility staff and hospice agency staff to meet the resident's nursing needs. The deficient practice was identified for 1 of 2 residents (Resident #366) reviewed for hospice/end of life care and was evidenced by the following. On 2/24/22 at 11:18 AM, the surveyor observed Resident #366 in bed. The resident's family member was at the resident's bedside. The resident's family member said the resident was on hospice. The resident appeared weak, looked at the surveyor and mouthed words but did not speak. The resident's family member said the resident could no longer hear or see very well. The resident's family member said the hospice aide went to the facility to see the resident every day at 7 AM. On 3/1/22 at 10:12 AM, the surveyor reviewed the resident's hybrid medical record which revealed the following: According to the Admission Record, Resident #366 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 1/26/22 Significant Change Minimum Data Set assessment tool, indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 and was enrolled in a hospice program. The 1/25/22 facility hospice care plan included interventions to provide personal care, pureed diet with pleasure foods, emotional and spiritual support, and notify hospice of any changes in condition or medication changes. Inside of the front cover of the resident's paper chart contained a sheet that read This patient is under the care of [Name of Hospice Provider] as of 1/21/22. The first page in the resident's chart was a sheet of paper that read Nursing Home-Nursing Visit. The top line had the resident's name and it read On 1/27/22 a nursing visit was made by the [hospice providers name] nurse .Computer generated nursing notes to be put in patient chart at next planned visit. If this nursing note should be required before next visit, please feel free to call us. That visit sheet was signed by the nurse. There was no other paper work from the hospice provider in the chart. On 3/1/22 at 10:12 AM, the surveyor asked the Unit Clerk for the hospice documentation that wasn't in the paper chart. She looked in the chart and agreed that there was no hospice documentation. She said she would find out where it was. On 3/1/22 at 1:10 PM, the Director of Nursing (DON) provided documentation that she stated was just sent over from the Hospice provider. The DON said she didn't know why the hospice provider was not leaving any documentation on the chart but she would call the hospice provider and ask. On 3/1/22 at 1:45 PM, the surveyor spoke with the DON, Administrator, the Regional Clinical Specialist and Regional Administrator and mentioned the concern with there being no documentation in the resident's record by the hospice provider. They agreed that the hospice provider should have documented each time they saw the resident and it should be part of the record. On the last day of the survey the surveyor asked the DON if she was able to find out from the hospice provider why there was no documentation left in the facility. The DON said she had not heard from the hospice provider about it. On 3/7/22 at 11:44 AM, the surveyor called the hospice provider and spoke with a Registered Nurse Supervisor (RNS). The surveyor asked the RNS what paperwork was required to be left in the resident's chart at the facility. The RNS stated the plan of care and any orders we recommend, we have an IDT (Interdisciplinary Team) note, that is the note by the hospice nurse, and when we have our meetings every two weeks those notes are sent over after being reviewed by the team. Non skilled care notes by the hospice aide should be kept in the chart after every visit. The Hospice Nurse sees the resident 1-2 times per week minimum, depending on the need. The notes are available for the facility to request at any time between the IDT meetings. On 3/7/22 at 12:00 PM, the surveyor reviewed the facility's policy and procedure titled Hospice Program with a review date of 3/2021. Under Policy Interpretation and Implementation 10 d. read Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. Number 12 read Our facility has elected the Director of Nursing or Designee to coordinate care provided to the resident by our facility staff and the hospice staff .He or she is responsible for the following: d. Obtaining the following information from the hospice: 1) The most recent hospice plan of care specific to each resident 2) Hospice election form 3) Physician certification and recertification of the terminal illness specific to each resident 4) Names and contact information for hospice personnel involved in hospice care of each resident 5) Instructions of how to access the hospice's 24 hour on-call system 6)Hospice medication information specific to each resident; and 7) Hospice physician and attending physician (if any) orders specific to each resident. NJAC 8:39-27.1 (a)

It was determined that the facility failed to ensure staff from nursing and the activities department wore gloves upon entering a room of a resident on transmission-based precautions for the prevention of spread of COVID-19 within the facility. This deficient practice was identified during the COVID-19 focused infection control survey conducted on 11/13/20 on 1 of 2 toured units (Newtonian unit/non-ill unit with no known exposures to COVID-19). The evidence was as follows: According to the U.S. CDC guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 11/4/2020, included to, Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. On 11/13/20 at 8:15 AM, the surveyor interviewed the Clinical Reimbursement Coordinator/Registered Nurse (CRC/RN) who stated that the facility currently had an outbreak of COVID-19 for residents residing on 1 of 5 units (the Sparta Unit). She stated that all the other residents on the remaining units were placed on transmission-based precautions (TBP) to reduce the spread of COVID-19. On 11/13/20 at 9:56 AM, the surveyor interviewed the Registered Nurse/Infection Preventionist (RN/IP) who confirmed that all residents on the Newtonian Unit had no known exposures to COVID-19, but all residents in the building were placed on transmission-based precautions due to the COVID-19 outbreak at the facility. She confirmed that all staff universally wear an N-95 respirator mask and eye protection (i.e. a face shield or goggles), and that staff must further wear personal protective equipment (PPE) (a barrier used to protect an individual's skin, mouth, nose, or eyes) and don a long-sleeve gown and clean gloves upon entry to each room. She stated that the long-sleeve reusable gowns are bagged and placed in an receptacle container for laundering after each resident use, adding the gowns are not shared between residents. She further added that the clean gloves are single-use only and discarded in the garbage in the resident room after each use. The surveyor toured the Newtonian (non-ill, no known exposures to COVID-19) unit and observed the following: On 11/13/20 at 10:13 AM, the surveyor observed the Licensed Practical Nurse/Unit Manager (LPN/UM) wearing an N-95 respirator mask and a face shield. The surveyor observed the LPN/UM standing outside the room of Resident #1 and Resident #2. Outside the resident's room was a stop sign indicating that the resident was on TBP. A picture on the residents door indicated that staff were to wear personal protective equipment upon entering the residents room including gloves. There was a bin outside the resident's room with PPE inside of it, including a box of clean gloves. The surveyor observed the LPN/UM don a long-sleeve gown but she did not don a pair of clean gloves and enter the resident's room. She closed the door behind her. At 10:15 AM, the surveyor observed the Activity Aide in the doorway of Resident #3's room preparing coffee for the resident. The surveyor observed a stop sign outside the door of Resident #3 which indicated the resident was on transmission-based precautions. There was a PPE bin outside the resident's room which was stocked with PPE including a box of clean gloves. The surveyor observed that the Activity Aide wore a gown, N-95 respirator mask and a face shield but did not don a pair of clean gloves. The Activity Aide then entered the room of Resident #3 and came in direct contact with the resident's bedside table. She then placed the coffee cup on the bedside table and exited the room. At 10:17 AM, the surveyor interviewed the Activity Aide regarding the use of PPE for residents on TBP for staff on the Newtonian unit. The Activity Aide stated that she was newly employed in the last week and had orientation including proper use of PPE and and when to perform hand hygiene. She further stated she had only worked on the Newtonian unit and was required to wear a face shield, gown and N-95 respirator mask upon entry of a resident's room on TBP. When asked if she wears gloves upon entering the rooms for residents on the unit and the Activity Aide stated, I don't wear gloves and was never told I needed to wear gloves with my residents .while on the Newtonian unit. The Activity Aide stated she used an alcohol-based hand rub (ABHR) for hand hygiene between each resident, before entering the resident's room, and after leaving the room. She further added that because she performed hand hygiene she didn't think she needed to wear gloves. At 10:48 AM, the surveyor interviewed the LPN/UM regarding the required PPE when entering the rooms of resident's on the Newtonian unit. The LPN/UM stated a gown, face shield, and an N-95 mask was required to be worn upon entering the resident's room. The surveyor asked about the use of clean gloves upon entering the resident rooms and the LPN/UM replied that gloves were recommended but if gloves were not used, then staff should perform hand hygiene with either an ABHR or soap and water. She further stated gloves were intended for more invasive contact with residents and when she performed something that was less invasive such as handing a resident their medications she stated that she personally preferred to use an ABHR instead of gloves to prevent cross-contamination. The surveyor and the LPN/UM reviewed a TBP sign that was located on all the resident's doors. The LPN/UM acknowledged a pair of gloves was also listed upon entry to each resident room who was on TBP. At 11:00 AM, after surveyor inquiry regarding the use of PPE, the surveyor observed the LPN/UM prepare the medications for Resident #4 at the medication cart in front of the Resident's #4 room. The LPN/UM wore an N-95 mask and face shield and she donned a clean gown and this time, she donned a pair of gloves outside of Resident's #3 room. The LPN/UM collected the medications on top of the cart and proceeded to enter Resident's #4 room and closed the door. The surveyor reviewed the in-service education/infection control competency (a measurable method to evaluate the ability of personnel to apply their skill, knowledge, and experience to perform their duties correctly) evaluations for the LPN/UM and the Activities Aide. A review of the Clinical Competency Validation: putting on (Donning) Personal Protective Equipment (PPE)/Taking Off (Doffing) PPE dated 6/12/2020 reflected that the LPN/UM successfully passed the critical elements of PPE-use including gloving by pulling the cuff of the gloves over the sleeves of the gown . and removing gloves as the Outside of Gloves Are Contaminated! A review of the Clinical Competency Validation: putting on (Donning) Personal Protective Equipment (PPE)/Taking Off (Doffing) PPE dated 11/4/2020 reflected that the Activities Aide successfully passed the critical elements of PPE-use including gloving by pulling the cuff of the gloves over the sleeves of the gown . and removing gloves as the Outside of Gloves Are Contaminated! On the same day 11/13/20 at 12:17 PM, the surveyor interviewed the Activities Director who stated that she didn't participate in the orientation competencies for the Activities Aide. She stated that the Activities Aide had only been employed at the facility for one week. At 12:30 PM, the surveyor interviewed the Director of Nursing (DON) and the RN/IP who acknowledged that the PPE training's included glove use upon entry into a resident room who was on transmission based precautions (TBP). She could not speak to why the LPN/UM and Activities Aide were not wearing gloves upon entry into resident rooms who were on TBP when they had passed their PPE competencies on 6/12/20 and 11/4/20 respectively. A review of the facility's undated Outbreak Response Plan included that the facility's outbreak response plan is in compliance with entities including the U.S. Centers for Disease Control and Prevention (CDC). The personal protective equipment (PPE) plan included that the facility shall require the individual to wear a facemask in the facility and additional protective equipment (PPE) as required by applicable Governmental Guidelines and Directives . The Facility trains all employees on proper use of PPE on an ongoing basis in accordance with applicable Governmental Guidelines and Directives. NJAC 8:39-19.4(a)(1-6)

Based on interview and record review, it was determined that the facility failed to follow acceptable standards of clinical practice for accurately following a physician's orders [REDACTED]. This deficient practice was observed for 1 of 3 facility residents reviewed for pain management, Resident #46, as 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 11/14/19 at 11:30 AM, during the initial tour, the resident was observed to be in bed in the room watching TV. The resident was alert and oriented. The surveyor interviewed Resident #46, who stated that he/she frequently experiences pain and requests pain medication from the nurse. On 1/18/19 at 11:25 AM, the surveyor reviewed the resident's physician's orders [REDACTED]. Review of the (MONTH) and (MONTH) 2019 EMAR, revealed that Resident #46 received numerous doses of [MEDICATION NAME] 325 mg 2 tablets (650 mg) for documented pain scale rates between 3 to 7. Review of the facility Pain Severity Scale Crosswalk (pain evaluation form) designated level 3 as moderate pain and level 7 as severe pain. On 11/19/19 at 12:25 PM, the surveyor interviewed Resident #46's nurse, who stated that before administering pain medication, she assesses the level of pain of the resident. The nurse added that she considers mild pain to be rated from 1-3, moderate pain as 4-6, and severe pain as 7-10. On 11/19/19 at 1:00 PM, the surveyor interviewed Resident #46, who stated that the Tylenol ordered by the Physician was effective for the pain experienced. A review of the facility's form titled. Pain Severity Scale Crosswalk under the section titled Numeric Rate Scale revealed that mild pain is from 1-2, moderate pain is 3-4, severe pain 5-6, very severe is 7-8, and worst possible is 9-10. On 11/19/19 at 2:25 PM, the surveyor informed the Administrator and the Director of Nursing, who both agreed that the medication was not being administered according to the physician's orders [REDACTED]. NJAC 8:39- 29.2 (d)

Complaint #: NJ Based on observation, interview and review of medical records and facility documentation, it was determined that the facility's practice for Certified Nursing Assistants (CNAs) to perform blood sugar testing and reporting results to the Registered Nurse (RN) resulted in a significant medication error for 1 of 4 sampled residents (Resident #3), who received Regular Insulin based on the blood sugar result for Resident #3 incorrectly reported to the RN by the CNA and the potential for medication error for at least 13 current residents receiving insulin coverage based on results of the blood glucose monitoring performed by CNAs with the results reported to facility nurses. This medication error caused Resident #3's blood sugar to drop from a documented level of 127 (which did not warrant insulin coverage), at 7:00 a.m. to the next documented level of 71 (borderline low), at 11:00 a.m. (Per Taber's Cyclopedic Medical Dictionary's "Duration of Effect of Various Insulins When Given by Subcutaneous Injection", Regular Insulin has a 30-60 minute onset of action, a peak action in 2-4 hours, and a duration of action of 6-8 hours.) The facility failed to provide any other documented blood sugar results nor assessments for Resident #3 for 4 hours post injection. On 10/8/2013 at 1:10 p.m., during a meeting with the Administrator and Director of Nursing, the surveyor made the facility aware of an Immediate Jeopardy situation for the residents who required blood glucose monitoring and insulin coverage based on results given the nurses by the CNAs. This deficient practice is evidenced by the following: 1. According to a Admission Record Face Sheet, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to a Minimum Data Set (MDS), (an assessment tool), dated 9/12/2013, Resident #3's BIM's (Brief Interview Mental Status), (an assessment of cognitive ability), was documented as 14 out of 15, which indicated good cognitive ability. Resident #3 required the assistance of one for activities of daily living, but was able to feed self once the food tray was delivered and set up. On surveyor record review, a physician order, dated 9/19/2013, for blood glucose monitoring/testing with orders for Regular Insulin to be administered specific to the test results, was documented as follows: "Accucheck (Blood Glucometer, a meter that registers blood sugar results) SSI (Sliding Scale Insulin) Regular Insulin (before meals and at bedtime) SQ (subcutaneously) as follows: 150-200 = 1 unit 201-250 = 2 units 251-300 = 3 units 301-350 = 4 units 351-400 = 6 units over 401 = 8 units and re-check (blood sugar) in 1 hour." Resident #3's Medication Administration Record (MAR), for 9/24/2013 at 7:00 a.m., indicated that Resident #3 received 3 units of Regular Insulin SQ for a blood sugar of 127. On the MAR, in the FBS (fingerstick blood sugar) column for this date and time was 261 with a line through it and 127 written off to the side of it. The RN who documented this, confirmed to the surveyor that she had changed the blood sugar result as documented after CNA #2 confirmed the error in her reporting of the blood sugars that she had taken to the RN. The physician order, as above, specified that no insulin was to be given for blood sugars until the blood sugar reached 150. Three (3) units were ordered if the blood sugar result reached a level of 251. On 10/7/2013 at 7:00 a.m., the surveyor interviewed a Licensed Practical Nurse (LPN #1) on the Sparta Unit regarding fingerstick blood sugar checks. (LPN #1) stated, "The CNAs do the blood sugar checks...we write down the room number and bed number on a slip of paper, hand it to the CNA and when they are finished they place the slip of paper on our med cart for us." The surveyor asked why there is not a resident's name on the piece of paper in case the resident changed rooms, to which the nurse had no reply." On 10/7/2013 at 7:06 a.m., the surveyor observed (CNA #1) perform fingerstick blood sugar checks on four (4) residents who reside on the Sparta unit. The surveyor asked why there are no names on the piece of paper, to which (CNA #1) replied, "I'm a regular on this hall so I know the residents." (CNA #1) completed the blood sugar check for the first resident on her list, but did not document it on the slip of paper until after she entered the 2nd resident's room at 7:12 a.m. The subsequent three (3) residents' blood sugar results were documented in their rooms. The surveyor asked (CNA #1) about the education she received on using the Glucometer. (CNA #1) stated, "I got education on hire about the Glucometer...I don't recall any afterward." (CNA #1 was hired on 11/15/2010, in documentation provided to the surveyor by the Administrator.) On 10/7/2013 at 7:32 a.m., (CNA #1) was observed to place the slip of paper with the blood sugar results on the med cart. At 7:45 a.m., the surveyor observed (LPN #1) transcribe the blood sugar results from the small sheet of paper (approximately 3 1/2 inches by 5 inches) to a regular sheet of paper (approximately 8 1/2 inches by 11 inches), again with just room and bed numbers, no resident names. (LPN #1) then transcribed the results from the larger sheet of paper to the respected resident's MAR. This was at the time that the medication pass for the respected resident was performed. On 10/7/2013 at 8:40 a.m., the surveyor interviewed the Staff Development Nurse (SDN) and requested all recent medication error investigations. On 10/7/2013 at 10:30 a.m., the Assistant Director of Nursing (ADON) brought a completed Medication Administration Error report form to the surveyor. The report was dated 9/24/2013, and confirmed Resident #3's, 9/24/2013 insulin medication error. The surveyor asked if there was an investigation and outcome that went along with the error report. The ADON reported that she had not known about the error until today. The ADON reported to the surveyor that there was no follow up on the medication error because the error form had not been written until today, 10/7/2013, by the RN who made the error. On 10/7/2013 at 11:22 a.m., the surveyor conducted an interview with the Registered Nurse (RN) who administered the insulin on 9/24/2013 at 7:00 a.m. The surveyor asked why Resident #3 received the insulin when the physician order [REDACTED]. The RN pointed out that she was told by CNA #2 that the blood sugar result was 261, but later learned that it was 127. The RN stated that she had crossed out the 261 result and wrote 127 next to it. The RN stated that she had given the insulin to the resident after explaining to Resident #3 that she was giving the resident 3 units of insulin for a blood sugar result of 261. The RN further stated that Resident #3 later (time frame unknown) came out of the room and said to the RN, "I don't think my blood sugar was that high, I think that was my roommate's blood sugar." When the RN heard this, she then questioned the CNA who performed the blood sugar checks that morning. The CNA realized that she had reversed the results for the 2 residents in the room and confirmed that to the RN. The RN reported to the surveyor that she was on orientation and reported the error to her preceptor for the day, (LPN #2). The RN reported to the surveyor that she made (LPN #2) aware and that (LPN #2) went off to speak to the Unit Manager (UM) about the error, but that she was not privy to the conversation. The RN also reported to the surveyor that she had called the physician and obtained orders to "Monitor patient for adverse effects and to recheck the blood sugar in 30 minutes and again in 1 hour." A review of the medical record for 9/24/2013 revealed no documented physician orders [REDACTED]. The RN further reported that (Resident #3) did not have any adverse effects from the insulin. The RN also stated, "I'll be doing my own blood sugars from now on." On surveyor review of Resident #3's medical record, there was no documented evidence of the medication error, physician notification, physician orders, family/responsible party notification, nor any reassessments performed for the resident. The facility failed to provide additional supportive documentation regarding this when requested by the surveyor. There was one post insulin administration blood sugar test result documented at 11:00 a.m. with a blood sugar result of 71. The facility failed to provide any additional documentation to support that any notifications or assessments were completed. On 10/7/2013 at 11:35 a.m., the surveyor conducted an interview with the preceptor nurse, (LPN #2), who confirmed that she knew of the incident and spoke with (CNA #2) who performed and reported the blood Glucometer results for Resident #3 and stated, "I told (CNA #2) you need to be more aware of what you are doing." The preceptor nurse, (LPN #2), also stated, "the resident had no signs or symptoms of high or low blood sugar from the insulin." When the surveyor asked (LPN #2) what else she had done about the medication error, (LPN #2) did not reply with an answer. On 10/7/2013 at 11:46 a.m., the surveyor conducted an interview with (CNA #2) who performed the blood glucose monitoring for Resident #3 on 9/24/2013. (CNA #2) stated, "The nurses never put names of residents on the scrap of paper that they give us to do the blood sugars on, just the room and bed number." (CNA #2) reported that she has worked here since 2008 and was trained on the Glucometer on orientation. (CNA #2) also reported that the previous trainer had competencied her in the past on the Glucometer, but unsure when the last competency was done. (CNA #2 was hired on 5/12/2008, in documentation provided to the surveyor by the Administrator.) The surveyor reviewed the facility policy on "Glucose Meter Monitoring", dated 6/1/1996 and revised 10/1/2012. The policy did not document who was responsible/able to perform the blood glucose monitoring. On 10/7/2013 at 11:43 a.m., the surveyor interviewed the Staff Development Nurse (SDN) and asked for the training that the CNAs received, as well as their last competency on use of the Glucometer. The SDN stated that she could not find the specific training that they had received, as she had only taken over the job a few months ago. She reported to the surveyor that "Only the nurses are competencied on Glucometer testing annually, not the CNA's...I couldn't find any competencies on the CNAs for Glucometer." On 10/7/2013, the surveyor reviewed the facility Job Description for a CNA dated 1/15/2002 and revised on 11/8/2012. The Administrator confirmed that under statement 1.7, "Assists physician and/or licensed nurse with treatments and procedures as needed" covers the performance of blood glucose monitoring by the CNA. On 10/7/2013 at 2:30 p.m., the surveyor interviewed nurses on the 5 resident care units and asked how many residents require blood glucose monitoring requiring insulin coverage. The results of the interviews were as follows: Hampton Unit: 6 residents; Franklin Unit: 2 residents (although the nurse on 7-3 shift reported that she usually does her own Glucometer checks) Blair Unit: (Dementia Unit) 0 residents Newtonian Unit: 3 residents Sparta Unit, 4 residents. On 3 of the 5 units, CNAs perform blood glucose monitoring. On 2 of the 5 units, nurses perform the glucose monitoring. A total of 15 residents currently require blood Glucometer testing, with 13 of the 15 residents housed on units that had blood glucose monitoring performed by CNAs. On 10/8/2013 at 11:21 a.m., the Administrator confirmed to the surveyor that the facility did not have a policy for the delegation of tasks by the RN to the Licensed Practical Nurse (LPN) and/or CNA. The Administrator confirmed to the surveyor that the facility defers to the Nurse Practice Act for delegation of duties by the RN. The surveyor reviewed the facility Job Description for a Registered Nurse (RN), dated 1/15/2002 and revised on 11/8/2012. In the "Position Summary" is documented the following: "He/she (RN) operates within the scope of practice defined by the State Nurse Practice Act and delegates aspects of patient care to LPNs and CNAs consistent with their scope of practice." Further documented in section 4.2 of the policy is documented: "(The RN) supervises staff to ensure that delegated tasks and interventions are implemented appropriately and per policy." The word "appropriately" was not defined. The surveyor reviewed the facility policy on "Medication Errors, dated 1/1/2004 and revised 10/1/2012." The following was noted: "...Report (medication errors) immediately to the DON or designee. Notify physician, patient, and responsible party. Obtain physician orders [REDACTED]. Monitor the patient. The person discovering the incident will complete a Resident/Patient Incident Report. Investigate the incident and implement interventions to prevent further errors. If indicated, the DON or designee will report the error to the appropriate agencies as required by state regulations." On 10/8/2013 at 12:10 p.m., the surveyor conducted an interview with the Director of Nursing (DON) and asked her about the medication error of 9/24/2013. The DON stated the following: "The RN should have been sent home that day (9/24/2013) since there was no RN to orient her secondary to call outs. This was a Significant Medication Error. The nurse (RN)should have called the doctor, documented the (physician) orders and follow up care/observations in the chart. The error form did not come to me. The medication error form should have had the MAR and investigation attached to it. The ADON told me that there is no documentation in the chart about this error at all or what they did about it...this is unacceptable." On 10/8/2013 at 5:00 p.m., the DON reported to the surveyor, "We need to tighten up our policies." The surveyor observed the following documentation in the medical record: "(Resident #3) was discharged to a Assisted Living (AL) facility at 3:00 p.m. on 9/24/2013...The (AL) accepting of transfer of patient per pt (patient) and family's request. SW (Social Worker) spoke with (family) and pt and all in agreement with transfer. (AL) has current information. SW informed nursing and therapy of transfer. Family to transport pt to (AL)." The immediate jeopardy to resident health and safety, which began on 9/24/2013, was identified by the surveyor who notified the Administrator and DON on 10/8/2013 at 1:10 p.m. The Immediate Jeopardy, however, continued ongoing until a acceptable Plan of Correction was accepted by the surveyor at 4:55 p.m. on 10/8/2013, as evidenced by the following: "1. The policy and procedure addressing glucose monitoring has been reviewed and revised by the Administrator, Director of Nursing and Medical Director. 2. Only licensed nursing staff will perform blood glucose monitoring. 3. The professional nursing staff are being re-educated on how and when to complete the medication error report. The necessary (sic) of completing the report immediately is being stressed through in-service education. 4. Nurses are also being educated to transcribe any and all orders from the physician to monitor residents condition into the medical record and to record this monitoring in the nurses notes. 5. Nurses will be re-educated on the blood glucose monitoring policies and procedures. 6. Unit managers will continue to investigate and follow the progress of all reported medication errors. 7. Unit managers and shift supervisors will review with each nurse administering medications, the results of the medication pass, ensuring that all errors of medication side effects are reported and handled immediately. 8. Any deficient practice will be resolved immediately and forwarded to the nursing office on that day. These findings will be reported to the monthly quality assurance committee for review." No further POC is required NJAC 8:39 - 29.2 (d)

Complaint #: NJ Based on observation, interview and review of medical records and facility documentation, it was determined that the facility failed to ensure services provided under the delegation by a Registered Professional Nurse (RN) was in accordance with the scope of practice defined by the State Nurse Practice Act. Facility RNs delegated aspects of patient care (Blood Glucose Monitoring) to Certified Nursing Assistants (CNAs) without having the knowledge that the CNAs were competent in performing that service. Because of this practice, the Registered Nurse (RN) administered 3 units of Regular Insulin subcutaneously (an injection), to a resident which resulted in a significant medication error, which jeopardized the health and safety of 1 of 4 (Resident #3) sampled residents and the potential jeopardy to health and safety for at least 13 current residents receiving insulin coverage based on results of the blood glucose monitoring performed by CNAs with the results reported to facility nurses. The significant medication error (injection of 3 units of Regular Insulin) caused Resident #3's blood sugar to drop from a documented level of 127 (which did not warrant insulin coverage), at 7:00 a.m. to the next documented level of 71 (borderline low), at 11:00 a.m. (Per Taber's Cyclopedic Medical Dictionary's "Duration of Effect of Various Insulins When Given by Subcutaneous Injection", Regular Insulin has a 30-60 minute onset of action, a peak action in 2-4 hours, and a duration of action of 6-8 hours.) The facility failed to provide documentation of ongoing monitoring of Resident #3's blood sugar results for 4 hours post injection. Resident #3 had documented nutritional concerns related to gastrointestinal problems and pain which could have impacted the resident's ability to eat and maintain their blood sugar level. On 10/8/2013 at 1:10 p.m., during a meeting with the Administrator and Director of Nursing, the surveyor made the facility aware of an Immediate Jeopardy situation for the residents who required blood glucose monitoring and receive insulin coverage based on results given to the nurses by the CNAs. This deficient practice is evidenced by the following: Reference to the New Jersey Statutes Annotated, Title 45, Chapter 11-45: 11-23 Board of Nursing Statutes. Subchapter 6. Nursing Procedures; 13:37-6.2 Delegation of selected nursing tasks: "A registered professional nurse shall not delegate the performance of a selected nursing task to ancillary nursing personnel who have not received verifiable education and have not demonstrated the adequacy of their knowledge, skill and competency to perform the task being delegated." Reference to the New Jersey Department of Health and Senior Services Certified Nurse Aide Scope of Practice, Certified Nurse Aide Authorized Duties: "...The Certified Nurse Aide will perform only the tasks in the New Jersey Department of Health curriculum skills competency standards, unless trained appropriately by licensed registered professional nurse of the facility with policies and procedures and a system for ongoing monitoring to assure compliance with the task: upon validation of competence in the skill by a registered professional nurse the Certified Nurse Aide may perform such skills as authorized by the facility..." 1. According to a Admission Record Face Sheet, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to a Minimum Data Set (MDS), (an assessment tool), dated 9/12/2013, Resident #3's BIM's (Brief Interview Mental Status), (an assessment of cognitive ability), was documented as 14 out of 15, which indicated good cognitive ability. Resident #3 required the assistance of one for activities of daily living, but was able to feed self once the food tray was delivered and set up. On 10/7/2013, the surveyor reviewed the closed record, and observed nutritional concerns in the following care plans: "Diabetes", "Resident exhibits or is at risk for gastrointestinal symptoms related to abdominal pain, constipation, gastrointestinal [MEDICATION NAME]", and "Resident is at nutritional risk: increased nutrient needs". On continued medical record review, the surveyor reviewed a nutritional progress note, dated 9/11/2013 by the dietician which stated: "A Nutrition Assessment was completed today. The resident's most recent weight is W (weight) 118.4 lb (pounds) - 9/5/2013 21:47 (9:47 p.m.) There is Nutrition Concern. Increased nutrient needs." The next weight documented was in the 14 day MDS, dated [DATE], and was 117 lb. The surveyor observed a physician order, dated 9/5/2013 as follows: "[MEDICATION NAME] 30 ml (milliliters) po (by mouth) q6h (every 6 hours) prn (as needed) for dyspepsia (upper abdominal discomfort/indigestion.) Resident #3 was medicated 10 times for dyspepsia over a period of 18 days, from 9/6/2013 thru 9/23/2013. On continued Medical Record review, the surveyor reviewed 15 episodes of documented pain over a period of 18 days, from 9/7/2013 thru 9/24/2013, in the Medication Administration Record. During this period of time, nurses notes also documented complaints of abdominal pain. A physician order, dated 9/5/2013 was as follows: "[MEDICATION NAME] 325 mg (milligrams) 2 tabs by mouth every 4 hours as needed for pain. An additional physician order, dated 9/8/2013 was as follows: "[MEDICATION NAME] 2 mg Q3h (every 3 hours) prn for pain. Resident #3 was medicated 2 times with [MEDICATION NAME] for pain, with relief, and 13 times with [MEDICATION NAME] for pain, with relief, over the period of time of 9/7/2013 thru 9/24/2013. On surveyor record review, a physician order, dated 9/19/2013, for blood glucose monitoring/testing with orders for Regular Insulin to be administered specific to the test results, was documented as follows: "Accucheck (Blood Glucometer, a meter that registers blood sugar results) SSI (Sliding Scale Insulin) Regular Insulin (before meals and at bedtime) SQ (subcutaneously) as follows: 150-200 = 1 unit 201-250 = 2 units 251-300 = 3 units 301-350 = 4 units 351-400 = 6 units over 401 = 8 units and re-check (blood sugar) in 1 hour" Resident #3's Medication Administration Record (MAR), for 9/24/2013 at 7:00 a.m., indicated that Resident #3 received 3 units of Regular Insulin SQ for a blood sugar of 127. On the MAR, in the FBS (fingerstick blood sugar) column for this date and time was 261 with a line through it and 127 written off to the side of it. The RN who documented this, confirmed to the surveyor that she had changed the blood sugar result as documented after CNA #2 confirmed the error in her reporting of the blood sugars that she had taken to the RN. On 10/7/2013 at 8:40 a.m., the surveyor requested of the Staff Development Nurse (SDN) all recent medication error investigations. On 10/7/2013 at 10:30 a.m., the Assistant Director of Nursing (ADON) brought a Medication Administration Error report, dated 9/24/2013, to the surveyor for Resident #3 which confirmed the insulin administration error. The surveyor asked for the investigation that went along with it and what education was done to prevent this from happening again. The ADON reported that she had not known about the error until today. The ADON reported to the surveyor that there was no follow up on the medication error because the error form had not been completed until today, 10/7/2013, by the RN who made the error. On 10/7/2013 at 11:22 a.m., the surveyor conducted an interview with the Registered Nurse (RN) who administered the insulin on 9/24/2013 at 7:00 a.m. The surveyor asked why Resident #3 received the insulin when the physician order [REDACTED]. The RN pointed out that she was told by CNA #2 that the blood sugar result was 261, but later learned that it was 127. The RN stated that she had crossed out the 261 result and wrote 127 next to it. The RN stated that she had given the insulin to the resident after explaining to Resident #3 that she was giving the resident 3 units of insulin for a blood sugar result of 261. The RN further stated that Resident #3 later (time frame unknown) came out of the room and said to the RN, "I don't think my blood sugar was that high, I think that was my roommate's blood sugar." When the RN heard this, she then questioned the CNA who performed the blood sugar checks that morning. The CNA realized that she had reversed the results for the 2 residents in the room and confirmed that to the RN. The RN reported to the surveyor that she was on orientation and reported the error to her preceptor for the day, a Licensed Practical Nurse (LPN #2). The RN reported to the surveyor that she had called the physician and obtained orders to "Monitor patient for adverse effects and to recheck the blood sugar in 30 minutes and again in 1 hour." A review of the medical record for 9/24/2013 revealed no documented physician orders [REDACTED]. The RN further reported that (Resident #3) did not have any adverse effects from the insulin. The RN also stated, "I'll be doing my own blood sugars from now on." On 10/7/2013 at 11:35 a.m., the surveyor conducted an interview with the LPN preceptor who confirmed that she knew of the incident. The preceptor stated, "the resident had no signs or symptoms of high or low blood sugar from the insulin." The surveyor asked (LPN #2) what she did after she heard about the mix up in the blood sugar results and the medication error, the LPN reported the following: "I went to (CNA #2) and told her she needs to be more aware of what she is doing." On continued closed record review for Resident #3, there was no documentation in the medical record to support that the medication error had occurred, that the physician was notified and orders obtained, that the family was notified, nor that any further assessments were done. There was one post insulin administration blood sugar test result documented on 9/24/13 at 11:00 a.m. with a blood sugar result of 71. The facility failed to provide any additional documentation to support that any notifications or assessments were completed. The surveyor conducted an interview with (CNA #2) who performed the blood glucose monitoring for Resident #3 on 9/24/2013. (CNA #2) stated, "The nurses never put names of residents on the scrap of paper that they give us to do the blood sugars on, just the room and bed number." CNA #2) reported that she has worked here since 2008 and was trained on obtaining blood sugar results and the use of the Glucometer on orientation. (CNA #2) also reported that the previous trainer had competencied her in the past on the Glucometer, but was unsure when the last competency was done. (CNA #2 was hired on 5/12/2008, in documentation provided to the surveyor by the Administrator.) On 10/7/2013 at 7:00 a.m., the surveyor interviewed a LPN, (LPN #1) on the Sparta Unit regarding fingerstick blood sugar checks. (LPN #1) stated, "The CNAs do the blood sugar checks...we write down the room number and bed number on a slip of paper, hand it to the CNA and when they are finished they place the slip of paper on our med cart for us." The surveyor asked why there is not a resident's name on the piece of paper in case the resident changed rooms, to which the nurse had no reply." On 10/7/2013 at 7:06 a.m., the surveyor observed (CNA #1) perform fingerstick blood sugar checks on 4 residents who reside on the Sparta unit. The surveyor asked why there are no names on the piece of paper, to which (CNA #1) replied, "I'm a regular on this hall so I know the residents." (CNA #1) completed the blood sugar check for the first resident on her list, but did not document it on the slip of paper until after she entered the 2nd resident's room at 7:12 a.m. The subsequent 3 residents blood sugar results were documented in their rooms. The surveyor asked (CNA #1) about the education she received on using the Glucometer. (CNA #1) stated, "I got education on hire about the Glucometer...I don't recall any afterward." (CNA #1 was hired on 11/15/2010, in documentation provided to the surveyor by the Administrator.) On 10/7/2013 at 7:32 a.m., (CNA #1) was observed to place the slip of paper with the blood sugar results on the med cart. At 7:45 a.m., the surveyor observed (LPN #1) transcribe the blood sugar results from the small sheet of paper (approximately 3 1/2 inches by 5 inches) to a regular sheet of paper (approximately 8 1/2 inches by 11 inches), again with just room and bed numbers, no resident names. (LPN #1) then transcribed the results from the larger sheet of paper to the specific resident's MAR. This was at the time that the medication pass for each specific resident was performed. The surveyor reviewed the facility policy on "Glucose Meter Monitoring", dated 6/1/1996 and revised 10/1/2012. The policy did not document who was responsible/able to perform the blood glucose monitoring. On 10/7/2013 at 11:43 a.m., the surveyor interviewed the Staff Development Nurse (SDN) and asked for the training that the CNAs received, as well as their last competency on use of the Glucometer. The SDN stated that she could not find the specific training that they had received, as she had only taken over the job a few months ago. She reported to the surveyor that "Only the nurses are competencied on Glucometer testing annually, not the CNA's...I couldn't find any competencies on the CNAs for Glucometer." On 10/7/2013 at 2:10 p.m., the surveyor reviewed the facility Job Description for a CNA dated 1/15/2002 and revised on 11/8/2012. The Administrator stated that under statement 1.7, "Assists physician and/or licensed nurse with treatments and procedures as needed" would cover the performance of blood glucose monitoring by the CNA. On 10/7/2013 at 2:30 p.m., the surveyor interviewed nurses on the 5 resident care units and asked how many residents require blood glucose monitoring requiring insulin coverage. The results of the interviews were as follows: Hampton Unit: 6 residents Franklin Unit: 2 residents (although the nurse on 7-3 shift reported that she usually does her own Glucometer checks) Blair Unit (Dementia Unit): 0 residents Newtonian Unit: 3 residents Sparta Unit: 4 residents. On 3 of the 5 units, CNAs perform blood glucose monitoring. On 2 of the 5 units, nurses perform the glucose monitoring. A total of 15 residents currently require blood Glucometer testing, with 13 of the 15 residents housed on units that had blood glucose monitoring performed by CNAs. On 10/8/2013 at 11:21 a.m., the Administrator confirmed to the surveyor that the facility did not have a policy for the delegation of tasks by the RN to the LPN and/or CNA. The Administrator confirmed to the surveyor that the facility defers to the Nurse Practice Act for delegation of duties by the RN. The surveyor reviewed the facility Job Description for the Registered Nurse (RN), dated 1/15/2002 and revised on 11/8/2012. In the "Position Summary" is documented the following: "He/she (RN) operates within the scope of practice defined by the State Nurse Practice Act and delegates aspects of patient care to LPNs and CNAs consistent with their scope of practice." Further documented in section 4.2 of the policy is documented: "The (RN) supervises staff to ensure that delegated tasks and interventions are implemented appropriately and per policy." The word "appropriately" was not defined. On 10/8/2013 at 12:10 p.m., the surveyor conducted an interview with the Director of Nursing (DON) and asked her about the medication error of 9/24/2013. The DON stated the following: "The RN should have been sent home that day (9/24/2013) since there was no RN to orient her secondary to call outs. This was a Significant Medication Error. The nurse (RN)should have called the doctor, documented the (physician) orders and follow up care/observations in the chart. The error form did not come to me. The medication error form should have had the MAR and investigation attached to it. The ADON told me that there is no documentation in the chart about this error at all or what they did about it...this is unacceptable." On 10/8/2013 at 5:00 p.m., the DON reported to the surveyor, "We need to tighten up our policies." The surveyor observed the following documentation in the medical record: "(Resident #3) was discharged to a Assisted Living (AL) facility at 3:00 p.m. on 9/24/2013...The (AL) accepting of transfer of patient per pt (patient) and family's request. SW (Social Worker) spoke with (family) and pt and all in agreement with transfer. (AL) has current information. SW informed nursing and therapy of transfer. Family to transport pt to (AL)." The immediate jeopardy to residents health and safety, which began on 9/24/2013, was identified by the surveyor who notified the Administrator and DON on 10/8/2013 at 1:10 p.m. The Immediate Jeopardy, however, continued ongoing until a acceptable Plan of Correction was accepted by the surveyor at 4:55 p.m. on 10/8/2013, as evidenced by the following: "1. The policy and procedure addressing glucose monitoring has been reviewed and revised by the Administrator, Director of Nursing and Medical Director. 2. Only licensed nursing staff will perform blood glucose monitoring. 3. The professional nursing staff are being re-educated on how and when to complete the medication error report. The necessary (sic) of completing the report immediately is being stressed through in-service education. 4. Nurses are also being educated to transcribe any and all orders from the physician to monitor residents condition into the medical record and to record this monitoring in the nurses notes. 5. Nurses will be re-educated on the blood glucose monitoring policies and procedures. 6. Unit managers will continue to investigate and follow the progress of all reported medication errors. 7. Unit managers and shift supervisors will review with each nurse administering medication, the results of the medication pass to include any unusual occurrences during medication pass. 8. The Nurse Practice Educator will be notified of any deficient practice as well. The nurses identified will be educated and or counseled regarding their individual practice. 9. Any deficient practice will be resolved immediately and forwarded to the nursing office on that day. These findings will be reported to the monthly quality assurance committee for review." No further POC is required NJAC 8:39 - 29.2 - 6 (d)

Complaint #: NJ Based on observation, interview and review of facility documentation and medical records, it was determined that the facility administration failed to develop policies and procedures on who could do blood sugar testing, develop a training program and monitor the process for Certified Nursing Assistants (CNAs) delegated tasks by the Registered Nurse (RN), which are not designated in their basic scope of practice but able to be performed in their scope of practice if trained appropriately by a licensed registered professional nurse of the facility with policies and procedures and a system for ongoing monitoring to assure compliance with the task. Then upon validation of competency in the skill by a registered professional nurse the CNA may perform such skills as authorized by the facility. Certified Nursing Assistants (CNAs) were delegated the duty of monitoring resident blood sugars via fingerstick for which the nurses were administering insulin coverage based on the results documented by the CNAs. This practice resulted in a significant medication error, which jeopardized the health and safety of 1 of 4 sampled residents(Resident #3), after blood sugar results were improperly reported by a CNA to a nurse and Resident #3 medicated with Regular Insulin based on that blood sugar result and the potential jeopardy to health and safety for at least 13 current residents receiving insulin coverage based on results of the blood glucose monitoring performed by CNAs with the results reported to facility nurses. The significant medication error caused Resident #3's blood sugar to drop from a documented level of 127 (which did not warrant insulin coverage), at 7:00 a.m. to the next documented level of 71 (borderline low), at 11:00 a.m. (Per Taber's Cyclopedic Medical Dictionary's "Duration of Effect of Various Insulins When Given by Subcutaneous Injection", Regular Insulin has a 30-60 minute onset of action, a peak action in 2-4 hours, and a duration of action of 6-8 hours.) Resident #3's blood sugar dropped from a level of 127 (which did not warrant insulin coverage) to a 71 (borderline low), when monitored 4 hours later, after having received three (3) units of Regular Insulin. (Regular Insulin has a 30-60 minute onset of action, a peak action in 2-4 hours, and a duration of action of 6-8 hours.) This deficient practice is evidenced by the following: Reference to the New Jersey Statutes Annotated, Title 45, Chapter 11-45: 11-23 Board of Nursing Statutes. Subchapter 6. Nursing Procedures; 13:37-6.2 Delegation of selected nursing tasks: "A registered professional nurse shall not delegate the performance of a selected nursing task to any licensed practical nurse who does not hold a current valid license to practice nursing in the State of New Jersey. A registered professional nurse shall not delegate the performance of a selected nursing task to ancillary nursing personnel who have not received verifiable education and have not demonstrated the adequacy of their knowledge, skill and competency to perform the task being delegated." Reference to the New Jersey Department of Health and Senior Services Certified Nurse Aide Scope of Practice, Certified Nurse Aide Authorized Duties: "...The Certified Nurse Aide will perform only the tasks in the New Jersey Department of Health curriculum skills competency standards, unless trained appropriately by licensed registered professional nurse of the facility with policies and procedures and a system for ongoing monitoring to assure compliance with the task: upon validation of competence in the skill by a registered professional nurse the Certified Nurse Aide may perform such skills as authorized by the facility..." 1. According to a Admission Record Face Sheet, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to a Minimum Data Set (MDS), (an assessment tool), dated 9/12/2013, Resident #3's BIM's (Brief Interview Mental Status), (an assessment of cognitive ability), was documented as 14 out of 15, which indicated good cognitive ability. Resident #3 required the assistance of one for activities of daily living, but was able to feed self once the food tray was delivered and set up. On surveyor record review, a physician order, dated 9/19/2013, for blood glucose monitoring/testing with orders for Regular Insulin to be administered specific to the test results, was documented as follows: "Accucheck (Blood Glucometer, a meter that registers blood sugar results) SSI (Sliding Scale Insulin) Regular Insulin (before meals and at bedtime) SQ (subcutaneously) as follows: 150-200 = 1 unit 201-250 = 2 units 251-300 = 3 units 301-350 = 4 units 351-400 = 6 units over 401 = 8 units and re-check (blood sugar) in 1 hour." The surveyor noted in Resident #3's Medication Administration Record (MAR), that on 9/24/2013 at 7:00 a.m., Resident #3 received three (3) units of Regular Insulin SQ for a blood sugar of 127. The physician order, as above, specified that no insulin was to be given for blood sugars until the blood sugar reached 150. Three (3) units were ordered only if the blood sugar result reached a level of 251. On 10/7/2013 at 7:00 a.m., the surveyor interviewed a Licensed Practical Nurse (LPN #1) on the Sparta Unit regarding fingerstick blood sugar checks. (LPN #1) stated, "The CNAs do the blood sugar checks...we write down the room number and bed number on a slip of paper, hand it to the CNA and when they are finished they place the slip of paper on our med cart for us." The surveyor asked why there is not a resident's name on the piece of paper in case the resident changed rooms, to which the nurse had no reply." On 10/7/2013 at 7:06 a.m., the surveyor observed (CNA #1) perform fingerstick blood sugar checks on four (4) residents who reside on the Sparta unit. The surveyor asked why there are no names on the piece of paper, to which (CNA #1) replied, "I'm a regular on this hall so I know the residents." (CNA #1) completed the blood sugar check for the first resident on her list, but did not document it on the slip of paper until after she entered the 2nd resident's room at 7:12 a.m. The subsequent three (3) residents' blood sugar results were documented in their rooms. The surveyor asked (CNA #1) about the education she received on using the Glucometer. (CNA #1) stated, "I got education on hire about the Glucometer...I don't recall any afterward." (CNA #1 was hired on 11/15/2010, in documentation provided to the surveyor by the Administrator.) On 10/7/2013 at 7:32 a.m., (CNA #1) was observed to place the slip of paper with the blood sugar results on the med cart. At 7:45 a.m., the surveyor observed (LPN #1) transcribe the blood sugar results from the small sheet of paper (approximately 3 1/2 inches by 5 inches) to a regular sheet of paper (approximately 8 1/2 inches by 11 inches), again with just room and bed numbers, no resident names. (LPN #1) then transcribed the results from the larger sheet of paper to the respective resident's MAR at the time that the medication pass for the respective resident was performed. On 10/7/2013 at 10:30 a.m., the Assistant Director of Nursing (ADON) brought a completed Medication Administration Error report form to the surveyor. The report was dated 9/24/2013, and confirmed Resident #3's, 9/24/2013 insulin medication error. The surveyor asked if there was an investigation and outcome that went along with the error report. The ADON reported that she had not known about the error until today. The ADON reported to the surveyor that there was no follow up on the medication error because the error form had not been written until today, 10/7/2013, by the RN who made the error. On 10/7/2013 at 11:22 a.m., the surveyor conducted an interview with the Registered Nurse (RN) who administered the insulin on 9/24/2013 at 7:00 a.m. The surveyor asked why Resident #3 received the insulin when the physician order [REDACTED]. The RN pointed out that she was told by CNA #2 that the blood sugar result was 261, but later learned that it was 127. The RN stated that she had crossed out the 261 result and wrote 127 next to it. The RN stated that she had given the insulin to the resident after explaining to Resident #3 that she was giving the resident 3 units of insulin for a blood sugar result of 261. The RN further stated that Resident #3 later (time frame unknown) came out of the room and said to the RN, "I don't think my blood sugar was that high, I think that was my roommate's blood sugar." When the RN heard this, she then questioned the CNA who performed the blood sugar checks that morning. The CNA realized that she had reversed the results for the 2 residents in the room and confirmed that to the RN. The RN reported to the surveyor that she was on orientation and reported the error to her preceptor for the day, (LPN #2). The RN reported to the surveyor that she made (LPN #2) aware and that (LPN #2) went off to speak to the Unit Manager (UM) about the error, but that she was not privy to the conversation. The RN also reported to the surveyor that she had called the physician and obtained orders to "Monitor patient for adverse effects and to recheck the blood sugar in 30 minutes and again in 1 hour." A review of the medical record for 9/24/2013 revealed no documented physician orders [REDACTED]. The RN further reported that (Resident #3) did not have any adverse effects from the insulin. The RN also stated, "I'll be doing my own blood sugars from now on." On surveyor review of Resident #3's medical record, there was no documentation of the medication error, physician notification, physician orders, family/responsible party notification, nor any reassessments performed for the resident. The facility failed to provide any additional supportive documentation regarding this when requested by the surveyor. The only blood sugar documentation is 71 for 11:00 a.m. On 10/7/2013 at 11:35 a.m., the surveyor conducted an interview with the preceptor nurse (LPN #2) who confirmed that she knew of the incident and spoke with (CNA #2) who performed and reported the blood Glucometer results for Resident #3 and stated, "I told (CNA #2) you need to be more aware of what you are doing." The preceptor nurse, (LPN #2) also stated, "the resident had no signs or symptoms of high or low blood sugar from the insulin." When the surveyor asked (LPN #2) what else she had done about the medication error, (LPN #2) did not reply with an answer. On 10/7/2013 at 11:46 a.m., the surveyor conducted an interview with (CNA #2) who performed the blood glucose monitoring for Resident #3 on 9/24/2013. (CNA #2) stated, "The nurses never put names of residents on the scrap of paper that they give us to do the blood sugars on, just the room and bed number." (CNA #2) reported that she has worked here since 2008 and was trained on the Glucometer on orientation. The CNA also reported that the previous trainer had competencied her in the past on the Glucometer, but unsure when the last competency was done. (CNA #2 was hired on 5/12/2008, in documentation provided to the surveyor by the Administrator.) The surveyor interviewed ten (10) CNAs about their training and their competency on Glucometer use. All ten reported that they were trained on orientation and that they were competencied before they were allowed to do Glucometer checks on their own. The following CNAs were interviewed on 10/7/2013: CNA #1: 7:06 a.m., "I got education on hire, don't recall any afterward." CNA #2: 11:46 a.m., "Definitely on hire...I was competencied in the past, don't remember last time though." CNA #3: 1:05 p.m., "Trained three years ago, no competency that she can remember...if you have a question, you ask." CNA #4: 1:09 p.m., "Trained 8 years ago...nurses will watch us." CNA #5: 1:12 p.m., "Educated on hire to days (day shift)..." CNA #6: 1:17 p.m., "Trained 1 1/2 years ago, nurse competencied me." CNA #7: 1:20 p.m., "Trained on hire and was competencied then, no competency since." The following CNAs were interviewed on 10/8/2013: CNA #8: 11:34 a.m., "Trained on orientation, no competency since." CNA #9: 11:36 a.m., Trained on orientation, no competency since." CNA #10: 11:38 a.m., "Learned in orientation, none since." On 10/7/2013 at 11:43 a.m., the surveyor interviewed the Staff Development Nurse (SDN) and asked for the training that the CNAs received as well as their last competency on use of the Glucometer. The SDN stated that she could not find the specific training that they had received, as she had only taken over the job a few months ago. She reported to the surveyor that "Only the nurses are competencied on Glucometer testing annually, not the CNA's." On 10/7/2013, the surveyor reviewed the facility Job Description for a CNA dated 1/15/2002 and revised on 11/8/2012. The Administrator confirmed that under statement 1.7, "Assists physician and/or licensed nurse with treatments and procedures as needed" covers the performance of blood glucose monitoring by the CNA. On 10/7/2013 at 2:30 p.m., the surveyor interviewed nurses on the 5 resident care units and asked how many residents require blood glucose monitoring requiring insulin coverage. The results of the interviews were as follows: Hampton Unit: 6 residents Franklin Unit: 2 residents (although the nurse on 7-3 shift reported that she usually does her own Glucometer checks) Blair Unit (Dementia Unit): 0 residents Newtonian Unit: 3 residents Sparta Unit: 4 residents On 3 of the 5 units, CNAs perform blood glucose monitoring. On 2 of the 5 units, nurses perform the glucose monitoring. A total of 15 residents currently require blood Glucometer testing, with 13 of the 15 residents housed on units that had blood glucose monitoring performed by CNAs. On 10/8/2013 at 11:21 a.m., the Administrator confirmed to the surveyor that the facility did not have a policy on the delegation of tasks by the RN to the LPN and/or CNA. The Administrator confirmed to the surveyor that the facility defers to the Nurse Practice Act for delegation of duties by the RN. The surveyor reviewed the facility Job Description for a Registered Nurse (RN), dated 1/15/2002 and revised on 11/8/2012. In the "Position Summary" is documented the following: "He/she (RN) operates within the scope of practice defined by the State Nurse Practice Act and delegates aspects of patient care to LPNs and CNAs consistent with their scope of practice." Further documented in section 4.2 of the policy is documented: "(The RN) supervises staff to ensure that delegated tasks and interventions are implemented appropriately and per policy." The surveyor reviewed the facility policy on "Glucose Meter Monitoring", dated 6/1/1996 and revised 10/1/2012. The policy did not document who was responsible/able to perform the blood glucose monitoring. The surveyor reviewed the facility policy on "Medication Errors, dated 1/1/2004 and revised 10/1/2012." The following was observed: "Report (medication errors) immediately to the DON or designee. Notify physician, patient, and responsible party. Obtain physician orders [REDACTED]. Monitor the patient. The person discovering the incident will complete a Resident/Patient Incident Report. Investigate the incident and implement interventions to prevent further errors. If indicated, the DON or designee will report the error to the appropriate agencies as required by state regulations." On 10/8/2013 at 12:10 p.m., the surveyor conducted an interview with the Director of Nursing (DON) and asked her about the medication error of 9/24/2013. The DON stated the following: "The RN should have been sent home that day (9/24/2013) since there was no RN to orient her secondary to call outs. This was a Significant Medication Error. The nurse (RN)should have called the doctor, documented the (physician) orders and follow up care/observations in the chart. The error form did not come to me. The medication error form should have had the MAR and investigation attached to it. The ADON told me that there is no documentation in the chart about this error at all or what they did about it...this is unacceptable." On 10/8/2013 at 5:00 p.m., the DON reported to the surveyor, "We need to tighten up our policies." The surveyor observed the following documentation in the medical record: "(Resident #3) was discharged to a Assisted Living (AL) facility at 3:00 p.m. on 9/24/2013...The (AL) accepting of transfer of patient per pt (patient) and family's request. SW (Social Worker) spoke with (family) and pt and all in agreement with transfer. (AL) has current information. SW informed nursing and therapy of transfer. Family to transport pt to (AL)." The immediate jeopardy to resident health and safety, which began on 9/24/2013, was identified by the surveyor who notified the Administrator and DON on 10/8/2013 at 1:10 p.m. The Immediate Jeopardy, however, continued ongoing until a acceptable Plan of Correction was accepted by the surveyor at 4:55 p.m. on 10/8/2013, as evidenced by the following: "1. The Administrator and the Director of Nursing along with the Medical Director have reviewed and revised the policies and procedures related to blood glucose monitoring. 2. The procedures and practice have been made specific regarding the training of licensed and or certified individuals to perform these tasks. 3. Competencies related to the practice of these tasks have been assigned a schedule of perform (sic) by the Nurse Practice Educator. 4. The Administrator and Director of Nursing along with the Nurse Practice Educator will review all tasks competencies currently being conducted and discuss the need for any further competencies. 5. Any other tasks identified will have competencies developed and implemented." 6. The nurse practice educator will provide tracking and trending of all competencies and any deficient practices to the monthly quality assurance committee for review. 7. The team will discuss any identified needs noted through daily rounds and determine if further education or competencies as needed. The nurse practice educator will follow these recommendations and report back to the monthly quality assurance committee." No further POC is required. NJAC 8:39 - 13.1 (a), 13.4 (b)