Every finding on record at Jersey Shore Post Acute Rehabilitation and Nursing

Based on observation, interviews, review of the clinical records and pertinent facility documentation, it was determined that the facility to a.) ensure the documentation for the administration of wound treatments for 1 of 2 residents (Resident #46) reviewed for wounds, b.) properly secure medications during medication administration observation, and c.) ensure the medication cart was locked when not in use for 1 of 4 medication carts (east high side) in accordance with professional standards of practice. Reference: New Jersey Statutes, 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 regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, 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 task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. This deficient practice was evidenced by the following: 1. A review of the Admission Record face sheet (admission summary) indicated that Resident #46 was admitted to the facility with the diagnoses which included but was not limited to; chronic osteomyelitis (bone infection) and peripheral vascular disease (PVD). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/7/25, reflected that Resident #46 was cognitively intact and required supervision with activities of daily living (ADLs). The MDS indicated that the resident had a diabetic foot ulcer. On 2/27/25 at 10:47 AM, during tour, the surveyor observed Resident #46 in the facility gym wearing bilateral white stockings to both lower extremities. The resident was alert and oriented and had no complaints. On 3/3/25 at 9:50 AM, the surveyor interviewed Resident #46's Certified Nursing Aide (CNA), who stated that the resident was alert an oriented and was able to voice their needs and wants. The CNA stated that the resident required complete care with their ADLs and was continent of bladder and bowel. The CNA explained that the resident wore some sort of stockings on the lower legs, however, did not know why. The CNA stated that the nurses applied the stockings. On 3/3/25 at 9:00 AM, the surveyor interviewed Resident #46, who stated that they usually wore unna boots (unna boot is a compression dressing made by wrapping layers of gauze around the leg and foot often used to protect an ulcer or open wound) to their bilateral lower extremities that were applied by the wound care center every Wednesday. The resident explained that the facility applied stockings to their lower extremities and that the facility nurses provided wound care to the left heel and applied the dressing on Saturday. The resident denied pain and stated that the wound on the left heel was slowly healing. A review of the Wound Care Center Report (WCCR) dated 2/12/25, reflected that Resident #46 had a non-pressure related chronic ulcer to their left heel and mid-foot with the fat layer exposed. The measurements were 0.3 centimeters (cm) by (x) 0.5 cm x 0.2 cm (0.3 x 0.5 x 0.2) with a small amount of exudate (fluid that leaks out of blood vessels into the surrounding tissues) that was amber in color and medium amount of eschar (necrotic tissue). A review of the WCCR dated 2/19/25, indicated that Resident #46 had a non-pressure related chronic but stable ulcer to their left heel and mid-foot with the fat layer exposed. The measurements of the wound were smaller at 0.3 x 0.5 x 0.1. The wound had no exudate with some granulation tissue (new pink or red fleshy tissue that formed during wound healing) with a medium amount of eschar. A review of the WCCR dated 2/26/25, indicated that Resident #46 had a non-pressure related chronic ulcer to their left heel and mid-foot with the fat layer exposed. The wound continued to have some granulation tissue with medium amount of eschar. The treatment orders had changed at that time. On 3/3/25 at 9:54 AM, the surveyor interviewed the Registered Nurse (RN), who stated that the resident had a treatment order to apply tubigrip (tubular elastic bandage designed to provide tissue support and compression) to their bilateral lower extremities and dressing to the left heel (calcaneus) three times a week. The RN stated that when she received the treatment order, the order was transcribed onto the Treatment Administration Record (TAR) and then the nurse signed the TAR when the treatment was complete. The surveyor reviewed the physician's order summary which revealed the following treatment orders: A review of the physician's order (PO) dated 2/5/25, for bilateral unna boots, full weight bearing bilaterally; must have Truvue boot bilateral (heel protector wedge boots) and change position every two hours. The resident may bear weight with a walker assist every shift for wound care. A review of the PO dated 2/27/25, indicated that the nurse was to apply tubigrip three times weekly every day shift on Tuesday, Thursday, and Saturday for left calcaneus. A review of PO dated 2/27/25, reflected an order to cleanse left calcaneus with normal saline solution (NSS); apply collagen; and cover with allevyn dressing (foam dressing) every day shift on Tuesday, Thursday, and Saturday. A review of Resident #46's TAR did not include the treatment orders for the unna boots, tubigrip or treatments to the left heel. The treatment orders were not transcribed onto the TAR. There were no signatures from the nursing staff that indicated that these treatments were being administered, however the resident indicated that treatments were being provided and the wound documentation indicated that the wound was smaller and improving. On 3/3/25 at 10:08 AM, the surveyor interviewed the RN who explained that the resident wore the tubigrip to the bilateral lower extremities three times weekly. The RN also stated that Resident #46 had a wound to the left heel and that a treatment to the left heel included; cleansing the wound with NSS, application of collagen, and covering the wound with an allevyn dressing (foam dressing) on Tuesday, Thursday, and Saturday. The RN reviewed the TAR in the presence of the surveyor and could not explain why the treatments were not documented on the TAR. The RN stated that she was the assigned nurse that performed the treatments and she knew that they were completed. The RN acknowledged that the treatment orders were not transcribed onto the TAR as ordered by the physician and there were no nurses' signatures that indicated that the treatments were performed. On 3/3/25 at 10:18 AM, the surveyor interviewed the Infection Preventionist (IP), who stated that she was responsible to complete wound reports on the weekends and explained that she was not sure why the treatments orders were not transcribed onto the TAR and she would have to review the resident's medical record. The IP stated that after she reviewed the resident's medical record, she would get back to the surveyor. On 3/3/25 at 11:14 AM, the surveyor interviewed the IP, who stated that that the RN who took the treatment order from the physician on 2/27/25, for the tubigrip and treatment for the left heel, did not put the order in the electronic medical record (EMR) correctly resulting in the treatments not being transcribed over to the TAR. The IP stated that the RN performed the treatment on Saturday 3/1/25, however the RN did not give the IP an explanation as to why she did not sign the treatment orders. The IP stated that if the RN signed the TAR after she completed the resident's wound care, that she would have identified that the treatment was not transcribed onto the TAR. The IP reviewed the treatment order dated 2/5/25, for unna boots every shift for wound care and confirmed that the order was also not transcribed to the TAR since that date even though the unna boots were in place as ordered. The IP stated that the wound care was provided as ordered, however it was a transcription error that occurred in the EMR. On 3/4/25 at 9:57 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who explained that when a nurse took a physician's order, the nurse had to make sure the order was transcribed to either to the Medication Administration Record (MAR) or the TAR. The RN/UM stated that it was important to assure proper transcription of the order so that there were no medication errors and to assure that a treatment or medication was provided to the resident. The RN/UM stated that he had reviewed Resident #46's treatment orders and confirmed that the RN had an error in documentation and did not transcribe the treatment orders to the resident's TAR. The RN/UM stated that the RN that took the orders had performed the treatments, but she did not sign that the treatments were performed on the TAR. On 3/4/25 at 12:43 PM, the surveyor interviewed the Director of Nursing (DON), who stated that she expected the nursing staff to transcribe the treatment orders to the correct location on the TAR so that the order could be followed and completed. On 3/5/25 10:22 AM, the DON stated that the 2/5/25, the order for the unna boots was written incorrectly with no specification for monitoring, however the unna boots were not to be removed and were to be monitored for placement every shift. The DON also stated that the PO for the Truvue boots was also not transcribed correctly and should have been written specifically to include the location, time, and removal of the boots. The DON stated that the treatment orders dated 2/27/25, should have been transcribed to the TAR and that the RN had made a transcription error. The DON stated that the same RN took the PO on 2/5/25 and 2/27/25, and confirmed that the orders should have been reviewed during the 24-hour chart check to assure that the orders were complete, accurate, written and transcribed onto the TAR. A review of the facility's Orders policy dated 12/2024, included that a verbally communicated order must contain all components of a valid written order . a RN or Licensed Practical Nurse (LPN) can accept and transcribe verbal or telephone orders and that the process for accepting verbally communicated orders was that the listener would transcribe the order to the electronic medical record and under the resident's chart . A review of the facility's 24 Hour Chart Check policy dated 9/2024, included that the facility would review medical records every 24 hours to identify any physician's orders that require processing or further attention . the facility would validate that orders were transcribed correctly onto the MAR and TAR and if any discrepancies were noted, corrections would be made . 51500 2. On 2/27/25 at 9:23 AM, the surveyor observed the Licensed Practical Nurse (LPN) leave a bottle of acidophilus with pectin 100 capsules on top on the medication cart unattended and the medication cart was left unlocked, while the nurse obtained vital signs on a resident. There were no residents present by the cart at that time. On 2/27/25 at 9:41 AM, the surveyor observed the LPN leave a bottle of eye drops on the top of the medication cart unattended, while administering medications to a resident. There were no residents present by the cart at that time. On 2/27/25 at 9:52 AM, the surveyor interviewed the LPN, who stated that the medication cart could be left unlocked and unattended as long as it was up against the room doorway. The LPN stated that the medications should not be left on top of the medication cart unattended. In addition, the LPN acknowledged that the acidophilus and eye drops were left on top of the medication cart unattended. On 2/28/25 at 1:00 PM, the surveyor interviewed the DON, who confirmed that the nurse should not have left the acidophilus and eyes drops on top of the medication cart unattended. The DON stated that a nurse could not leave medications unattended and should not turn their back with medications on top to the medication cart. The DON confirmed that medication carts should be locked when unattended. A review of the facility's Medication Administration policy dated reviewed 10/2024 included: .7. No medications on top of cart. 8. Medication cart locked when not in use . NJAC 8:39-27.1(a); 29.4(h)

Based on observation, interview, and record review, it was determined that the facility failed to maintain a individualized comprehensive care plan (ICCP) that included interventions that were specific to a resident identified as having a diabetic ulcer. This deficient practice was identified for 1 of 18 residents reviewed (Residents #46), and was evidenced by the following: A review of the Admission Record face sheet (admission summary) indicated that Resident #46 was admitted to the facility with diagnoses which included but was not limited to; diabetes mellitus (DM), chronic osteomyelitis (bone infection), and peripheral vascular disease (PVD). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/7/25, reflected that Resident #46 was cognitively intact and required supervision with activities of daily living (ADLs). The MDS also indicated that the resident had a diabetic foot ulcer. On 2/27/25 at 10:47 AM, during tour, the surveyor observed Resident #46 in the facility gym wearing bilateral white stockings on both lower extremities. The resident was alert and oriented and had no complaints. On 3/3/25 at 9:50 AM, the surveyor interviewed Resident #46's Certified Nursing Aide (CNA), who stated that the resident was alert and oriented and was able to voice their needs and wants. The CNA stated that the resident required complete care for their ADLs and was continent of bladder and bowel. The CNA explained that the resident wore some sort of stockings on the lower legs, however, he did not know why. The CNA stated that the nurses applied the stockings. On 3/3/25 at 9:00 AM, the surveyor interviewed Resident #46, who stated that they usually wore unna boots (unna boot is a compression dressing made by wrapping layers of gauze around the leg and foot often used to protect an ulcer or open wound) on their bilateral lower extremities that were applied by the wound care center every Wednesday. The resident explained that the facility applied stockings on their lower extremities and that the facility nurses provided wound care to the left heel and applied the dressing on Saturday. The resident denied pain and stated that the wound on the left heel was slowly healing. On 3/3/25 at 9:54 AM, the surveyor interviewed the Registered Nurse (RN), who stated that the resident had a treatment order to apply tubigrip (tubular elastic bandage designed to provide tissue support and compression) on their bilateral lower extremities and a dressing on their left heel (calcaneus) three times a week. The RN stated that it was important to include any pertinent information regarding treatments, wounds, and preventative care on the resident's ICCP because the ICCP provided information about the resident and how to care for the resident. The surveyor reviewed the physician's order summary which revealed the following treatment orders: A review of the physician's order (PO) dated 2/5/25, for bilateral unna boots, full weight bearing bilaterally; must have Truvue boot bilateral (heel protector wedge boots) and change position every two hours. The resident may bear weight with a walker assist every shift for wound care. A review of the PO dated 2/27/25, indicated that the nurse was to apply tubigrip three times weekly every day shift on Tuesday, Thursday, and Saturday for left calcaneus. A review of PO dated 2/27/25, reflected an order to cleanse left calcaneus with normal saline solution (NSS); apply collagen; and cover with allevyn dressing (foam dressing) every day shift on Tuesday, Thursday, and Saturday. A review of Resident #46's ICCP included a focus area for skin alteration ICCP, but did not include that the resident wore Truvue boots, unna boots, tubigrip, or that the resident was provided with wound care to the left heel. On 3/3/25 at 10:08 AM, the surveyor interviewed the RN, who explained that the resident wore the tubigrip to the bilateral lower extremities three times weekly. The RN also stated that Resident #46 had a wound to the left heel and that a treatment to their left heel included; cleansing the wound with NSS, application of collagen, and covering the wound with an allevyn dressing on Tuesday, Thursday, and Saturday. The RN reviewed the resident's ICCP in the presence of the surveyor, and could not explain why the treatments were not documented in the ICCP. On 3/4/25 at 9:57 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who explained that the resident's ICCP was resident specific and provided a detailed account on how to take care that resident. The RN/UM stated that it was important to update the ICCP with an accurate record to include current wounds and wounds that have healed. The RN/UM continued to explain that it was also important to include preventative interventions to prevent further development of wounds and to heal existing wounds. The RN/UM stated that the ICCP should be an accurate account of what was going on with that resident and acknowledged that Resident #46's ICCP was not updated to include interventions and treatments related to their left heel ulcer. On 3/4/25 at 12:43 PM, the surveyor interviewed the Director of Nursing (DON), who acknowledged that Resident #46's ICCP should have been updated with accurate wound care interventions. The DON stated that the ICCP should include what kind of care the resident was receiving and the nurses followed the ICCP. The DON explained that any new interventions or changes in care were documented on the ICCP. A review of the facility's undated Care Plans-Comprehensive policy included that the residents ICCP would reflect treatment goals and revised as changes in the resident's condition dictate . NJAC 8:39-11.2(e)

Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to activate their emergency response system by calling 911 and immediately initiating Cardiopulmonary Resuscitation (CPR) for 1 of 3 residents reviewed who were full-code and were found unresponsive and without respirations and a heart rate (Resident #82), in accordance with the American Heart Association and the Basic Life Support (BLS) for Healthcare Providers. Resident #82 was a full-code status and had requested aggressive life-saving treatment despite medical decline. The resident was last seen on [DATE] at 7:58 AM, by the nurse who took vital signs, administered blood pressure medications, and left the resident in stable condition. On [DATE] at approximately 8:40 AM, the resident was found unresponsive by the Registered Dietician (RD) who immediately alerted the Licensed Practical Nurse (LPN) who in response had a Certified Nursing Aide (CNA) accompany her to the resident's room. The resident was found unresponsive laying slumped over in bed. The LPN documented she began to panic and shake [him/her] and checked vital signs. The LPN later asked the CNA to help reposition the resident. The LPN proceeded to call the Physician and the family member on the telephone. The LPN while on the computer, noticed the resident was a full code status and went into full blown panic mode, and went back to the room to start CPR and the [family member] walked in the room to ask what was doing, and said to stop. The LPN proceeded to not administer CPR against the resident's code status request. The LPN left the room and the Licensed Nursing Home Administrator (LNHA) asked if the LPN called 911 in which she responded no. According to documentation, the facility never initiated CPR, called 911, or accessed the automated external defibrillator (AED; a device used to deliver an electric shock to the heart to restore heart rhythm) in an attempt to provide life-saving measures. Resident #82 was pronounced dead at 10:04 AM, by a physician [name redacted]; cause was an unexpected death. The LPN was terminated from employment at the facility and survey team attempted to reach the nurse multiple times by telephone for an interview and were unsuccessful. There was no documented evidence a Code Blue (a signal used to communicate an acute medical emergency) was initiated, or that CPR, or 911 was activated upon becoming aware resident was unresponsive. According to NN on [DATE], 911 was not called until 9:10 AM. There was no documented evidence once paramedics arrived that the resident was evaluated for intubation, or the use of the AED. Interview with the Director of Nursing (DON) on [DATE] revealed all nurses were certified in CPR, so there was always someone in the facility that could perform CPR. The DON provided a copy of the LPN's valid CPR certification. The facility's failure to appropriately initiate CPR and the appropriate activation of emergency response (including calling 911) for a resident who was a full-code and was found to be unresponsive without a heart rate and respirations, placed all residents who were a full-code at risk for imminent death if found to be unresponsive without a pulse and without respirations. This resulted in an Immediate Jeopardy situation. The Immediate Jeopardy (IJ) began on [DATE] at 8:40 AM, when the resident was found unresponsive and ran until [DATE] after in-services of staff began, and the LPN was terminated at 3:00 PM. The IJ was Past Non-Compliance. The facility was notified of the Past Non-Compliance IJ situation on [DATE] at 3:51 PM. The facility was back in compliance when they addressed this situation by calling 911; suspending and then terminating the LPN upon investigation; all staff were in-serviced on code-status; when to initiate CPR; documentation in an emergency situation and communication with nursing management; performed a mock code; and in-serviced all Agency staff on facility policy. The evidence was as follows: Reference: The American Heart Association (AHA) 2010 . guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). These guidelines reflect global resuscitation science and treatment recommendations . In the guidelines, AHA has established evidenced-based decision-making guidelines for initiating CPR when cardiac or respiratory arrest occurs in or out of the hospital. AHA urges all potential rescuers to initiate CPR unless: 1) a valid Do Not Resuscitate (DNR) order is in place; 2) obvious clinical signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers, and the general public. On [DATE] at 9:17 AM, the surveyor reviewed the closed medical record for Resident #82 who had expired in the facility. A review of the Admission Record face sheet reflected the resident was admitted to the facility in December of 2022 with diagnoses which included malignant neoplasm of hypopharynx and retromolar area (cancer of the throat and oral cavity), diabetes, pancytopenia (a reduction in all three major cellular elements of blood), essential (primary) hypertension (high blood pressure). A review of the Admission/Readmission Evaluation dated [DATE] at 12:45 PM, reflected the resident was alert and oriented to person, place, and time with clear speech. A review of the Order Summary Report (OSR) included a physician's order (PO) dated [DATE], for full code status. A review of the Progress Notes (PN) for Resident #82 which included the following notes: A Nursing Note (NN) dated [DATE] at 6:30 AM, written by the resident's 11:00 PM to 7:00 AM shift Registered Nurse (RN), included the resident was toileted three times during this shift; alert and verbally responsive; blood sugar done and coverage given as ordered; left comfortable in bed, call bell with-in reach; no signs or symptoms of pain or discomfort noted. A Health Status Note (HSN) dated [DATE] at 9:08 AM, written by the LPN, revealed the resident had expired around 8:45 AM; feeding tube (a tube inserted through the wall of the abdomen into the stomach which can be used to give medications or liquids) disconnected; the resident was bathed and growned by nurse and CNA; family member called spoke with [name redacted] explained the situation and he/she hung up the phone; Physician notified. A NN dated [DATE] at 9:10 AM, written by the Infection Preventionist/LPN (IP/LPN), revealed upon entering this building this nurse was called to resident's room; resident was noted with no blood pressure or no pulse; 911 called immediately as resident was a full code. A NN dated [DATE] at 10:10 AM, written by the IP/LPN, included paramedics on scene; no blood pressure or heart rate maintained; resident was pronounced by physician [name redacted] at 10:04 AM with family at bedside. There was no documented evidence that 911 was called at the time the resident was found non-responsive; CPR was immediately initiated or initiated at all; or a AED was used. On [DATE] at 9:33 AM, the surveyor attempted to call the LPN on the telephone, a male party answered, the surveyor stated his/her name and the purpose of the call, and the call was disconnected. The surveyor placed the call again, there was no answer, and the surveyor left a message on the voicemail to please return the call as soon as possible. LPN did not return surveyor's call. On [DATE] at 9:40 AM, the surveyor interviewed the IP/LPN who stated Resident #82 had been admitted to the facility for rehabilitation; was very sickly and expired at the facility. She further stated she was not in the building when the situation occurred on [DATE], she walked into the building with the paramedic arriving right after. On [DATE] at 10:19 AM, the surveyor interviewed the DON who stated she was familiar with Resident #82 that he/she had been at the facility for a short term, had cancer, and was ailing. She further stated the resident had expired at the facility and had been taken care of that day by an Agency Nurse (LPN). The DON stated she had interviewed the LPN who stated she had been flustered and had gone into the room; she tried to get his/her code status; left the room and called the Physician and family member; and then she called 911; she did not start CPR. When the surveyor asked the DON what the facility's procedure was when you find a resident unresponsive, she responded when you find someone unresponsive, you should call the code, then call 911. The DON stated she did have a copy of the LPN's witness statement; she conducted an investigation. On [DATE] at 10:35 AM, the DON provided the surveyor with the LPN's statement dated [DATE], which indicated the nurse was assigned to the resident that morning. The resident was seen during rounds with their feeding tube running; they took vital signs; preformed mouth care; and administered medication for their blood pressure of ,d+[DATE]. The resident was alert and did not verbalize any discomfort, no facial grimacing, and breathing unlabored. Around 8:40 AM, the RD informed her the resident was slumped over leaning in their bed. The LPN stated she rushed to the resident's room with the CNA and noted the resident was slumped over and non-responsive. The LPN began to panic and she shook the resident and took vital signs, but there was no pulse. The LPN asked the CNA to get the DON, and the CNA informed them they were coming. The LPN reported being so flustered trying to think what to do. The LPN called the Physician and then called the resident's family member. When on the computer, the LPN noticed the resident was a full-code and went into full blown panic mode, and she went back into the room to start CPR. The family member was in the room at this time and did not want me to start CPR. The LPN left the room to give them privacy and saw the LNHA who asked if 911 was called. The LPN stated no and proceeded to call 911. On [DATE] at 10:54 AM, the surveyor interviewed the DON in the presence of the survey team. When the surveyor asked where the code status of a resident can be found, the DON replied all residents' code statuses were located in the electronic medical record on the opening screen; as well as a hard copy was included on the physician's orders which were printed monthly and placed in the residents' hard charts. The DON stated the facility also had a backup system for recalling a few hours of information if the electricity or electronic medical record were unavailable. The DON stated that the CNAs had access to residents' code statuses in their task manager. The DON stated she was not in the building at the time of Resident #82's death, but stated every nurse should know they should call a code if the resident was unresponsive and begin CPR if applicable. The DON stated she also thought the problem was the family member told the LPN to stop CPR when the LPN tried to initiate it. When asked if the family had the authority to stop the CPR, the DON stated I do not know. On [DATE] at 11:08 AM, the DON stated the family member was not the Power of Attorney (POA; authority to make decisions on behalf of another) so therefore would not have the authority to cease CPR. On [DATE] at 11:49 AM, the surveyor interviewed the RD in the presence of the survey team. The RD stated she came into Resident #82's room early in the morning, maybe between 8:00 AM and 8:05 AM, and the resident was turned onto his/her side and belly and feeding tube was on administering enteral formula, and the formula appeared to be spilled on the floor. The RD stated she called out the resident's name, he/she did not respond, so she then got the LPN immediately. The LPN went to the room called his/her name, and the RD left the room as the CNA closed the door behind them. On [DATE] at 12:01 PM, the surveyor attempted to interview the CNA via telephone, she did not answer, and surveyor left voicemail to return the call. On [DATE] at 12:22 PM, the surveyor attempted to call the LPN again, surveyor left another message to call back. LPN did not return surveyor's call. On [DATE] at 1:09 PM, the DON provided the survey team a copy of the facility's Incident Investigation Summary for Resident #82. On [DATE] at 1:13 PM, the surveyor interviewed resident's Physician and Medical Director (MD) in the presence of the survey team. The MD stated he evaluated the residents and reviewed the medications and other paperwork on admission to the facility, one of those would be code status. If the resident had a Practitioner Orders for Life Sustaining Treatment (POLST; a form that specifies the type of medical treatments a person wants to receive during serious illness) form, it would be reviewed, and he would make a physician's order for the code status. The MD stated full-code status meant everything should be done, CPR started, 911 called and advanced life support as well with use of an AED. The MD stated CPR should be started immediately if a person had no pulse or respirations, then immediately tell a staff member to call a code, then follow protocol of airway and breathing, and circulation. The staff member would continue CPR until paramedics arrived to take over. When asked if a family member could stop CPR, the MD replied only if the family member was the medical POA could they authorize staff to stop CPR. At this time, the surveyor reviewed the LPN's statement with the MD who confirmed 911 and CPR should have been first. The MD also stated the patient was always first, not notifying the Physician or family, and the nurse should never leave a resident during a code. On [DATE] at 1:59 PM, the survey team interviewed the DON, who confirmed Resident #82 was a full code status which meant the resident wanted all treatments to revive them including being sent to the hospital. The DON continued if staff walked into a room and a resident was unresponsive, they must call a code; tell another staff to call 911 because you should never leave the resident alone; start CPR; have another staff member grab the crash cart which contained the AED and oxygen. The DON further stated all nurses who worked in the facility were certified in CPR, so there was always someone in the facility that could administer CPR, and staff should continue administering CPR until paramedics arrive to take over. The DON stated the LPN stated she had been flustered, and confirmed she did not call the code so 911 was not immediately called and CPR was not immediately initiated. The DON also stated the family member did not have the authority to stop CPR so the LPN should have initiated it. The DON stated the facility conducted an investigation to determine why the LPN who was an Agency Nurse did not call the code. The DON stated she informed the LPN's Agency that the facility did not want her back because of her incompetency. On [DATE] at 2:21 PM, the surveyor reviewed LPN's witness statement to the DON who stated disregard the LPN's Progress Note which indicated the resident was expired at 8:45 AM, the resident was pronounced dead at 10:04 AM after the paramedics arrived. The DON confirmed the LPN had not acted in accordance with professional standards of practice in regard to following resident's code status preference. On [DATE] at 2:41 PM, the survey team interviewed the LNHA who stated he had worked [DATE], and stated while in building, saw the LPN in the hallway outside of Resident #82's room and the LPN made him aware the resident was found unresponsive. The LNHA asked the code status which he was told was full-code, so he asked if the LPN if she called 911. The LNHA stated the LPN stated no and instructed her to call. The LNHA stated as a result of their conversation the LPN called 911, but he did not recall when the paramedics arrived. The LNHA further stated there were no other nurses helping the LPN when he was there. The facility's failure to ensure the appropriate activation of emergency response for a resident who was a full-code status by calling 911 and initiating CPR when the resident was found to be unresponsive without a heart rate and respirations, placed all residents who were a full code at risk for imminent death if found to be unresponsive without a pulse and without respirations. This resulted in an Immediate Jeopardy situation. The IJ was identified on [DATE], and the LNHA and DON were notified of the IJ at 3:51 PM. The IJ was a Past Non-Compliance IJ that ran from [DATE] at 8:40 AM, when Resident #82 was found unresponsive to [DATE] at 10:04 AM, when the paramedics arrived and pronounced the resident dead. The facility was back in compliance when they addressed this situation by immediately suspending the LPN upon investigation which led to her termination; in-servicing of all staff on emergency situations including CPR; a mock code performed with all staff; and in-servicing of all Agency nurses as scheduled on facility process. This was verified by the survey team on-site on [DATE]. On [DATE] at 7:46 AM, the surveyor interviewed the CNA assigned to Resident #82 on [DATE] via telephone. The CNA stated she was in another resident's room performing care down the hall and she went into the hallway to retrieve supplies when the LPN called her to come to Resident #82's room. The CNA stated she went into the room and the resident was not responding; the LPN shook him/her; checked the pulse, resident's stomach, and ankles; and rubbed their sternum. The LPN then instructed her to get the DON, who was not in the building, and she immediately returned to the LPN to let her know. The CNA confirmed she did not inform any other staff members; she just did what she was told to do by the LPN. The LPN then instructed her to help clean-up the resident. When asked what clean-up meant, the CNA stated the resident was soiled so they changed their incontinent brief and shorts putting the resident in a gown. The CNA stated the resident's top portion of his/her body was folded over and their knees were on the ground as if they rolled over; it did not appear as if the resident fell . The CNA stated that the LPN did not tell her if the resident had a pulse, but stated the resident did not look alive to her. The CNA stated she did not recall the LPN calling a Code Blue and the LPN did not perform CPR. The CNA further stated anyone can call a code; that she assumed the nurse did not call the code because she was already aware of the resident's code status. The CNA stated she was CPR certified, but also did not initiate CPR. A review of the facility's Incident Investigation Summary included a copy of the LPN's CPR certification. The LPN had a CPR Adult, child, infant and AED training valid from [DATE] until [DATE]. A review of the facility provided daily staffing sheet for [DATE] revealed on the day shift from 7:00 AM until 3:00 PM, there were four nurses assigned to work and eight CNAs assigned to work that day. A review of the facility's Code Blue or Code Status Process policy dated effective [DATE] and revised [DATE], included a Code Blue is the standardized signal used to indicate any acute medical emergency (i.e. respiratory distress, reduced function due to arrhythmia, cardiac arrest or status epilepticus). Every individual whose vital signs are not life sustaining or unobtainable is a candidate for resuscitation unless there has been written patient care wishes to withhold treatment and an existing order in place. It is the responsibility of the licensed nurse to check for the status code order .the first responder is the staff member who discovers an unresponsive individual. The will: call for help - call out to other staff members .He or she stays with the individual .Administer assistance to level of their expertise. Verify unresponsive, absence of respirations or absence of pulse and start CPR if trained .The second responder should be a staff member trained in BLS. They will: alert the receptionist to call Code Blue .bring the crash cart to the Code location. The third responder will be responsible for calling 911 .monitor and assist with CPR if required . NJAC 8:,d+[DATE].6(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days. This deficient practice was identified for 4 of 4 residents (Resident #3, #29, #51, and #55) reviewed for physician visits and was evidenced by the following: 1. On 1/27/23 at 10:59 AM, the surveyor observed Resident #51 sitting in their wheelchair at their tray table in their room. The resident was being administered oxygen via nasal cannula (tubing used to deliver oxygen through the nose) at a rate of five liters per minute (5 lpm). The resident informed the surveyor that he/she administered their own oxygen which was usually administered at four liters per minute (4 lpm), but he/she will increase the rate as needed. The resident stated they had chronic obstructive pulmonary disease (COPD; a lung disease which impacts effective breathing), and he/she had been managing their oxygen for years. The resident stated he/she was educated by the facility, and they had all their marbles. The surveyor reviewed the medical record for Resident #51. A review of the Admission Record face sheet reflected the resident was admitted to the facility in June of 2019 with diagnoses including COPD, major depressive disorder, essential hypertension (high blood pressure), and personal history of other diseases of the circulatory system. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 11/22/22, reflected that the resident had a brief interview for mental status (BIMS) score of a 15 out 15, which indicated a fully intact cognition. A further review reflected the resident received oxygen while in the facility, and he/she had received oxygen daily during a seven-day lookback period. A review of the resident's physician visits since January of 2022, revealed that the resident was seen monthly until 10/31/22. There was no further documentation that the resident was seen by his/her primary care Physician since then. On 1/30/23 at 1:43 PM, the surveyor interviewed the Director of Nursing (DON) who stated the Resident #51's Physician conducted all the visits for his residents and he did not have a nurse practitioner see his residents. The DON confirmed the last completed note from the Physician was from 10/31/22. The DON stated that the Physician was recently at the facility and could not speak to why the resident was not seen. On 2/1/23 at 1:13 PM, the surveyor interviewed the Medical Director who stated one of his job roles included coordinating with other physicians at the facility for patient care. The Medical Director stated that a resident should be seen by their physician at least monthly. On 2/2/23 at 9:27 AM, the surveyor interviewed the resident who stated it had been a long time since he/she saw the Physician. The resident stated he/she had seen the Physician in passing in the hallway, but it had been a while since they actually sat down with the Physician. On 2/2/23 at 9:52 AM, the surveyor attempted to interview the Physician via telephone at their office. The Receptionist who answered the phone stated the Physician would not be in the office, and the surveyor left a message to call back. On 2/2/23 at 11:53 AM, the surveyor interviewed the Physician via telephone who stated he came to the facility two to three times a month. The Physician stated he did not document his notes from these visits on all his residents and there was probably missing notes. When asked how often he saw his residents, the Physician stated he was very aware of the regulations. When asked to clarify, the Physician stated he was aware long term care residents needed to be seen once a month and that he did not have a nurse practitioner who saw his residents. The Physician stated he saw his own residents and he was in the middle of a meeting so he hung-up the phone. On 2/3/23 at 9:03 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, Infection Preventionist/Licensed Practical Nurse (IP/LPN), and survey team acknowledged the Physician was not seeing his residents on a monthly basis. 2. On 1/27/23 at 10:52 AM, the surveyor observed Resident #55 sitting in a wheelchair in their room. The surveyor attempted to interview the resident who appeared to have some confusion with their responses. The surveyor reviewed the medical record for Resident #55. A review of the Admission Record face sheet reflected the resident was admitted to the facility in December of 2018 with diagnoses which included cerebral infarction (stroke), aphasia (loss of ability to understand or express speech), and depression. A review of the most recent annual MDS dated [DATE], reflected a BIMS score of 3 out 15, which indicated a severely impaired cognition. A review of the resident's physician visits from the past six months revealed that the resident was last seen by the Physician was 10/31/22. On 2/1/23 at 1:13 PM, the surveyor interviewed the Medical Director who stated one of his job roles included coordinating with other physicians at the facility for patient care. The Medical Director stated that a resident should be seen by their physician at least monthly. On 2/2/23 at 9:52 AM, the surveyor attempted to interview the Physician via telephone at their office. The Receptionist who answered the phone stated the Physician would not be in the office, and the surveyor left a message to call back. On 2/2/23 at 11:53 AM, the surveyor interviewed the Physician via telephone who stated he came to the facility two to three times a month. The Physician stated he did not document his notes from these visits on all his residents and there was probably missing notes. When asked how often he saw his residents, the Physician stated he was very aware of the regulations. When asked to clarify, the Physician stated he was aware long term care residents needed to be seen once a month and that he did not have a nurse practitioner who saw his residents. The Physician stated he saw his own residents and he was in the middle of a meeting so he hung-up the phone. On 2/2/23 at 3:16 PM, the surveyor informed the LNHA and DON that Resident #55 was last seen by their Physician on 10/31/22. On 2/3/23 at 9:03 AM, the LNHA in the presence of the DON, IP/LPN, and survey team acknowledged the Physician was not seeing his residents on a monthly basis. 39460 3. On 1/27/23 at 10:19 AM, the surveyor observed Resident #3 in bed with bed in the lowest position and padding on the bed side-rails. The resident responded to surveyor greetings, but then closed his/her eyes and did not further respond. The surveyor reviewed the medical record for Resident #3. A review of the Admission Record face sheet reflected the resident was admitted to the facility in July of 2019 with diagnoses including dementia, encephalopathy, major depressive disorder, and hypertension. A review of the most recent quarterly MDS dated [DATE], reflected the resident had a BIMS score of a 1 out 15, which indicated severely impaired cognition. A review of the resident's physician visits from the past six months revealed that the resident was last seen by the Physician on 10/31/22. There was no further documentation that the resident was seen by his/her primary care Physician since then. On 2/1/23 at 1:13 PM, the surveyor interviewed the Medical Director who stated one of his job roles included coordinating with other physicians at the facility for patient care. The Medical Director stated that a resident should be seen by their physician at least monthly. On 2/2/23 at 9:52 AM, the surveyor attempted to interview the Physician via telephone at their office. The Receptionist who answered the phone stated the Physician would not be in the office, and the surveyor left a message to call back. On 2/2/23 at 11:53 AM, the surveyor interviewed the Physician via telephone who stated he came to the facility two to three times a month. The Physician stated he did not document his notes from these visits on all his residents and there was probably missing notes. When asked how often he saw his residents, the Physician stated he was very aware of the regulations. When asked to clarify, the Physician stated he was aware long term care residents needed to be seen once a month and that he did not have a nurse practitioner who saw his residents. The Physician stated he saw his own residents and he was in the middle of a meeting so he hung-up the phone. On 2/2/23 at 3:16 PM, the surveyor informed the LNHA and DON that Resident #3 was last seen by their Physician on 10/31/22. On 2/3/23 at 9:03 AM, the LNHA in the presence of the DON, IP/LPN, and survey team acknowledged the Physician was not seeing his residents on a monthly basis. 4. On 1/27/23 at 12:05 PM, the surveyor observed the resident in bed, dressed and well groomed, wearing glasses, with blankets to his/her chest. The resident stated he/she had a urinary catheter (a semi-flexible plastic tube that is inserted into the bladder and is attached to a bag that collects urine). The surveyor observed the urinary collection bag hanging below the bladder in a privacy bag, fluid was amber in color. The surveyor reviewed the medical record for Resident #29 A review of the Admission Record face sheet reflected the resident was originally admitted to the facility in January of 2015 with diagnoses including obstructive and reflux uropathy (a condition where urine does not flow properly from the kidney to the bladder), major depressive disorder, and neoplasm of the prostate (cancer of the prostate). A review of the most recent significant change MDS dated [DATE], reflected that the resident had a BIMS score of 10 out 15, which indicated a moderately impaired cognition. A review of the resident's physician visits from the past six months revealed that the resident was last seen by the Physician was 10/31/22. On 2/1/23 at 1:13 PM, the surveyor interviewed the Medical Director who stated one of his job roles included coordinating with other physicians at the facility for patient care. The Medical Director stated that a resident should be seen by their physician at least monthly. On 2/2/23 at 9:52 AM, the surveyor attempted to interview the Physician via telephone at their office. The Receptionist who answered the phone stated the Physician would not be in the office, and the surveyor left a message to call back. On 2/2/23 at 11:53 AM, the surveyor interviewed the Physician via telephone who stated he came to the facility two to three times a month. The Physician stated he did not document his notes from these visits on all his residents and there was probably missing notes. When asked how often he saw his residents, the Physician stated he was very aware of the regulations. When asked to clarify, the Physician stated he was aware long term care residents needed to be seen once a month and that he did not have a nurse practitioner who saw his residents. The Physician stated he saw his own residents and he was in the middle of a meeting so he hung-up the phone. On 2/2/23 at 2:28 PM, the surveyor interviewed Resident #29 who stated his/her primary care Physician did not come to see him/her very often, he was busy all the time. On 2/2/23 at 3:16 PM, the surveyor informed the LNHA and DON that Resident #29 was last seen by their Physician on 10/31/22. On 2/3/23 at 9:03 AM, the LNHA in the presence of the DON, IP/LPN, and survey team acknowledged the Physician was not seeing his residents on a monthly basis. A review of the facility's Physician Visits policy dated reviewed 10/2022, included .after the first ninety days, if the Attending Physician determines that a resident need not be seen by him/her every thirty (30) days, an alternate schedule of visits may be established, but not to exceed every sixty (60) days. A physician assistant or nurse practitioner may make alternate visits after the initial ninety (90) days following admissions, unless restricted by law or regulation . NJAC 8:39-23.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) assess and educate a resident on self-administration of oxygen and respiratory inhalers; b.) obtain a physician's order for the self-administration of oxygen and respiratory inhalers; c.) care plan for the self-administration of oxygen and respiratory inhalers; d.) accurately sign in the Treatment Administration Record for the administration of oxygen; and e.) accurately sign the Medication Administration Record for the administration of a respiratory inhaler in accordance with standards of practice. The deficient practice was identified for 1 of 2 residents reviewed for respiratory care (Resident #51), and was evidenced by the following: On 1/27/23 at 10:59 AM, the surveyor observed Resident #51 sitting in their wheelchair at their tray table in their room. The resident was being administered oxygen via nasal cannula (tubing used to deliver oxygen through the nose) at a rate of five liters per minute (5 lpm). The resident informed the surveyor that he/she administered their own oxygen which was usually administered at four liters per minute (4 lpm), but he/she will increase the rate as needed. The resident stated they had chronic obstructive pulmonary disease (COPD; a lung disease which impacts effective breathing), and he/she had been managing their oxygen for years. The surveyor also observed three respiratory inhalers on the resident's bed, and they informed the surveyor that he/she administered their own respiratory inhalers. The resident stated he/she was educated by the facility, and they had all their marbles. The surveyor reviewed the medical record for Resident #51. A review of the Admission Record face sheet reflected the resident was admitted to the facility in June of 2019 with diagnoses including COPD, major depressive disorder, essential hypertension (high blood pressure), and personal history of other diseases of the circulatory system. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 11/22/22, reflected that the resident had a brief interview for mental status (BIMS) score of a 15 out 15, which indicated a fully intact cognition. A further review reflected the resident received oxygen while in the facility, and he/she had received oxygen daily during a seven day look back period. A review of the individualized person-centered care plan included a focus area initiated 2/11/2020, for an as needed order for oxygen use with regards to shortness of breath from COPD. Interventions were to administer supplemental oxygen at two liters per minute (2 lpm) via nasal canula for oxygen saturation less than 92% of for SOB. The care plan did not include the resident self-administered their oxygen. A further review of the care plan included a focus area initiated 3/24/2020, for COPD. Interventions included to educate resident/family/caregivers regarding side effects and overuse of inhalers and nebulizers; encourage prompt treatment of any respiratory infection; and give medications as ordered (i.e. nebulizers and inhalers) monitor/document side effects and effectiveness. The care plan did not include the resident administered their own respiratory inhalers. A review of the Order Summary Report (OSR) included the following physician's orders (PO) A PO dated 3/27/21, to administer oxygen at 2 lpm via nasal cannula every twenty-four hours as needed for SOB or oxygen saturation less than 92%. A PO dated 7/2/21, for budesonide-formoterol fumarate aerosol 160-4.5 micrograms to actuation (mcg/act) (Symbicort), a respiratory inhaler, administer two puff inhale two times a day for COPD; rinse mouth after each use. A PO dated 5/16/22, for Spiriva Respimat Aerosol 2.5 mcg/act, a respiratory inhaler, administer 2 puff inhale orally one time per day for COPD; two inhalation of one capsule in hand inhaler. Separate each puff by one minute for maximum drug absorption and effect. A PO dated 1/25/23, for Ventolin HFA Aerosol Solution 108 mcg/act (albuterol sulfate HFA) a respiratory inhaler, administer 2 puff inhale orally every four hours as needed for SOB; shake well before administration. Wait one minute between puffs. The OSR did not include a PO that the resident could administer their oxygen or respiratory inhalers themselves. A review of the corresponding November 2022 Medication Administration Record (MAR) reflected the nurse was signing daily for the administration of the Symbicort and Spiriva respiratory inhalers. The MAR also included a PO dated 7/24/22 and discontinued 1/25/2, for albuterol sulfate HFA to administer two puff inhale orally every four hours as needed for SOB; shake well before administration. The albuterol sulfate HFA was documented as not administered for the month. A review of the corresponding November 2022 Treatment Administration Record (TAR) reflected the resident did not receive oxygen for the month. A review of the corresponding December 2022 MAR reflected the nurse was signing daily for the administration of the Symbicort and Spiriva respiratory inhalers, and the as needed albuterol sulfate HFA was not administered for the month. A review of the corresponding December 2022 TAR reflected the resident did not receive oxygen for the month. A review of the corresponding January 2023 MAR reflected the nurse was signing daily for the administration of the Symbicort and Spiriva respiratory inhalers, and the as needed albuterol sulfate HFA was not administered for the month. A review of the January 2023 TAR reflected the resident did not receive oxygen for the month. A review of the Physician Progress Notes included a note dated 11/18/22, that the resident was seen by the Pulmonology Nurse Practitioner (PNP) and was observed with oxygen being administered at 4 lpm via nasal cannula. The resident was complaint with the Symbicort and Spiriva respiratory inhalers. The plan was to continue with baseline oxygen, Spiriva, and Symbicort. A further review of the Physician Progress Notes included a noted dated 1/15/23, that the resident was seen by the Pulmonologist (medical doctor) and was observed with oxygen being administered at 4 lpm via nasal cannula. The resident was compliant with Symbicort and Spiriva respiratory inhalers and was dependent on oxygen. The plan was to continue Symbicort and Spiriva respiratory inhalers with albuterol sulfate HFA respiratory inhaler as needed. On 1/30/23 at 9:30 AM, the surveyor observed the resident sitting in their room eating breakfast with oxygen being administered at 5 lpm via a nasal cannula. The resident confirmed he/she set the oxygen to that level and that he/she reduced the level to 4 lpm while sleeping. The resident stated the Physician was aware they administered their own oxygen, that he/she had being doing it for years. The resident also confirmed he/she kept their Symbicort, Spiriva, and albuterol sulfate HFA respiratory inhalers and administered themselves because it was pain waiting for the nurse to get it. The resident stated it had been forever since he/she had been administering their own respiratory medications. On 1/30/23 at 11:57 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated the resident was very independent and preferred to not have assistance from staff. The CNA stated the resident always had oxygen on, and that the nurse handled the oxygen. On 1/30/23 at 12:15 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated there were no residents who self-administered medications and there was no medications in any of the residents' rooms. The LPN stated Resident #51 had breathing issues and was on continuous oxygen which she checked the setting. The LPN reviewed the PO with the surveyor and confirmed the resident received oxygen at 2 lpm via nasal canula which she stated she did not sign for the administration of the oxygen. The LPN also stated they received three respiratory inhalers (Symbicort, Spiriva, and albuterol sulfate HFA as needed), which she opened her medication cart and located an unopened box of Spiriva, an opened box of Symbicort, and there was no albuterol sulfate HFA which she stated the resident must be out of. On 1/30/23 at 12:31 PM, the surveyor accompanied by the LPN went into Resident #51's room and the LPN confirmed the oxygen was being administered at 5 lpm. The LPN questioned the resident why the oxygen was at 5 lpm, and the resident responded he/she turned the oxygen to that level and both their Primary Care Physician and Pulmonologist were aware the oxygen needed to be at that level. The LPN then confirmed the resident had all three respiratory inhalers (Spiriva, Symbicort, and albuterol sulfate HFA) in their possession, and the resident stated he/she was aware how to administer their respiratory inhalers, they were doing it for a long time. The LPN turned the resident's oxygen down to 2 lpm and informed the resident she needed to call the Primary Care Physician. Outside the resident's room, the LPN informed the surveyor she had not administered the resident's respiratory inhalers this morning that she was running late with medications, so another nurse administered the resident's medications. The LPN also confirmed the resident did not have a PO to self-administer their own respiratory inhalers or oxygen. On 1/30/23 at 12:40 PM, the surveyor reviewed the MAR for the day which revealed the LPN signed for the administration of the Spiriva and Symbicort that morning. On 1/30/23 at 12:45 PM, the surveyor reviewed the MAR for the day with the LPN who confirmed she signed for the administration of the Spiriva and Symbicort that morning and she did not administer it, so she should not have signed it. At this time, the surveyor and LPN returned to Resident #51's room and the LPN checked the resident's oxygen saturation level which was 98%. The LPN then asked the resident if he/she administered their respiratory inhalers that morning, and the resident confirmed he/she used the Spiriva, Symbicort, and albuterol sulfate HFA that morning. The resident continued he/she administered the albuterol sulfate HFA every four hours. On 1/30/23 at 12:47 PM, the surveyor interviewed the Nursing Supervisor/LPN who stated the process for self-administration of medications was to first assess the resident to make sure they can administer the medication as ordered. If the resident was able to do that, the nurse called the physician who wrote the order for self-administration. The Nursing Supervisor/LPN confirmed Resident #51 did not have a PO to self-administer their oxygen or respiratory inhalers. The Nursing Supervisor/LPN stated the resident should not be touching their own oxygen, and the nurses should have signed for the administration of oxygen. The Nursing Supervisor/LPN also confirmed the resident's PO for oxygen was 2 lpm. On 1/30/23 at 1:04 PM, the surveyor interviewed the Director of Nursing (DON) who stated the process for self-administration of medication was to first assess the resident to determine if they were capable of administering their own medication. If the resident was able to, the nurse called the physician for an order and the care plan was updated to reflect self-administration of a medication. The nurse would follow-up with the resident to ensure they administered the medication as ordered and the nurse would sign the MAR that the medication was verified as received. The DON stated she was just made aware Resident #51 was self-administering their respiratory inhalers and oxygen. The DON confirmed there was no assessment or PO for the resident to do that. The DON stated for oxygen, the nurse would turn on the oxygen and the resident would regulate it. On 1/30/23 at 1:46 PM, the surveyor interviewed the Pulmonologist via telephone who stated Resident #51 was very particular of their care and kept their respiratory inhalers in their room. The Pulmonologist stated that the resident was on continuous oxygen she thought at 2 lpm. The surveyor reviewed the Pulmonologist's note from 1/15/23 in which she documented the resident was receiving 4 lpm of oxygen. The Pulmonologist stated with the resident's medical condition, the resident may need at times an increased amount of oxygen which would not harm the resident. The Pulmonologist acknowledged the oxygen should be administered to the PO. The Pulmonologist stated she may have known the resident was administering their own respiratory inhalers because they were particular, but she could not recall if she wrote an order for self-administration of the respiratory inhalers. On 2/3/23 at 9:03 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Infection Preventionist, Director of Clinical Services, and the survey team acknowledged Resident #51 was self-administering their respiratory inhalers without a PO and the resident was receiving oxygen continuously which was not being signed for by the nurses on the TAR and the order need to be changed from an as needed to a continuous order. The DON also acknowledged the oxygen order was for 2 lpm and not 4 or 5 lpm. A review of the facility's Self-Administration of Medication policy dated reviewed 12/2022, included the procedure: evaluate resident using the Self-Administration of Medication Assessment form to determine if criteria for participation in self administration is met .resident self-administration of medication shall only be permitted upon written order of the physician; pharmacy shall label the containers with full directions for use including cautionary labels; the resident shall be taught to properly self-administer medications. nurse shall review with residents directions for use, indication for medication and possible side effects of medication . A review of the facility's Oxygen Administration policy dated updated 12/2022, included it is the policy and procedure of the [facility] to provide oxygen to the residents in compliance with their physician order as followed out by their resident's care provider . NJAC 8:39-11.2(b)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff to resident neglect that occurred on [DATE] when the Licensed Practical Nurse (LPN) failed to call 911 and initiate cardiopulmonary resuscitation (CPR) for a resident (Resident #82) with a full-code status. This deficient practice was identified for 1 of 2 investigations reviewed, and was evidenced by the following: On [DATE] at 9:17 AM, the surveyor reviewed the closed medical record for Resident #82 who had expired in the facility. The surveyor reviewed the medical record for Resident #82. A review of the Admission Record face sheet reflected the resident was admitted to the facility in December of 2022 with diagnoses which included malignant neoplasm of hypopharynx and retromolar area (cancer of the throat and oral cavity), diabetes, pancytopenia (a reduction in all three major cellular elements of blood), essential (primary) hypertension (high blood pressure). A review of the Admission/Readmission Evaluation dated [DATE] at 12:45 PM, reflected the resident was alert and oriented to person, place, and time with clear speech. A review of the Order Summary Report (OSR) included a physician's order (PO) dated [DATE], for full code status. A review of the Progress Notes reflected a Nursing Note (NN) dated [DATE] at 9:08 AM, written by the LPN who indicated the resident expired around 8:45 AM; feeding tube (a tube inserted through the wall of the abdomen into the stomach which can be used to give medications or liquids) disconnected, bathed, and groomed by Nurse and Certified Nursing Aide (CNA). Family member called and explained the situation; Physician called. An additional NN dated [DATE] at 9:10 AM, written by the Infection Preventionist/LPN (IP/LPN) indicated upon entering the building this nurse was called to resident's room; resident was noted with no blood pressure, no pulse, 911 was immediately called since resident was a full-code. A NN dated [DATE] at 10:10 AM, written by the IP/LPN indicated paramedics on scene, no blood pressure or heart rate maintained. Resident was pronounced dead by physician [name redacted] at 10:04 AM with family at bedside. On [DATE] at 9:33 AM, the surveyor attempted a phone interview with the LPN who did not answer. The surveyor left a message to call back. On [DATE] at 9:40 AM, the surveyor interviewed the IP/LPN who stated Resident #82 expired at the facility. The IP/LPN stated she was not in the building when the situation occurred, she walked into the building with the paramedics arriving right after. The IP/LPN continued a family member was in with the resident, so she offered emotional support. The LPN, who was an Agency Nurse, was the nurse at the time of the death. On [DATE] at 10:19 AM, the surveyor interviewed the Director of Nursing (DON) who stated Resident #82 was a short-term resident at the facility and was very sick with cancer. The day the resident expired, there was an Agency Nurse (LPN) who was flustered when she went into the resident's room; she tried to get the code status; called the Physician and family member; called 911, but she did not start CPR. The DON stated she obtained a statement from the LPN and conducted an investigation. On [DATE] at 10:35 AM, the DON provided the surveyor with the LPN's statement dated [DATE], which indicated the nurse was assigned to the resident that morning. The resident was seen during rounds with their feeding tube running; they took vital signs; preformed mouth care; and administered medication for their blood pressure of ,d+[DATE]. The resident was alert and did not verbalize any discomfort, no facial grimacing, and breathing unlabored. Around 8:40 AM, the Registered Dietitian (RD) informed her the resident was slumped over leaning in their bed. The LPN stated she rushed to the resident's room with the CNA and noted the resident was slumped over an non-responsive. The LPN began to panic and she shook the resident and took vital signs, but there was no pulse. The LPN asked the CNA to get to the DON, and the CNA informed they were coming. The LPN reported being so flustered trying to think what to do. The LPN called the Physician and then called the resident's family member. When on the computer, the LPN noticed the resident was a full-code and went into full blown panic mode, and she went back into the room to start CPR. The family member was in the room at this time and did not want me to start CPR. The LPN left the room to give them privacy and saw the Licensed Nursing Home Administrator (LNHA) who asked if 911 was called. The LPN stated no and proceeded to call 911. On [DATE] at 1:13 PM, the surveyor interviewed the Medical Director (MD) who stated a full-code status meant the resident wanted everything done; which included calling 911; initiating basic CPR or advanced CPR with an automated external defibrillator (AED; a device used to deliver an electric shock to the heart to restore heart rhythm). The MD stated if the resident was a full-code and non-responsive, the nurse would immediately call a code and all staff would be helping assist. One staff member would immediately call 911, while another staff would start CPR until the paramedics arrived who would then take over. The MD stated that unless the family member was the medical Power of Attorney (POA), they could not authorize staff to stop CPR. At this time, the surveyor reviewed the LPN's statement with the MD. The surveyor asked if the LPN should have called the Physician first and then the family member when the resident was non-responsive, the MD replied no, you would call 911 first and initiate CPR which were the important part of the code. The MD stated the patient was always first, not notifying the Physician or family, and the nurse should never leave the resident during a code. On [DATE] at 1:58 PM, the surveyor interviewed the DON who confirmed the resident was a full-code status which meant the resident wanted all treatments to revive them including being sent to the hospital and CPR. If the resident was a full code and non-responsive, the first thing the nurse would do was call the code and other staff would come. The LPN should never leave the resident, other staff would be delegated to check the code status, call 911, start CPR, grab the crash cart which contained the AED and oxygen. The LPN who was CPR certified would have continued to perform CPR until the paramedics arrived and took over. The DON confirmed the LPN did not call the code, and 911 was not notified immediately, and CPR was not initiated immediately or at all. The DON also confirmed the family member was not the POA, so the nurse should have initiated CPR despite the family's request not to. The DON stated the facility conducted an investigation to determine why the LPN who was an Agency Nurse did not call the code. The DON stated she informed the LPN's Agency that the facility did not want her back because of her incompetency, but acknowledged she did not notify the NJDOH of the incident and should have. On [DATE] at 10:21 AM, the surveyor re-interviewed the DON who stated she choose to investigate this incident to determine where the system breakdown was because this was basic nursing. A review of the facility's Incident/Accident Investigating and Reporting Policy and Procedure dated updated ,d+[DATE], included .in the event the incident is found to be reportable based on the DOH reportable guidelines, the necessary information will be reported to the DOH in a timely manner. NJAC 8:,d+[DATE].4(f)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain proper infection control practices identified for 1 of 2 nurses observed during medication administration and for 1 of 4 nurses interviewed during medication storage and b.) perform hand hygiene after 1 of 6 observed kitchen staff pull their surgical mask down and then back up. This deficient practice was evidenced by the following: 1. On 1/30/23 at 9:05 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare to administer medication to Resident #59. LPN #1 entered the resident's room with an infra-red thermometer scan and obtained a temperature of 97.3 degrees Fahrenheit (F). LPN #1 went to the medication cart and placed the thermometer on top of the cart without disinfecting the thermometer. The surveyor observed LPN #1 prepare and administer Resident #59 medications. On 1/30/23 at 9:15 AM the surveyor observed LPN #1 obtain a blood sugar using a blood glucose meter for Resident #36. The blood sugar was 298. LPN #1 returned to the medication cart and placed the blood glucose meter on top of the medication cart. LPN #1 then placed the blood glucose meter into the top drawer of the medication cart. On 1/30/23 at 9:45 AM, the surveyor interviewed LPN #1 who stated that she was not aware that she did not disinfect the thermometer and thought she did. LPN #1 acknowledged the glucometer was not disinfected, and that the thermometer and the glucose meter should have been cleaned with the disinfectant wipes after each use. On 2/1/23 at 10:43 AM, the surveyor inspected the West Wing medication cart in the presence of LPN #2. The surveyor observed an UltraTrak Complete blood glucose meter inside the medication cart and interviewed LPN #2 at this time. LPN #2 stated that she used the blood glucose meter during her shift to check the blood sugars of several residents before breakfast and lunch. The surveyor asked LPN #2 about the way that she cleaned and disinfected the blood glucose meter between residents. LPN #2 stated that she used 70% isopropyl alcohol prep pads. The surveyor asked if LPN #2 waited a set amount of time after using the alcohol prep pads. LPN #2 stated, I never really counted but that by the time she walked to the next room that the blood glucose meter was ready. LPN #2 stated that the container of disinfectant wipes was too large to bring into resident rooms and that was why she used alcohol prep pads. The surveyor asked how many blood glucose meters were in the medication cart? LPN #2 responded that there should be two blood glucose meters in the medication cart, but that there was only one. On 2/1/23 at 11:33 AM, the surveyor interviewed the Infection Preventionist/LPN (IP/LPN). The IP/LPN stated that staff were expected to disinfect the blood glucose meter between residents using disinfectant wipes and to wait two minutes before using the blood glucose meter to test the blood sugar on the next resident. The IP/LPN stated that alcohol prep pads were not an acceptable disinfectant to use on a blood glucose meter. The surveyor reviewed the list of residents on the West Wing who received regular blood sugar monitoring. The list of residents included Residents #1, #19, #36, #59, #60, #62, #65. The surveyor reviewed the medical record for Resident #1: A review of the Admission Record face sheet reflected the resident was admitted to the facility in September of 2022 with diagnoses that included human immunodeficiency virus (HIV) disease (a virus that attacks the body's immune system and can be transmitted through contact with infected blood). On 2/1/23 at 1:07 PM, the surveyor conducted a follow-up interview with LPN #2. LPN #2 stated that Resident #1 had HIV and that their blood sugar was monitored with the same blood glucose meter as the other West Wing residents. The surveyor asked if there was a reason why a resident with HIV did not have a dedicated blood glucose meter that only they used. LPN #2 stated that she started at the facility three months ago and that, this is how it's been. On 2/1/23 at 1:11 PM, the surveyor conducted a follow-up interview with the IP/LPN. The IP/LPN stated that it was not discussed with her when Resident #1 was admitted whether the resident should have a dedicated blood glucose meter. On 2/2/23 at 11:52 AM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) of the above concerns with the blood glucose meters. The surveyor asked if this was how they would expect a nurse to disinfect a shared blood glucose meter? The DON responded, no. On 2/2/23 at 3:15 PM, the surveyor informed the LNHA and DON that LPN #1 did not sanitize the thermometer and glucose meter after each use. On 2/3/22 at 9:03 AM, the DON in the presence of the LNHA, IP/LPN, Regional Infection Preventionist, Director of Clinical Services, and the survey team confirmed that the nurses should disinfect the thermometer and blood glucose monitors after each use with disinfectant wipes. On 2/6/23 at 3:04 PM, the surveyor interviewed the IP/LPN who stated that the importance of disinfecting reusable equipment would be because they do not want to transfer organisms between residents, and she also stated that disinfectant wipes should have been used after use for both the blood glucose meter and thermometer. A review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy dated reviewed 12/2022, included .reusable items are to be cleaned/disinfected between before reuse by another resident . A review of the facility's Blood Glucose Meter Cleansing and Disinfecting policy dated reviewed 9/2022, included .the glucose meter should be cleansed between each resident's use. The meter needs to be disinfected with a germicidal wipe allow to air dry . A review of the manufacturer's instructions, UltraTrak Complete Sample Policy and Procedures dated 5/11, included the blood glucose meter should be cleaned and disinfected between each patient test . to disinfect the meter a pre-moistened disinfecting wipe needed to be used . 38080 2. On 1/27/23 at 10:13 AM, the surveyor accompanied by the Food Service Director (FSD) conducted a tour of the kitchen. During the tour, the surveyor observed the FSD pull down her surgical mask and continued to talk to the surveyor. When asked if the FSD should be wearing her mask to cover her mouth and nose, the FSD confirmed yes and proceeded to cover her mouth and nose with her mask. The FSD then proceeded to open the reach-in refrigerator and reached her hand into the refrigerator. At this time, the surveyor asked if there was anything she should have done after touching her mask? The FSD acknowledged she should have washed her hands and proceeded to the sink to perform hand hygiene appropriately using soap and water. On 2/3/23 at 9:03 AM, the DON in the presence of the LNHA, IP/LPN, Regional Infection Preventionist, Director of Clinical Services, and the survey team confirmed the FSD should have washed her hands after touching her surgical mask. A review of the facility's undated Handwashing/Hand Hygiene policy included .in most situations, the preferred method is washing hands with soap and water. If hands are not visibly soiled, the use of an alcohol-based hand rub may be used for the following situations: .after contact with inanimate objects . NJAC 8:39-19.4; 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation performed on 1/30/23, the surveyors observed two nurses administer medication to five ( 5) residents. There were 28 opportunities, and two (2) errors were observed, which calculated to a medication administration error rate of 7.14%. This deficient practice was identified for 1 of 5 residents (Resident # 36) that were administered medications by 1 of 2 nurses. The deficient practice was evidenced by the following: On 1/30/23 at 9:15 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) obtain a blood sugar (BS) result of 298 and stated Resident #36 had a physician's order (PO) for a sliding scale coverage of insulin; meaning that certain BS results corresponded to the amount of insulin to be administered. There was no observed breakfast tray in the resident's room. Upon returning to the medication cart, the surveyor with the LPN reviewed the Medication Administration Record (MAR). The LPN stated that according to the PO on the MAR, the resident was to receive 6 units of insulin for the sliding scale and 14 units of the lispro (Humalog) insulin to total 20 units of insulin. Humalog insulin was fast acting insulin that was used to control high blood sugar. The surveyor observed the LPN prepare six medications for Resident #36; which included the lispro (Humalog). The surveyor observed the LPN administer the insulin subcutaneously to the resident's left upper abdomen using an insulin syringe. (Error #1) At that time, the LPN stated the resident had breakfast and the resident confirmed that they ate their breakfast. The LPN then reviewed the MAR and stated the resident had an order for Lantus (insulin glargine) 18 Units. Lantus insulin was a long-acting insulin that helped control high blood sugar levels. The surveyor then observed the LPN prepare, then administered the insulin subcutaneously to the resident's right upper abdomen using an insulin syringe. (Error #2) On 1/30/23 at 9:45 AM, at the medication cart, the surveyor interviewed the LPN who stated that the usual insulin technique was to administer insulin before the resident ate breakfast. The surveyor with the LPN reviewed the MAR for Resident # 36 which revealed the insulin ordered was displaying pink. The LPN stated that when medication orders displayed pink, it was a computer alert that indicated that the medication was late to be administered. Further review indicated the lispro insulin was plotted to be administered for 7:30 AM and the Lantus insulin was plotted to be administered for 8:00 AM. The LPN stated that the insulin administration for both the insulins were late and should have been administered on time and before the resident had eaten breakfast. The surveyor reviewed the medical record for Resident #36. A review of the Admission Record face sheet reflected the resident had a diagnosis of diabetes mellitus (DM). A review of the most recent annual Minimum Data Set (MDS), an assessment tool dated 11/2/22, reflected the resident had a brief interview for mental status (BIMS) score of 14 out of 15, which indicated a fully intact cognition. A review of the January 2023 MAR included a PO dated 9/1/21, for insulin lispro solution 100 unit/milliliters (unit/mL); inject 14 units subcutaneously two times a day every Monday, Wednesday, Friday for DM on dialysis days; plotted to be administered at 7:30 AM. Further review of the January 2023 MAR included a PO dated 8/25/21, for Humalog solution 100 units/ml (insulin lispro), inject as per sliding scale: if 0 - 150 = 0 units; 151 - 200 =2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units; 451- 999 = 14 units and call the physician. Administer subcutaneously three times a day every Monday, Wednesday, and Friday for DM on dialysis days; plotted to be administered at 7:30 AM. Further review of the January 2023 MAR reflected a PO dated 10/25/21, for Lantus solution 100 unit/ml (insulin glargine) inject 18 units subcutaneously two times a day for DM; plotted to be administered at 8:00 AM. On 1/30/23 at 9:50 AM, the surveyor interviewed the Infection Preventionist/LPN (IP/LPN) who stated it was important to administer insulin on time because of the peak time of the medication and because of the blood sugar in the body. On 1/30/23 at 1:50 PM, the surveyor interviewed the Director of Nursing (DON) who stated the insulin orders should have been administered at the times ordered by the physician. The DON stated she did not know why the nurse was late with the insulin administrations. On 2/3/23 at 9:03 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and IP/LPN. The DON acknowledged that medications should be administered on time. A review of the facility's Medication Administration policy dated reviewed 6/2022, included .medications to be administered at the right time because medications are scheduled to avoid drug/food interactions and per manufacturer recommendations . According to information from the American Diabetes Association on Insulin Basics included rapid acting insulin begins to work about 15 minutes after injection. In addition, information on Insulin Routines reflected that Insulin shots are most effective when you take them so that insulin goes to work when glucose from your food starts to enter your blood. For example, regular insulin works best if you take it 30 minutes before you eat. According to the Lantus prescribing information included under indications and usage Lantus is a long-acting human insulin analog indicated to improve glycemic control in adults and pediatric patients with type I diabetes mellitus and in adults with type 2 diabetes mellitus .Dosage and Administration .the insulin to be administered subcutaneously at the same time every day . NJAC 8:39-11.2(b)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to a.) communicate a hospice recommendation for a toe treatment to the physician and b.) to follow hold parameters for the administration of a blood pressure medication in accordance with professional standards of practice. This deficient practice was identified for 2 of 24 residents (Resident #66 and #82) reviewed for standards of practice and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On [DATE] at 12:00 PM, the surveyor observed Resident #66 lying in bed enjoying a visitor playing a guitar. The visitor identified themself as being from hospice. On [DATE] at 9:13 AM, the surveyor observed Resident #66 lying in bed positioned upright eating potato chips. Their legs were positioned in two slotted pillows, and they wore non-skid socks on their feet. The resident stated they were on hospice care, and someone from hospice visited them daily. The surveyor reviewed the medical record for Resident #66. A review of the Admission Record face sheet reflected the resident was admitted to the facility in December of 2021 with diagnoses which included end stage heart failure, hypertension (high blood pressure), and breast cancer. A review of the most recent annual Minimum Data Set (MDS), and assessment tool dated [DATE], reflected a brief interview for mental status (BIMS) score of 15 out 15, which indicated a fully intact cognition. A further review reflected the resident received hospice care. A review of the individualized person-centered care plan reflected a focus area initiated [DATE], for hospice care for end stage heart failure. Interventions included to communicate needs to hospice to work together to obtain comfort and care for resident; give support and reassurance to resident and family members as needed; hospice to be part of the interdisciplinary care team; and plan of care to be reviewed by the interdisciplinary care team, resident, family, and hospice as needed. A review of the Hospice Recommendations included a recommendation dated [DATE] to right great toe at 3 o'clock lateral to nail bed cleanse skin tear with wound cleanser or normal saline solution; pat dry; apply triple antibiotic ointment to wound bed; cover with band aide; change daily for fourteen days. The wound size was 0.5 centimeters (cm) by 0.1 cm by 0.1 cm deep with brown eschar (dead skin tissue cast off from the surface of the skin or a scab) on non-adherent pad of band aide with no drainage or odor. The Hospice Nurse indicated she made the facility's Licensed Practical Nurse (LPN #1) aware of the order. A review of the Order Summary Report (OSR) did not include this treatment as a physician order. A review of the corresponding [DATE] Treatment Administration Record (TAR) did not reflect the resident received this treatment. On [DATE] at 1:17 PM, the surveyor interviewed the resident's Certified Nursing Aide (CNA #1) who stated the resident was particular with who cared for them and preferred to have care done at 5:00 AM by the 11:00 PM to 7:00 AM aide and by their Hospice Aide. CNA #1 stated their Hospice Aide came daily and provided care during the day shift. On [DATE] at 1:21 PM, the surveyor observed the resident in bed with their Hospice Aide performing personal grooming. On [DATE] at 1:33 PM, the surveyor interviewed the Nursing Supervisor/LPN who stated after a resident was evaluated for hospice care, the nurse called the Physician to receive an order for hospice care. The Nursing Supervisor/LPN stated that the Hospice Aide came daily Monday through Friday to provide care, and the Hospice Nurse came too, but he could not speak to the frequency. The Nursing Supervisor/LPN stated any recommendation the Hospice Nurse had, they documented it in the resident's paper medical record and informed the facility's nurse. It was the facility nurse's responsibility to communicate the recommendation with the Physician to obtain a physician order. At this time, the surveyor reviewed with the Nursing Supervisor/LPN the Hospice Recommendation from [DATE]. The Nursing Supervisor/LPN confirmed LPN #1 was the nurse documented as informed and confirmed that the physician order was not obtained and there was no documentation as to why the Physician would not want to carry out the recommendation. The surveyor requested to observe the resident's wound. On [DATE] at 1:46 PM, the surveyor accompanied by another surveyor and the Nursing Supervisor/LPN went into Resident #66's room to observe the wound. The Hospice Aide removed the resident's non-skid sock, and the Nursing Supervisor/LPN proceeded to remove a band aide from the toe. The surveyor asked when that band aide was applied, and both the resident and Hospice Aide stated the Hospice Nurse applied the band aide last week during their visit, but they could not recall the exact day. The resident stated the facility's nurse did not change the band aide daily. The Nursing Supervisor/LPN attempted to locate the wound and he stated it appeared to have healed. The Hospice Aide confirmed the wound had improved from last week based on the appearance. On [DATE] at 1:58 PM, the surveyor interviewed LPN #1 who stated the resident was on hospice and the Hospice Aide came daily and the Hospice Nurse came weekly. LPN #1 stated if the Hospice Nurse had a recommendation, they would document in the resident's paper medical record and flag the page. LPN #1 stated sometimes the Hospice Nurse in addition communicated directly with her, but it was her responsibility to daily check the resident's paper medical record. When asked what the process was after receiving a recommendation from hospice, LPN #1 stated she would inform the Nursing Supervisor/LPN because she was new to the facility and was unaware how to input a physician order. LPN #1 stated she had not received a recommendation from hospice yet. At this time, the surveyor reviewed the Hospice Recommendation dated [DATE], and LPN #1 denied seeing that recommendation. LPN #1 confirmed she did not administer this treatment to the resident today. On [DATE] at 2:08 PM, the surveyor interviewed the Director of Nursing (DON) who stated once a resident had a physician order for hospice care, the Hospice Aide and Hospice Nurse along with the facility staff would care for the resident. The DON stated any recommendations made by the Hospice Nurse were documented in the resident's paper medical record and flagged for the staff. It was the responsibility of the nurse on duty to review the chart to ensure no new recommendations. Any new recommendations, the nurse would call the Physician to communicate the recommendation and obtain a physician's order if the Physician choose to carry-out the recommendation. The DON confirmed if the Physician did not want to carry-out the recommendation, the nurse had to document in the medical record. On [DATE] at 9:03 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Infection Preventionist, Director of Clinical Services, and survey team acknowledged that the Hospice Recommendation from [DATE] was not communicated to the Physician in accordance with professional standards of practice. A review of the facility's Hospice Program policy dated reviewed ,d+[DATE], included .when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms .the facility and hospice will identify the specific services that will be provided by each entity and this information will be communicated in the plan of care; the hospice and facility will communicate with each other when any changes are indicated or made to the plan of care . A review of the facility's undated Order Transcription policy included .the ,d+[DATE] shift will do a 24 hours chart check to ensure all orders are being carried out properly. 39460 2. On [DATE] at 9:17 AM, the surveyor reviewed the closed medical record for Resident #82 who had expired in the facility. The surveyor reviewed the medical record for Resident #82. A review of the Admission Record face sheet reflected the resident was admitted to the facility in December of 2022 with diagnoses which included malignant neoplasm of hypopharynx and retromolar area (cancer of the throat and oral cavity), diabetes, pancytopenia (a reduction in all three major cellular elements of blood), essential (primary) hypertension (high blood pressure). A review of the Admission/Readmission Evaluation dated [DATE] at 12:45 PM, reflected the resident was alert and oriented to person, place, and time with clear speech. A review of the OSR included a physician's order (PO) dated [DATE], for Kapspargo Sprinkle Capsule ER 24 Hour 25 milligram (mg) (metoprolol succinate); give 1 capsule via gastrostomy tube (g-tube; a tube inserted through the wall of the abdomen into the stomach which can be used to give medications or liquids) one time a day for hypertension; hold (do not administer) for systolic blood pressure (SBP) less than 110 or heart rate (HR) less than 60. A review of the corresponding [DATE] Medication Administration Record (MAR) revealed the 9:00 AM metoprolol succinate dose was administered on [DATE] with a HR of 59, which was less than 60 and should have been held. On [DATE] at 11:19 AM, the surveyor interviewed the facility's Consultant Pharmacist (CP) via telephone. When asked if a blood pressure medication order had a parameter to hold for a SBP less than 110 or a HR less than 60, and the nurse documented a BP of ,d+[DATE] and HR of 59, should the nurse have administered the medication? The CP responded if there was a hold parameter, the nurse should have held the medication as the Physician instructed to. On [DATE] at 11:55 AM, the surveyor interviewed the DON in presence of the survey team who stated there were hold parameters for blood pressure medications because a resident could be at risk for falls if the blood pressure dropped too low. The DON further stated that if a physician's order had hold parameters for either the BP or HR, the nurse was expected to hold the medication if the BP or HR was outside the parameters. At this time, the surveyor reviewed with the resident's [DATE] MAR for the metoprolol succinate, and the DON confirmed the nurse should not have administered the medication on [DATE] because the resident's HR was below 60. On [DATE] at 12:20 PM, the surveyor interviewed the resident's Physician/Medical Director (MD) via telephone. When asked what the purpose of hold parameters were, the MD responded to manage symptoms; you do not want the resident to be hypertensive (high blood pressure) or hypotensive (low blood pressure). The MD stated if the physician's order had a parameter to hold for a HR of 60 or lower, then the nurse was expected to not administer the medication. The MD stated if the nurse called and informed him that the BP was ,d+[DATE] and the HR was 59; he would have instructed the nurse to administer the medication. The MD confirmed that the professional standard of practice would be to check the parameters and hold the medication as prescribed when necessary. The nurse should not administer the medication outside the parameters without calling the Physician for instructions. A review of the facility's Medication Administration policy dated reviewed ,d+[DATE], included .Hold Parameters: check blood pressure and/or pulse rate immediately prior to pouring . The policy did not include following physician's order regarding medication hold parameters. NJAC 8:,d+[DATE].2(b); 27.1(a)

Based on interview and review of facility documentation, it was determined that the facility failed to test staff for Coronavirus Disease 2019 (COVID-19) at a frequency based on the COVID-19 Activity Level Index (CALI) Weekly Report. This deficient practice was identified for 3 of 3 staff members, who had worked on 3 of 3 units, which were reviewed for testing as evidenced by the following: On 1/28/21 at 9:30 AM, the surveyor met with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) in the conference room. The ADON/IP stated that staff were tested for COVID-19 at a frequency of once per week. The surveyor requested the facility ' s testing plan, testing schedule, county positivity rate, and three staff ' s most recent two COVID-19 test results. A review of the staff ' s most recent two COVID-19 test results for the three staff reviewed reflected the following: 1. A Physical Therapist (PT) tested negative for COVID-19 on 1/19/21 and 1/26/21. 2. A Minimum Data Set (MDS) Coordinator tested negative for COVID-19 on 1/19/21 and 1/27/21. 3. The Maintenance Director tested negative for COVID-19 on 1/21/21 and 1/26/21. During an interview with the surveyor on 1/28/21 at 12:36 PM, the ADON/IP provided the facility ' s testing schedule with the county positivity rate and stated staff were tested weekly in the facility on either Tuesday or Wednesday. The ADON/IP further noted that the facility ' s county positivity rate was 11.3% but was unsure of the CALI Weekly Report positivity rate. The surveyor reviewed the three staff members ' COVID-19 test results, and the ADON/IP acknowledged the staff were tested on ce per week. Review of the facility ' s testing schedule, undated, included Staff: Tuesday/Weds and Staff – Weekly. A review of the CALI Weekly Report for the week ending January 23, 2021, included a percent positivity rate of 11.15% for the Central East region where the facility was located. During a follow-up interview with the surveyor on 1/28/21 at 12:47 PM, the ADON/IP stated the facility should have tested staff twice per week based on the CALI Weekly Report, and the IP was responsible for checking the CALI Weekly Report to determine testing frequency. Review of the facility ' s Coronavirus (COVID-19) Policy, revised 12/16/20, included, Testing of Staff and Patients is to be completed as per current CDC/Federal, State, and/or local guidance. Review of the New Jersey Department of Health Executive Directive No. 20-026, revised 1/6/21, included, Continued testing of staff as follows: . Routine testing should be based on the extent of [MEDICAL CONDITION] in the community, therefore facilities should use the regional positivity rate reported in the COVID-19 Activity Level Index (CALI) Weekly Report in the prior week, as the trigger for staff testing frequency as follows: . Regional CALI Level: High/Very High – Regional Percent Positivity Rate in the past week: >10% - Minimum Testing Frequency: Twice a Week. NJAC 8:39-5.1(a); 19.1(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to utilize appropriate personal proactive equipment (PPE) to prevent the potential spread of infection in accordance with the facility policy and acceptable standards of practice. This deficient practice was identified for 1 staff member on 1 of 3 units reviewed for infection control practices and was evidenced by the following: During an interview with the surveyors on 01/07/2021 at 10:20 AM, the Administrator stated the PPE to be worn on the yellow zone PUI/observation units and red zone Covid positive unit included a face shield, N95 respirator mask, and a gown and gloves when entering the resident's rooms. During a tour on the West Wing, the yellow zone, on 01/07/2021 at 11:10 AM, the surveyor observed a Licensed Practical Nurse (LPN) wearing a surgical mask with an N95 respirator over the surgical mask, and a surgical mask over the N95 respirator. At that time, the surveyor interviewed the LPN who stated she had been wearing her masks that way to preserve the integrity and the life of the of the N95 respirator. She stated she was educated on how to apply a N95 respirator and the proper use of the masks and would fix her masks. During an interview with the surveyor on 01/07/2021 at 2:15 PM, the Infection Control Preventionist stated the staff were educated on the proper use of the N95 respirator and wearing a surgical mask underneath the N95 would not create a correct seal to work properly. The facility was unable to provide the education for the LPN. Review of the facility's Coronavirus (Covid-19) Policy dated 3/4/20, with a last revision date of 12/16/20, revealed staff entering and caring for residents should follow Center for Disease Control (CDC) recommendations for PPE and current guidance is Standard and Transmission Based Precautions. Review of a facility document titled, CDC Proper N95 Respirator Use for Respiratory Protection Preparedness with a last updated date of 8/14/2020, revealed one of the three criteria required for a respirator to be effective the respirator must fit the user's face snugly to create a seal to minimize the numbers of particles that bypass the filter through gaps between the user's skin and the respirator seal. According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Responding to Coronavirus (COVID-19) in Nursing Homes updated 4/30/20 included, Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown .All recommended COVID-19 PPE (personal protective equipment) should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e. goggles or a disposable face shield that covers the front and sides of the face),gloves, and gown. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. NJAC 8:39-19.4(a)(2);27.1(c)

Complaint # NJ 2 Based on interviews, review of the Medical Records (MR), and pertinent facility documents on 1/6/2020 and 1/7/2020, it was determined that the facility nursing staff failed to notify a resident's family timely, and failed to follow the facility policy titled Change in a Resident's Condition or Status for 1 of 4 sampled residents (Resident #3), when the resident had a change in condition and was transferred out to the hospital. This deficient practice is evidenced by the following: 1. According to the Admission Record, Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool date 11/14/2019, Resident #3 had a Brief Interview for Mental Status (BIMS) Score of 12/15, indicating that the resident had moderate cognitive impairment. The MDS also indicated that this resident required extensive assistance for Activities of Daily Living (ADLs). Review of Resident #3's Progress Notes (PN) documented by the nurse, revealed an entry showing Resident #3 was transferred to the Hospital by Ambulance for an evaluation of his skin on 4/14/2019 at 11:09 a.m. Further review of the PN revealed documentation by the nursing staff on 4/15/2019 at 11:20 p.m., included the following: Late Entry: Resident was sent out to the ER (emergency room ) .for [MEDICAL CONDITION] Resident was admitted upon assessment at the emergency room . Family member was notified on late entry and full responsibility taken for not notifying earlier In addition, the PN, dated 4/15/2019 at 11:48 p.m., showed documented by the nurse apologizing to the family member for not calling earlier about sending the resident to the hospital. During an interview on 1/7/2020 at 11:35 a.m., the Acting Assistance Director of Nursing (ADON) reported the Change of Condition Policy states: notify the family promptly and promptly is within 24 hours. Review of the facility policy titled Change in a Resident's Condition or Status, under Policy Statement, with a revised date of (MONTH) (YEAR), included the following: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's condition and/or status N.[NAME][NAME]C. 8:39-13.1(c)

COMPLAINT # NJ 7 Based on interviews, review of Medical Records (MR), and review of other pertinent facility documents on 1/6/2020 and 1/7/2020, it was determined that the facility failed to notify/report to the New Jersey Department of Health (NJDOH) an Injury of Unknown Origin. In addition, the facility failed to follow their policies titled, Abuse and Neglect and Reporting Unusual Occurrences, for 1 of 4 sampled residents, (Resident #1). This deficient practice was evidenced by the following: 1. According to the MR, Resident #1 was originally admitted to the facility in 2014, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), an assessment tool dated 10/9/2019, revealed the staff were unable to conduct a Brief Interview for Mental Status (BIMS) for Resident #1 since the resident is rarely or never understood, indicating severe cognitive impairment. Review of Resident #1's Care Plan with an initiated date of 11/13/2020 (sic), under Focus listed the following: .bruise easily due to my [MEDICATION NAME] medication regimen. I prefer all administrations in my stomach. Review of the Facility's Medication Administration Record [REDACTED]. Inject 1 ml subcutaneously every 8 hours for anticoagulants, with a start date of 6/26/2019. Review of the Facility's Progress Notes (PN) for Resident #1 dated 11/9/2019 at 4:15 a.m., revealed documentation by the Licensed Practical Nurse (LPN) reporting the following: A bruise/discoloration was observed to the residents left upper arm, deltoid area, measuring 7 to 8 centimeters (cm) with black and blue discoloration. In addition, the LPN documented: Resident is on Q8 (every 8) hours blood thinner [MEDICATION NAME] injections, which does put resident . at high risk and very prone to easily bruising. Review of the Facility document Incident Report, dated 11/9/2019 at 6:29 a.m., and a revision date of 11/11/2019 at 7:11 a.m., showed the following documentation by the LPN: .nurse noticed a bruise measuring 7 to 8 cm with black and blue discoloration on resident's upper left arm deltoid area. In addition, under Immediate Action Taken the LPN documented that the situation was reported to the family and the Director of Nursing (DON) was called and notified about the bruise. During an interview on 1/6/2020 at 2:11 p.m., the DON reported an investigation was done regarding the bruise to Resident #1 left arm; however; the New Jersey Department of Health (NJDOH) was not notified about the Injury of Unknown Origin on Resident #1 because it was from the [MEDICATION NAME]. During a follow-up interview on 1/6/2020 at 2:47 p.m., the DON stated: The bruise was an Injury of Unknown Origin prior to the results of the investigation. Review of the facility's Policy titled Abuse and Neglect with a revised date of (MONTH) (YEAR), revealed the following under Treatment/Management #2. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Review of the facility's Policy titled Reporting Unusual Occurrences dated 3/2015, revealed the following under Policy Statement: Unusual occurrences are reported by the facility to regulatory authorities as required by federal, state laws N.[NAME][NAME]C. 8:39-9.4(f)

Based on observation, interview and record review, it was determined that the facility failed to a.) maintain proper kitchen sanitation practices, and b.) properly store food items in a safe and sanitary environment to prevent the development of foodborne illness. This deficient practice was evidenced by the following: The surveyor toured the kitchen with the Cook on 05/19/19 at 09:03 AM. The Cook stated that in the absence of the Director, the Cooks took on the role of supervisor. During the tour the following was observed: An unsolid, unfinished wooden ramp that led into the walk-in refrigerator. Wood is a porous surface. The floor of the walk-in refrigerator had a build up of an orange and brown rust-like substance. The Cook stated the build up was rust. A five gallon opened container of mayonnaise on a shelf in the walk-in refrigerator. The container was not labeled with a received or opened date. The Cook stated the container should have been dated. The bottom rack on the left side of the the walk-in refrigerator was approximately an inch from the floor and with debris underneath. It was observed that there would have been no room to pass a broom and/or mop underneath the rack. Floor debris was noted on the right side as well. A heavy build up of a black substance was observed on the two, four-tier racks, located on either side of the walk-in refrigerator. The racks are used to store food. The Cook used a clean blue cloth to wipe the racks. A large amount of black sticky debris came off and onto the blue rag after the Cook wiped the racks. She stated it should not have been that way. The surveyor observed two fan covers in the walk-in refrigerator blowing air onto food storage. There was a build up of a black substance on the outside and in the crevices of the fan covers. The Cook stated it should not have been that way. There was a broken tile on the wall above the prep table, located past the walk-in refrigerator. The Cook could not state if the maintenance department was aware of the broken tile. The surveyor observed a heavy build up of a black substance on the range backsplash. The surveyor observed a heavy orange-brownish grease like substance on the tiles behind the cooking area. The surveyor observed a heavy build up of a light brownish substance on the right side of the range and the bottom left side of the double stacked convection ovens (directly opposite of each other). The Cook stated she thinks the area is cleaned every two weeks and could not state if there was a cleaning schedule. There were three clear bins under a prep area. The Cook stated two bins held thickener and the third was rice. The surveyor observed a scoop stored inside one of the thickener containers, as well as a burgundy plastic soup bowl stored in each of the other bins. The Cook stated nothing was to be stored in the dry ingredient containers. The surveyor also observed a build up of food particle like substances on the lids of all three dry ingredient containers. There was a few broken tiles on the right side and bottom corner of the wall underneath the dish machine. There was a two door reach-in refrigerator that held desserts and beverages. The gaskets on the inside of both doors were ripped and were in disrepair. There was a heavy black build up on the inside of the ice machine. The substance was observed on the entire baffle (a partition used to restrain ice flow and regulate ice production) and on the right interior side of the ice machine. The Cook used a clean blue cloth to wipe the side and baffle. A large amount of a thick black substance was observed on the blue rag. The Cook stated it should not have been that way and could not state when the last time the ice machine was cleaned. She stated that there should be a cleaning sign with dates. There was a heavy build up of a brownish-grayish dust like substance on the right side of the ice machine, near the venting area, and also on the wall behind the ice machine. The Cook acknowledged the build up and that it should not have been that way. During an interview with the surveyor on 05/19/19 at 10:30 AM, the Food Service Director (FSD) stated that he did not have a formal way of communicating maintenance concerns. He stated that sometimes he would email the Maintenance Director and the Administrator and had not reported anything lately. He further stated there was no facility policy that spoke to this process. On 05/20/19 at 12:29 PM, the surveyor observed white debris hanging from the middle of the ceiling in the kitchen. During an interview with the FSD at that time, he stated that it was part of the ceiling hanging because of water leaks. He further stated that the Maintenance Department was aware because they have tried to patch it. On 05/21/19 at 12:11 PM, the surveyor observed a Dietary Aide (DA) exit the kitchen pushing a lunch tray cart without a beard restraint. During an interview with the DA at that time, he stated that there were no beard nets and that he was not wearing anything. He further stated he typically used a hair net as a beard restraint. On 05/21/19 at 12:17 PM, the surveyor observed the FSD enter and then exit the kitchen without a beard restraint. During an interview with the surveyor on 05/21/19 at 12:20 PM, the FSD stated that beard nets were available and acknowledged that he entered the kitchen without a beard restraint and should not have done that. A review of a Daily Cleaning Schedule, dated 05/06/19 to 05/19/19, revealed no evidence of assignments to clean the walk-in refrigerator racks, the refrigerator fans covers or the walls behind the cooking area. A review of the facility's undated Food Storage policy reflected that food storage areas should be maintained in a clean, safe and sanitary manner and be kept clean at all times. The document also indicated that all foods stored in walk-in refrigerators should be stored above the floor or other surfaces to facilitate thorough cleaning. The document further indicated that all food would be dated at the time of receipt. A review of the facility's Ice Machines and Ice Storage Chests policy, with a revised date of (MONTH) 2012, reflected that ice machines should be used and maintained to assure a safe and sanitary supply of ice. A review of the facility's undated Personnel Standards policy reflected that all beards should be kept well trimmed and covered with an effective hair restraint (beard guard, etc.). A review of the facility's undated Sanitation policy reflected that the food service area should be maintained in a clean and sanitary manner. The document also reflected that all kitchen areas should be kept clean and free from liter or rubbish. The document further reflected that all counters, shelves and equipment should be kept clean, maintained in good repair and be free from breaks, corrosions, open seams, cracks or chipped areas. In addition, the document reflected that ice which was used in connection with food or drink should be from a sanitary source and should be handled and dispensed in a sanitary manner. NJAC 8:39-17.2(g)

Based on observation, interview, record review and review of other facility documents, it was determined that the facility failed to ensure that medications were dated when opened and discarded when expired and discontinued. This is a repeat deficiency from the last standard survey dated 05/24/18. This deficient practice was identified on medication carts on two units and was evidenced by the following: On 5/19/19 at 09:09 AM, the surveyor inspected the East Unit medication (med) cart #1 with a Licensed Practical Nurse (LPN #1) and observed an opened, undated [MEDICATION NAME] 100 units/milliliter (ml) 3 ml injection pen (diabetic injectable medication) in a sealed bag and an opened [MEDICATION NAME] multi-dose flex pen (diabetic injectable medication) dated 01/27/19. At that time, LPN #1 confirmed the [MEDICATION NAME] pen was opened, used and that it should have been dated when it was initially opened. Additionally, LPN #1 stated that the [MEDICATION NAME] flex pen should have been removed from the cart. On 05/19/19 at 09:48 AM, the surveyor inspected med cart #3 on the low end of the East Unit with LPN #3 and observed the following: Three (3) bottles of Dorzolamide 2% (eye drop medication) and two (2) bottles of Latanoprost 0.005% (eye drop medication) that were opened and not dated. One of the bottles of Latanoprost 0.005% had smeared black marker that was not legible. This bottle of Latino was stored within a plastic pill container that was labeled as opened 09/28/18. During the time of observation, LPN #3 confirmed that the date on the medication bottle was illegible and should have contained a legible label with the opened date. One (1) vial of [MEDICATION NAME] 5000 units/10 ml multi-dose was opened and not dated. During the time of the observation, LPN #3 stated that the medication should have been dated when it was opened. During an interview with the surveyor on 05/21/19 at 12:29 PM, the Director of Nursing stated that all medications should be dated when opened on the medication bottle and any expired medications should be immediately removed from the med cart. She further stated that each medication nurse was responsible every shift to check their med cart for expired and discontinued medications. Review of the facility contracted pharmacy list of medications and the expirations, provided by the Pharmacy Consultant, revealed the following: Latanoprost to be discarded 42 days after removing from refrigeration; Dorzolamide to be discarded fifteen days after opening the pouch; [MEDICATION NAME] Flex pen and [MEDICATION NAME] to be discarded after 28 days. Review of the Storage of Medications policy and procedure, dated 4/2007, revealed that nursing staff is responsible for maintaining medication storage in a safe manner and the facility shall not use discontinued and outdated drugs. All such drugs will be returned to the pharmacy or destroyed. Review of the Administering Medications policy and procedure, dated 12/2012, revealed, the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date will be recorded on the container. NJAC:8:39-29.4(a)(g)

Based on observation, interview, record review and review of other facility documents, it was determined that the facility failed to develop a baseline, individualized care plan for a resident on oxygen therapy. This deficient practice was identified for Resident #83, 1 of 20 residents reviewed for care plans and was evidenced by the following: On 05/19/19 at 11:35 AM, the surveyor observed Resident #83 in bed wearing a nasal cannula (oxygen tubing that is inserted in the nose) that was connected to an oxygen concentrator (oxygen delivery system) at a rate of 2 liter per minute (lpm). The surveyor observed the resident received oxygen at 2 lpm through a nasal cannula on 05/19/19, 05/20/19, 05/21/19, 05/22/19, and 05/23/19. Review of the Admission Record reflected Resident #83 was readmitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of Resident #83's physician's orders [REDACTED]. Review of Resident #83's Minimum Data Sets (MDS) an assessment tool, dated 04/24/19 and 05/01/19 revealed that the resident was on oxygen therapy and had shortness of breath or trouble breathing when sitting at rest. Review of Resident #83's Care Plans included an admission date of [DATE] and did not reveal any focus area, goals or interventions that applied to the oxygen therapy in use for Resident #83. During an interview conducted by the surveyor on 05/22/19 at 10:00 AM, the Licensed Practical Nurse (LPN) on Resident #83's unit, stated any potential problems such as pressure ulcer, falls, rehabilitation or oxygen, would be on a resident's care plan. Additionally, the LPN stated that when a resident is admitted , the nurse who admitted the resident would put the care areas on the initial 48 hour care plan, or the nurses would inform the supervisors who would implement the care areas on the care plan. During an interview conducted by the surveyor on 05/22/19 at 10:06 AM, the 7 AM-3 PM shift LPN supervisor stated that when a resident is admitted , the admission nurse would initiate the baseline care plan or inform her (the supervisor) if the nurse was unable to initiate the baseline care plan. The LPN supervisor stated the care plan should address areas such as behaviors, medications, falls, treatment changes, physical therapy, occupational therapy, and oxygen. The LPN supervisor stated the Director of Nursing (DON) or she would be responsible to monitor the care plans for accuracy. During a follow up interview conducted by the surveyor on 05/22/19 at 10:12 AM, the LPN supervisor stated the care plans are updated at least quarterly and that any new concerns or changes are discussed in morning meeting. The LPN supervisor stated any new concerns or changes discussed will be added to the care plan. The LPN supervisor stated that if the nurse did not already change the care plan, she would have been responsible to do it. During an interview conducted by the surveyor on 05/22/19 at 11:21 AM, the LPN supervisor stated she was familiar with Resident #83. The LPN supervisor, in the presence of another surveyor, reviewed the care plan for Resident #83 and acknowledged the oxygen therapy was not on the care plan. The LPN supervisor stated she should have definitely caught the omission of the oxygen therapy which should have been care planned. During an interview conducted by the surveyor on 05/22/19 at 11:30 AM, the DON stated that when a resident is admitted to the facility, the orders will trigger and show on the resident's care plan. The DON stated that if the resident was a new admission, the nurses would be responsible to enter the care areas on the baseline care plan and that the nursing supervisors would be responsible for monitoring the care plans daily for accuracy. A review of the facility, Care Plan - Baseline policy, dated revised (MONTH) (YEAR), revealed the baseline plan of care is developed within 48 hours of admission to address the resident's immediate needs as the Interdisciplinary Team had identified by the healthcare practitioner's orders. The baseline care plan would be used until the staff can conduct the comprehensive assessment and person-centered care plan. A review of the facility, Care Plans, Comprehensive Person-Centered policy, dated revised (MONTH) (YEAR), revealed the person-centered care plan will include measurable objectives and timeframe's, describe the services that are to be furnished to maintain the resident's highest practicable well-being, incorporate identified problem areas and the risk factors associated with them, reflect treatment goals, timetables and objectives in measurable outcomes and to identify the professional services that are responsible for each element of care. The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS. NJAC 8:39- 11.2 (d)(e 1-2)(f)

Based on observation, interview and record review, it was determined that the facility failed to ensure medication administration times were sequenced to accommodate a resident's [MEDICAL TREATMENT] (HD), a process of purifying the blood of a person whose kidneys are not working normally, schedule in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 residents reviewed on [MEDICAL TREATMENT] (Resident #82) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The nurse practice act for the State of New Jersey 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. Reference: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 05/20/19 at 09:01 AM, the surveyor observed the resident in bed with eyes closed. The resident did not rouse on surveyor approach. During an interview with the surveyor on 05/20/19 at 1:20 PM, Resident #82 stated that he/she went to HD on Mondays, Wednesdays, and Fridays. The resident stated that now he/she went to HD on Saturdays as well due to holding onto excess fluid. The resident acknowledged that he/she was not compliant with a fluid restricted diet. The resident stated the HD schedule was approximately 2:00 PM pick up time and 7:00 PM return time. A review of Resident #82's Admission Record revealed that the resident was admitted on [DATE] and included the resident's diagnoses, including but not limited to End Stage Renal (kidney) Disease ([MEDICAL CONDITION]), Dependence on [MEDICAL TREATMENT], Acute [MEDICAL CONDITIONS], Hypertensive [MEDICAL CONDITION], and Type 1 Diabetes Mellitus. A review of the residents Quarterly Minimum Data Set (MDS), an assessment tool dated 04/22/19, reflected the resident had an intact cognition. The MDS further reflected that the resident received HD. A review of the residents Care Plan (CP), dated as last reviewed on 05/03/19, reflected the resident had [MEDICAL CONDITION] and attended HD. It also reflected the resident was on a fluid restricted diet with a history of noncompliance. The CP further reflected the resident was prescribed the medication [MEDICATION NAME] (a medication that helps to increase blood pressure) for [MEDICAL CONDITION] (low blood pressure). A review of Resident #82's Medication Review Report (MRR), dated 05/22/19, reflected physician orders [REDACTED]. 1. Order dated 04/24/19: [MEDICATION NAME] capsule (medication used for [MEDICAL CONDITION] and pain management) 400 milligram (mg) give one capsule by mouth three times a day. 2. Order dated 04/24/19: [MEDICATION NAME] HCl tablet 5 mg give two tablets by mouth three times a day for blood pressure, hold for systolic blood pressure greater than 120. 3. Order dated 05/03/19: Renal Multivitamin Formula Tablet (B Complex-C-Folic Acid vitamin supplement) give one tablet by mouth one time a day. 4. Order dated 04/24/19: [MEDICATION NAME] tablet (lowers phosphorous levels) 800 mg give one tablet by mouth three times a day, with or after meals. 5. Order dated 04/24/19: Insulin Regular Human Solution (injectable diabetic medication) 100 unit/ml, inject as per sliding scale if 0-149 =0, 150-200 = two units, 201-250 = four units, 251-300 = six units, 301-350 = eight units, 351-400 = 10 units, 401-999 = 0 units - notify the doctor if blood glucose is greater than 400, subcutaneously before meals for blood glucose control. The MRR also reflected a physician's orders [REDACTED]. There was no evidence that indicated physician's orders [REDACTED]. A review of the HD Center's Post Treatment Documentation reflected HD treatment end times on the following dates: 1. On 05/01/19 at 6:53 PM 2. On 05/03/19 at 6:16 PM 3. On 05/04/19 at 5:40 PM 4. On 05/06/19 at 6:28 PM 5. On 05/08/19 at 6:53 PM 6. On 05/10/19 at 6:11 PM 7. On 05/11/19 at 5:51 PM 8. On 05/13/19 at 6:55 PM 9. On 05/15/19 at 7:04 PM 10. On 05/17/19 at 6:48 PM 11. On 05/18/19 at 5:10 PM 12. On 05/20/19 at 6:02 PM A review of a Nursing Note, dated 05/04/19, reflected the resident returned from HD at 6:30 PM. A review of the Medication Administration Record [REDACTED] 1. On 05/01/19, the MAR indicated [REDACTED]. 2. On 05/03/19, the MAR indicated [REDACTED]. 3. On 05/04/19, the MAR indicated [REDACTED]. The Insulin with sliding scale coverage and blood sugar check was blank. There was no documented evidence that these physician's orders [REDACTED]. 4. On 05/06/19, the MAR indicated [REDACTED]. 5. On 05/08/19, the MAR indicated [REDACTED] 6. On 05/10/19, the MAR indicated [REDACTED]. 7. On 05/11/19, the MAR indicated [REDACTED]. 8. On 05/13/19, the MAR indicated [REDACTED]. 9. On 05/15/19, the MAR indicated [REDACTED] 10. On 05/17/19, the MAR indicated [REDACTED]. 11. On 05/18/19, the MAR indicated [REDACTED]. 12. On 05/20/19, the MAR indicated [REDACTED]. There was no documented evidence that this physician's orders [REDACTED]. During an interview with the surveyor on 05/21/19 at 09:00 AM, the Licensed Practical Nurse (LPN) stated that Resident #82 went to HD on Mondays, Wednesdays, Fridays, and Saturdays. She stated that the resident left at approximately 2:00 PM and the treatment takes approximately four hours. She stated that the resident typically returned to the facility between 6:00 PM and 07:00 PM. The surveyor and LPN reviewed the residents MAR indicated [REDACTED]. The surveyor and LPN observed the administration times for the Renal Multivitamin, the [MEDICATION NAME], the blood sugar check with sliding scale Insulin, the [MEDICATION NAME] and blood pressure check, and the [MEDICATION NAME]. The LPN acknowledged that the medication dispension times were not ordered or scheduled around the HD treatment times. During an interview with the surveyor on 05/21/19 at 09:20 AM, the Registered Nurse Supervisor (RNS) stated that Resident #82 went to HD on Mondays, Wednesdays, and Fridays. The RNS stated that the resident left at approximately 2:00 PM and returned to the facility between 6:00 PM and 07:00 PM. The surveyor and RNS reviewed the residents MAR indicated [REDACTED]. The surveyor and RNS observed the administration times for the Renal Multivitamin, the [MEDICATION NAME], the blood sugar check with sliding scale Insulin, the [MEDICATION NAME] and blood pressure check, and the [MEDICATION NAME]. The RNS acknowledged that the medication dispension times were not scheduled around the HD treatment. He stated the process was that upon admission or if there was a change in a HD schedule, medications times should be scheduled around the HD treatment schedule and he could not speak to why that had not been done for this resident. During an interview with the surveyor on 05/22/19 at 11:05 AM, the Director of Nursing (DON) stated that the process for timing medication administration around a residents HD schedule is the responsibility of the nurse and this was overseen by the RNS to ensure accuracy. She further stated that this should be done on admission, readmission and with any change in a HD schedule. On 05/22/19 at 11:46 AM, the Director of Nursing (DON) and the surveyor reviewed a print out of the residents MAR for May. The surveyor and DON observed the administration times for the Renal Multivitamin, [MEDICATION NAME] and blood pressure check, and [MEDICATION NAME]. The surveyor and DON also reviewed the HD Center's Post Treatment document dated 05/01/19 which indicated the resident's treatment ended at 06:53 PM. The DON acknowledged that the resident was not in the building at the time the medications were signed for. She could not speak to why the nurse would have signed for these medications and further stated the medications should have been timed around the HD schedule as per the previously mentioned process. A review of the facility's undated Care of a Resident with [MEDICAL CONDITION] policy reflected that education and training of staff included but was not limited to timing and administration of medications, particularly those before and after [MEDICAL TREATMENT]. A review of the facility's Administering Medications, dated revised 12/2012, revealed that medications must be administered in accordance with the orders, including any required time frames and that medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). NJAC 8:39-27.1(a)

Based on interview and review of facility documentation, it was determined that the facility failed to verify that a nurse aide (NA) was enrolled in a Nurse Aide Training and Competency Evaluation Program (NATCEP) prior to date of hire. This deficient practice was identified for 1 of 1 nurse aide employee files reviewed and was evidenced by the following: On 05/22/19, the surveyor reviewed the employee file for the NA which revealed a hire date of 03/28/19. There was no evidence in the employee file that the NA was enrolled in a NATCEP. Review of the NA's schedule and time card revealed that the NA worked in the facility on 04/01, 04/02, 04/03, 04/04, 04/05, and 04/14/19. The NA was scheduled to work with a Certified Nurses Aide (CNA). During an interview with the surveyor on 05/22/19 at 09:43 AM, the Human Resources (HR) Director stated she did not verify that the NA was enrolled in a NATCEP during the hiring process because the NA gave verbal confirmation that she was in school. During an interview with the surveyor on 05/22/19 at 10:02 AM, the Director of Nursing (DON) stated the NA was per diem (as needed) and believed that the NA no longer worked in the facility. The DON stated that HR should have verified that the NA was in school. During a follow up interview with the surveyor on 05/22/19 at 11:53 AM, the HR director stated that she called the NA who stated that she was not enrolled in a NATCEP. During an interview with the surveyor on 05/23/19 at 10:17 AM, the Administrator stated that the NA was not returning to the facility. NJAC 8:39-43.1(a)(2)

Based on observation, interview and record review, it was determined that the facility failed to 1. document the administration and the accurate dose administered of a narcotic medication on the Electronic Medication Administration Record (EMAR) for 1 of 6 residents observed for medication passage (Resident #245), the facility failed to 2. withhold a blood pressure medication when Systolic Blood Pressure (SBP) parameters indicated that the for 1 of 1 resident reviewed for blood pressure monitoring and control, (Resident #95), the facility failed to 3. frequently document the output of urine on the EMAR for a resident with a Foley catheter required for 1 of 1 resident reviewed for output of urine, Resident # 60 and the facility failed to 4. properly handle used insulin syringes. 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 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 5/16/18 at 9:18 AM, the surveyor observed the Licensed Practical Nurse (LPN) medication Nurse awaken Resident #245 to administer (2) tablets of [MEDICATION NAME] 5 mg. The resident had earlier requested the pain medication. The LPN informed the surveyor that she could not document the administration of the [MEDICATION NAME], a controlled substance medication on the EMAR. The LPN explained to the surveyor that the [MEDICATION NAME] could not be documented on the EMAR because the administration time was not in the time frame ordered by the Physician. The medication was orders every 12 hours as needed and only 11 hours and 20 minutes had elapsed since the previous dose. The surveyor reviewed the medical records for Resident #245. Resident #245 was admitted to the facility on [DATE] and readmitted on [DATE] with a physician's orders [REDACTED]. The EMAR documented that the previous dose of [MEDICATION NAME] 5 mg was administered on 5/15/18 at 10:39 PM but had no documentation of the current dose administered at 9:18 AM on the EMAR. On 5/16/18 at 10:45 AM the surveyor reviewed the EMAR and noted [MEDICATION NAME] HCl tablet 5 mg Give 2 tablet by mouth one time only for pain documented with the LPN's initials for the administration of the [MEDICATION NAME] 5 mg at 9:30 AM. On 5/17/18 at 10:45 AM, the surveyor reviewed the facility policy titled Documentation of Medication Administration which included Administration of medication must be documented immediately after (never before) it is given. 2. On 5/18/18 at 11:45 AM the surveyor reviewed the discharge records for Resident #95. Resident #95 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was treated with [MEDICATION NAME] (HCl) 5 mg (1) tablet twice daily for [MEDICAL CONDITION]. The order on the Electronic Medical Administration Record (EMAR) contained the warning to hold the medication if the Systolic Blood Pressure (SBP) is greater than 100. [MEDICATION NAME] is used for treating dizziness that occurs upon sitting up or standing (orthostatic [MEDICAL CONDITION]). [MEDICATION NAME] is used to increase blood pressure and works by causing blood vessels to constrict. According to the manufacturer's recommendation, the administration of [MEDICATION NAME] when the SBP is over the ordered parameter might cause a marked elevation of supine (lying down) arterial blood pressure, which, if sustained, may cause stroke, [MEDICAL CONDITION] infarction, [MEDICAL CONDITIONS] or similar disorders which individually or collectively may be fatal. The surveyor reviewed the (MONTH) (YEAR) EMAR for Resident #95 that showed the administration of [MEDICATION NAME] HCl 5 mg tablet on 2 separate times when the SBP was documented as over 100. The surveyor reviewed the (MONTH) (YEAR) EMAR for Resident #95 that showed the administration of [MEDICATION NAME] HCl 5 mg tablet on 7 separate times when the SBP was documented as over 100. The surveyor reviewed the (MONTH) (YEAR) EMAR for Resident #95 that showed the administration of [MEDICATION NAME] HCl 5 mg tablet on 3 separate times when the SBP was documented as over 100. 3. On 5/17/18 at 12:03 PM, the surveyor reviewed the medical records belonging to Resident #60. Resident #60 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #60 was documented having a Foley Catheter with an order to monitor and record Foley Catheter output every shift on the EMAR. The surveyor reviewed the (MONTH) (YEAR) EMAR that had 9 missing output levels as well as 5 days which included 14 shifts lacking any order for Foley catheter care every shift. The surveyor reviewed the (MONTH) (YEAR) EMAR which had 11 output levels that were found to be blank as well as 7 blank areas for Foley catheter care every shift. The documentation on the (MONTH) (YEAR) EMAR lacked levels of output as well as nursing signatures for both output and catheter care. The surveyor reviewed the (MONTH) (YEAR) EMAR which had 5 output levels that were found to be blank as well as 3 blank areas for Foley catheter care every shift. The documentation on the (MONTH) (YEAR) EMAR lacked levels of output, as well as nursing signatures for both output and catheter care. The surveyor also identified the lack of documentation on 4/26/18 when reviewing the (MONTH) (YEAR) EMAR, for changing the Foley catheter every 30 days. The surveyor reviewed the facility Catheter Care Procedure (CCP) which indicated Maintain an accurate record of the resident's daily output within the Input/Output section. The Documentation section of the CCP, also identified The following information should be recorded in the resident's medical record: The date and time that catheter care was given. 4. On 05/17/18 at 08:23 AM, the surveyor observed the medication LPN on the sub-acute unit. The medication cart was located in front of the nursing desk close to resident room [ROOM NUMBER]. The surveyor observed the LPN who drew up insulin in a syringe and walked down the hall with the insulin syringe and supplies in her hands to room [ROOM NUMBER]. The LPN closed the door and about 8:25 AM walked out of room [ROOM NUMBER] with nothing in her hands. The LPN walked back down the hall to the medication cart, removed the used insulin syringe from her right scrub top pocket and discarded it into the sharps container located on the side of the medication cart. On 05/17/18 at 08:27 AM, the surveyor observed the same LPN. The LPN drew up insulin from the medication cart that was still stationed in front of the nurses desk on the sub-acute unit. The LPN walked down the hall with the insulin syringe and supplies in her hands to room [ROOM NUMBER]. The LPN went behind the resident's drawn curtain. The LPN exited the room about 8:30 AM with nothing in her hands. The LPN walked back down the hall to the medication cart, removed the used insulin syringe from her right scrub top pocket and discarded it into the sharps container located on the side of the medication cart. On 05/17/18 at 08:30 AM, the LPN stated that it was ok to carry used syringes in my pocket. I don't want to carry a used syringe in my hand down the hall. My boss has seen me do it and it's fine. My cart (medication cart) is up here (by the nursing desk) with the computer plugged in and I don't take it everywhere I go. On 05/17/18 at 08:40 AM, the DON stated there shouldn't be any medications or supplies in anyone's pockets. On 05/17/18 at 11:04 AM, the DON provided the: 1) Sharps Disposal policy dated revised 1/2012 that revealed, contaminated sharps will be discarded into containers that are: closable; puncture resistant; leak proof on both sides and bottom; impermeable and capable of maintaining impermeability through final waste disposal. During use, containers for contaminated sharps will be handled as follows: designated individuals will ensure that the containers are easily accessible to employees and located as close as feasible to the immediate area where sharps are used or can be reasonable anticipated to be found. 2) Insulin Administration policy dated revised 9/2014 that revealed after injection is administered, dispose of the needle in a designated container. On 05/18/18 at 12:22 PM, the DON provided the, Administering Medications policy dated revised on 12/2012 that revealed in section 16: The cart must be clearly visible to the personnel administering medications, Section 22: Staff shall follow facility infection control procedures for the administration of medications. Upon request for the facility infection control procedures for the administration of medications, on 05/21/18 at 10:41 AM, the DON provided the Infection Control Prevention, Control and Antibiotic Stewardship policy dated revised 10/13/17 that revealed, The goals of the program are to: 1. Provide a safe and sanitary environment. The policy also revealed, the implementation of control measures and precautions such as standard and transmission based precautions. The policy revealed that Part O. Compliance with Governmental, Regulatory and Accrediting Agencies and Infection prevention and control policies and procedures are contained within nursing clinical procedures manual. NJAC 8:39-27.1(a)

Based on observation, interview and record review it was determined that the facility failed to: 1) clarify and follow a physician's [MEDICAL TREATMENT] order, 2) clarify or monitor [MEDICAL TREATMENT] medications, and 3) communicate with the [MEDICAL TREATMENT] center. This deficient practice was identified for Resident #26, 45 and 82; three of three residents reviewed for [MEDICAL TREATMENT] and was evidenced by the following: 1. On 5/15/18 at 10:22 AM, the surveyor toured the facility and identified that Resident #26 received Peritoneal [MEDICAL TREATMENT] at their bedside. The surveyor reviewed the medical records of Resident #26 who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 26 was admitted to the facility with [DIAGNOSES REDACTED]. On 5/18/18 at 10:09 AM, the surveyor reviewed the Continuous Cycling Peritoneal [MEDICAL TREATMENT] (CCPD) order faxed to the facility on [DATE]. The surveyor compared the specific 'weight to solution used' orders to the (MONTH) (YEAR) Electronic Medication Administration Record (EMAR). The surveyor reviewed the (MONTH) (YEAR) EMAR which documented 5 days of discrepancies of the Physician order [REDACTED]. The surveyor reviewed the (MONTH) (YEAR) EMAR which documented 5 days of discrepancies of the Physician order [REDACTED]. The surveyor reviewed the (MONTH) (YEAR) EMAR from 4/1/18 to 4/13/18 which documented an order which was also evident in the (MONTH) (YEAR) EMAR and did not vary the solutions according to the weight of the resident. On 5/18/18 at 10:30 AM, the surveyor asked the Director of Nursing (DON) to explain the Peritoneal [MEDICAL TREATMENT] Procedure. The DON explained that the Peritoneal [MEDICAL TREATMENT] is performed in the facility and once a month the resident visits the [MEDICAL TREATMENT] Center for evaluation. The DON stated that once the resident is evaluated, the facility is faxed a [MEDICAL TREATMENT] order created for the specific needs of that resident. The surveyor informed the DON that the surveyor could not find the [MEDICAL TREATMENT] order for (MONTH) (YEAR). On 5/18/18 at 10:46 AM, the DON presented the surveyor with a CC order dated 2/22/18, which was faxed to the facility. The DON stated We never received this order. The resident goes out to the [MEDICAL TREATMENT] center monthly and receives orders to be followed by the facility. The surveyor identified that the [MEDICAL TREATMENT] order was changed on 2/22/18 but was not reflected on the EMAR until 4/14/18. The DON could not give any further information why the orders for (MONTH) and (MONTH) (YEAR) were not followed correctly nor why the new order from 2/22/18 was not received and the physician's orders [REDACTED]. 2) On 05/18/18 at 11:55 AM, the surveyor reviewed the medical record of Resident #45 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #45 had a physician's orders [REDACTED]. The surveyor reviewed the Electronic Medication Administration Record (EMAR) and noted there were no blood pressure documented with the administration of the [MEDICATION NAME]. 05/18/18 at 12:10 PM, the surveyor reviewed the EMAR for 4/2018 which revealed the [MEDICATION NAME] was administered on 4/13/18 and 4/18/18. The surveyor reviewed the EMAR for 3/2018 which revealed 3/23/18, 3/26/18 and 3/28/18 that the [MEDICATION NAME] was not administered because the blood pressure was outside parameters and to see the nurses notes. The order did not stipulate any BP parameters and there were no BP's documented that correlated with the [MEDICATION NAME] being administered or being held on the EMARs. On 05/18/18 at 12:15 PM, the surveyor reviewed the residents [MEDICAL TREATMENT] communication book that revealed on the days the [MEDICATION NAME] was administered, the blood pressure readings were documented were in the higher range. On 4/13/18 the pre [MEDICAL TREATMENT] blood pressure at the [MEDICAL TREATMENT] unit was 140/92 and on 4/18/18 the pre [MEDICAL TREATMENT] blood pressure at the [MEDICAL TREATMENT] unit was 154/94. On 05/18/18 at 12:25 PM, the surveyor reviewed the medical record of Resident #45. The blood pressure summary contained no documented blood pressures for the month of (MONTH) (YEAR). On 05/18/18 at 12:36 PM, the DON stated that the order indicated that the nurses should check the blood pressure to be sure it is low. The DON also stated the [MEDICATION NAME] was meant to go with the resident to [MEDICAL TREATMENT] to be given at [MEDICAL TREATMENT] if the blood pressure was low. On 05/18/18 at 11:55 AM, the Registered Nurse at the resident's [MEDICAL TREATMENT] center stated that the resident's BP usually runs high, the systolic (top reading) ranging from 130-160 or over and diastolic (bottom reading) ranging from 90-100 or over. The RN stated the [MEDICAL TREATMENT] center is aware that the resident is on [MEDICATION NAME] and that the facility should be aware not to give it prior to [MEDICAL TREATMENT] if the BP is elevated. The RN at the [MEDICAL TREATMENT] center stated that the [MEDICAL TREATMENT] doctor did not write the order and therefore stated it was not the responsibility of the [MEDICAL TREATMENT] center to put parameters on the order. The RN stated there was no documentation that the facility ever informed the [MEDICAL TREATMENT] center that Resident #45's BP was elevated and that they were holding the [MEDICATION NAME] or had any questions about it. On 05/18/18 at 12:22 PM, the DON provided the, Administering Medications policy dated revised (MONTH) 2012 that revealed, Part 8. the following information must be checked/verified for each resident prior to administering medications: b. vital signs, if necessary 3. On 5/17/18 at 9:37 AM, the surveyor reviewed Resident #82's EMAR which revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. On 5/18/18 at 12:58 PM, the Director of Nursing (DON) supplied the surveyor with the [MEDICAL TREATMENT] Care Guidelines Treatment and Care policy dated 9/09/14, which revealed the following: 1) Residents ordered [MEDICAL TREATMENT] therapy will be monitored and documentation will be maintained in the medical record. All residents receiving [MEDICAL TREATMENT] will be assessed before and after [MEDICAL TREATMENT] treatment and for compliance with their individualized plan of care. Medical information/record received from the [MEDICAL TREATMENT] Provider shall be maintained as part of the facility's medical record for the resident. Should such information not be received from the [MEDICAL TREATMENT] Provider upon the residents return, the facility shall contact the [MEDICAL TREATMENT] Provider to obtain such medical information. On 5/21/18 at 10:00 AM, the surveyor reviewed Resident #82's Care Plan dated 1/15/18 which revealed the following:1)Focus: Resident has [MEDICAL TREATMENT] with potential for fluid volume excess/deficit, and infection; 2) a) Interventions: Keep open communication with [MEDICAL TREATMENT] center; b) [MEDICAL TREATMENT] Monday, Wednesday, Friday. On 5/21/18 at 11:00 AM, the surveyor reviewed Resident #82's [MEDICAL TREATMENT] log, which revealed the following: 1) On 3/12/18, 3/16/18, 3/21/18, 3/23/18, 3/26/18, 3/28/18, 3/30/18, 4/02/18, 4/04/18, 4/06/18, 4/09/18, 4/11/18, 4/13/18, 4/18/18, 4/23/18, 4/25/18, 4/27/18, 5/02/18, 5/07/18, 5/11/18, 5/14/18 and 5/16/18 there was no [MEDICAL TREATMENT] center communication documented in the [MEDICAL TREATMENT] log. This was a total of 22 complete [MEDICAL TREATMENT] center omissions. 2) On 3/07/18 there was no post [MEDICAL TREATMENT] weight documented, on 3/09/18 there were no log review nurse initials, on 3/14/18 there was no post [MEDICAL TREATMENT] weight documented, on 3/22/18 there was no log review nurse initials, on 4/16/18 there was one set of vital signs and no weights documented, on 4/30/18 there was no log review nurse initials, on 5/09/18 there was no post [MEDICAL TREATMENT] weight documented, and on 5/18/18/ there was no post [MEDICAL TREATMENT] vital signs and weight documented. On 5/21/18 at 11:10 AM, the surveyor reviewed Resident #82's [MEDICAL TREATMENT] log with the West Wing Registered Nurse (WW RN) who stated, I truthfully just look to see if there are the any concerns or orders communicated from the [MEDICAL TREATMENT] center, and not the weights and vital signs, when the resident gets back from [MEDICAL TREATMENT], then I initial the log. The WW RN was shown the [MEDICAL TREATMENT] log of the missing documentation dates in question. She could not explain why there was no [MEDICAL TREATMENT] center documentation on the days in question, or why a nurse had not initialed the log on the dates in question. The WW RN further showed the surveyor the Consultation Record form that is filled out by the receiving facility nurse upon the resident's return when there is no [MEDICAL TREATMENT] log documentation. No Consultation Reports were observed in the [MEDICAL TREATMENT] log or provided to the surveyor for the dates in question. On 5/21/18 at 11:15 AM, the DON stated that the unit manager keeps up on the [MEDICAL TREATMENT] logs, but since there had been a change in staff, that there was no one currently overseeing the completeness of the [MEDICAL TREATMENT] logs. The DON further stated that the [MEDICAL TREATMENT] log should be reviewed by the unit nurse, and if any [MEDICAL TREATMENT] information is missing, the unit nurse was responsible to contact the [MEDICAL TREATMENT] center. NJAC:8:39-27.1(a)

Based on observation, interview and record review it was determined that the facility failed to provide medication as per physician's orders to treat a resident's acute medical condition that resulted in severe and uncontrolled pain and subsequent transfer to the Emergency Department (ED) for evaluation and treatment. This deficient practice was identified for 1 of 17 residents, Resident #17, reviewed for quality of care and evidenced by the following: On 2/9/16 at 10:25 a.m., Resident #17 approached the surveyor and requested an interview. The resident stated that upon admission they did not receive their pain medication, [MEDICATION NAME], as ordered and had to go to the ED due to increased pain. Resident #17 stated that s/he had [MEDICAL CONDITION] Cell [MEDICAL CONDITION] and was on [MEDICATION NAME] for the past [AGE] years for pain management. Resident #17 began crying during the interview. The surveyor reviewed Resident #17's medical record on 2/9/16 at 12:45 p.m. According to the Resident [DIAGNOSES REDACTED]. The red blood cells became rigid and sticky which slow or block blood flow and oxygen to parts of the body. Treatments were for pain relief and to help prevent further problems associated with [MEDICAL CONDITION] Cell [MEDICAL CONDITION]. Resident #17 was admitted to the facility on [DATE] after 6 p.m. admission orders [REDACTED]. In addition, Resident #17 was on [MEDICATION NAME] 400 mg every 8 hours for pain and [MEDICATION NAME] 15 mg, 2 tabs every 6 hours as needed for pain. The surveyor reviewed the January 2016 Medication Administration Record(MAR). The entry spaces for [MEDICATION NAME] and [MEDICATION NAME] were blank. The surveyor reviewed the electronic Progress Notes (ePN) on 2/9/16 at 1:30 p.m. An entry dated and timed 1/31/16 at 07:52 (7:52 a.m.) documented that Resident #17 complained of back pain radiating to legs, pain level of 10 . The next entry was timed at 08:19 (8:19 a.m.) and documented that Resident #17 wanted information about the pain med [MEDICATION NAME] and that she/he has not had it for 2 days . The entry also documented that Resident #17 had been taking the medication for [AGE] years. The nurse documented the resident saying that she/he fears (gender specific) may go in withdrawal . The nurse contacted the facility pharmacy regarding why [MEDICATION NAME] was not delivered to the facility. The nurse documented that the pharmacy stated they needed the physician to write a hard copy prescription for the controlled substance per New Jersey state law. The resident's physician was called and was going to write a hard copy prescription but the pharmacy did not open until 9 a.m. and the resident did not want to wait any longer. The physician gave an order to send the resident to the emergency department. According to the Manufacturer's Packet Insert, [MEDICATION NAME] should be gradually stopped to avoid withdrawal symptoms. The surveyor then reviewed the Discharge Instructions for Resident #17 performed by the ED on 1/31/16. The [DIAGNOSES REDACTED]. Under Special Notes it was documented that the ED physician wrote a hard copy prescription for [MEDICATION NAME] with an increase of dosage from 40 mg to 50 mg after speaking with the facility physician. The surveyor reviewed the facility's Pain Management Policy and Procedure (P&P) on 2/10/16 at 2 p.m. According to the P&P, pain must be assessed and managed in a timely fashion . and, pain can increase suffering by causing helplessness, anxiety, depression, reduced activity, diminished appetite and disturbed sleep. Under the title Implementing Pain Management Strategies, staff should Implement the medication regimen as ordered, carefully documenting the results of the interventions. The surveyor interviewed the Unit Manager (UM) on 2/10/16 at 9:50 a.m. The UM stated that all narcotics needed to have a written prescription from the physician for the pharmacy to fill. The UM stated the nurse who received an order for [REDACTED]. The surveyor spoke with the Director of Nursing (DON) and the Administrator regarding the above concern on 2/10/16 at 2:10 p.m. The DON stated [MEDICATION NAME] was not delivered because the physician did not write a hard copy. The DON had no answer as to why [MEDICATION NAME] was not available. N.J.A.C. 8:39-27.1(a)