Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to physician orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 7 (seven) residents during the medication observation pass (Resident #46). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 07/12/23 at 9:40 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN#1) in the room of Resident #46. The surveyor observed RN#1 checking the resident's identification bracelet and informing Resident #46 that she will be administering the resident's medications. The surveyor observed the resident in bed and just finished eating breakfast. On 07/12/23 at 9:45 AM, the surveyor observed RN#1 preparing to administer five (5) medications to Resident #46 which included Metoprolol Succinate Extended Release (ER) 50 mg tablet (medication for lowering blood pressure), Potassium Chloride 20 MEQ ER tablet (potassium supplement), Eliquis 2.5 tablet (irregular heartbeat), Torsemide 10 mg tablet (medication for lowering blood pressure) and Rhopressa eye drops (medication for pressure in the eye). The surveyor observed RN #1 prepared the resident's medication and then brought it into Resident #46's room. At that time, Resident #46 asked RN#1 if she could split the Potassium ER 20 MEQ tablet in half since it was too big to swallow. The surveyor observed RN#1 take the medications to the medication cart and then scooped out the Potassium Chloride tablet and proceeded to crush Potassium ER 20 MEQ tablet. After crushing the tablet, RN#1 placed it into a medication cup and then added apple sauce. RN#1 then added the remaining tablets into the medication cup containing the crushed Potassium Chloride ER tablet and apple sauce. The surveyor stopped RN#1 prior to administering the medications and asked RN#1 if she can bring the medication cup outside of the resident's room. At that time, the surveyor interviewed RN#1 who stated that she crushed the Potassium ER 20 MEQ tablet because the resident complained that they were unable to swallow the whole tablet. The surveyor asked RN#1 if it was recommended to crush an extended-release tablet. RN#1 stated that an extended-release tablet should not be crushed and that when the resident complained that they were unable to swallow the tablet that she should have held the medication and contacted the physician for a recommendation. The surveyor reviewed the medical record for Resident # 46. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hypertension (elevated blood pressure), glaucoma (pressure in the eye) and atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atrial chamber of the heart). A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 7/04/23, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident was cognitively intact. A review of the July 2023 Physician Order Sheet (POS) revealed no physician order (PO) for medications to be crushed. Further review of the July 2023 POS revealed a PO dated 7/7/23, for Potassium Chloride ER Oral Extended-release 20 MEQ tablet give (1) tablet by mouth two times daily for supplement with food. A review of the July 2023 Electronic Medication Administration Record (eMAR) revealed an order dated 7/7/23, for Potassium Chloride ER Oral Extended-release 20 MEQ tablet give (1) tablet by mouth two times daily for supplement with food. A review of the Manufacturer's specifications for Potassium Chloride ER 20 MEQ revealed the following: To take each dose without crushing, chewing, or sucking the tablet. If those patients are having difficulty swallowing whole tablets, they may try one of the following alternate methods of administration: a. Break the tablet in half and take each half separately with a glass of water. b. Prepare an aqueous (water) suspension as follows: 1. Place the whole tablet (s) in approximately 1/2 glass of water (4-fluid ounces). 2. Allow approximately 2 minutes for the tablet (s) to disintegrate. 3. Stir for about half a minute after the tablet (s) has disintegrated. 4. Swirl the suspension and consume the entire contents of the glass immediately. 5. Add another 1 fluid ounce of water, swirl and consume immediately 6. Then, add an additional 1 fluid ounce of water, swirl, and consume immediately. On 07/12/23 at 10:20 AM, the surveyor interviewed the RN/UM#2 Unit Manager (UM) who stated that the resident's Potassium Chloride ER 20 MEQ tablet should not have been crushed because it was an extended-release tablet. The RN/UM#2 further stated that the facility called the resident's physician, and the order was changed after surveyor inquiry. On 7/13/23 at 1:30 PM, the surveyor discussed the above observations and findings with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy for sub-acute/Skilled Nursing Household Medication Administration-General Guidelines dated 6/25/19, which was provided by the DON included the following, Cautionary information on the MAR or medication package/container (e.g., don't crush, shake well, give food on an empty stomach, etc.) is checked and adhered to prior to medication administration. Nurse personnel must contact the physician/Physician assistant (PA) and Advance Nurse Practitioner (APN) when there is a discrepancy based on the written order or for any questions related to cautionary information. NJAC 8:39-11.2 (b), 29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications for 2 of 2 medication room refrigerators inspected. This deficient practice was evidenced by the following: On [DATE] at 6:50 PM, the surveyor inspected the 2nd-floor medication room refrigerator in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an expired bottle of Rocklatan eye drops that had an opened date of [DATE]. The surveyor interviewed LPN #1, who stated that the Rocklatan eye drops were expired and belonged to a resident discharged from the facility. LPN #1 said that all expired and medications belonging to a discharged resident should have been removed from the medication refrigerator. On [DATE] at 7:15 PM, the surveyor inspected the 3rd-floor medication room refrigerator in the presence of LPN #2. The surveyor observed an expired Purified Protein Derivative (PPD) vial with an opened date of [DATE] and an opened Novolog pen that had an expiration date of [DATE] inside the medication refrigerator. The surveyor interviewed LPN #2, who stated that the PPD dated [DATE] was expired and should have been removed from the medication refrigerator. LPN #2 also noted that the expired Novolog pen was for a discharged resident and should have been removed from the medication refrigerator. A review of the Manufacturer's Specifications for the above medications indicated the following: 1. Rocklatan eye drops, once opened, had an expiration date of 42-days 2. PPD vial, once opened, had an expiration date of 30-days 3. Novolog Insulin pen, once opened, had an expiration date of 28-days. On [DATE] at 3:15 PM, the surveyor met with the Licensed Nursing Home Administrator and the Director of Nursing (DON). The facility provided no further information. A review of the facility's policy for Storage of Medications dated [DATE] that the DON provided indicated the following: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exist. A review of the facility's policy for Disposal of Medications and Medication-Related Supplies dated [DATE] that the DON provided indicated the following: Medications are removed from the medication cart immediately upon receipt of an order to discontinued (to avoid inadvertent administration). Medications awaiting disposal or return are stored in a locked, secure area designated for that purpose until destroyed or picked up by pharmacy. NJAC: 8:39-29.4 (a) (h) (d)