Complaint NJ #161104 Based on record review, interviews and other facility documentation, it was determined that the facility failed to notify the Board of Nursing (BON) (evaluates license applications, issues licenses, renews licenses, and takes disciplinary action in response to professional misconduct) for a Licensed Practical Nurse/Supervisor (LPN/S #1) who was under investigation for misappropriation of Residents' narcotic medication. This deficient practice was identified for one of one investigation reviewed. This deficient practice was evidenced by the following: On 02/21/24 at 2:40 pm, the Director of Nursing (DON #1) provided the survey team with a file for an investigation dated 12/18/22. A review of the file revealed a Reportable event [Resident's name redacted] 12/18/22; Summary and Conclusion: On 12/18/22, the nurse assigned to [name redacted] went to administer his/her Oxycodone (an opioid pain medication-narcotic) around 9am. The nurse went to the declining inventory form (a record used to keep accurate count of controlled substances) for [name reacted] Oxycodone. The nurse observed three signatures timed 10a, 12p, and 2:20 p for 12/17/22. This nurse was also the nurse that worked this assignment on 12/17/22 7a-3p. The three signatures were not her signature. The nursing supervisor (LPN/S #2) notified the Director of Nursing (DON #2) and the Administrator. The signatures could not be identified. Further review of the investigation identified 2 other residents that had unidentified signatures on their declinining inventory sheets. Based upon the investigation and review of statements, the supervisor (LPN/S #1) who worked 3p-11p on 12/17/22 was the only nurse that had access to all three residents that had unidentifiable signatures on their declining inventory sheets .She was suspended pending investigation. Further review revealed that on 12/22/22, the Human Resource Director (HRD) reached out to the supervisor (LPN/S #1) to come in and meet with administration. A meeting was scheduled for 1/3/23. The supervisor (LPN/S #1) did not show up for the meeting. The HRD called her, but she did not answer. Further review of the investigation file revealed a certified letter dated 1/10/23 sent to the LPN/S #1, On Tuesday 01/03/23 at 1:30 pm you had a meeting scheduled at this facility with [name redacted] DON and me to discuss the outcome of an investigation. Since you did not attend this meeting, we are considering this a voluntary resignation. This letter was signed by the HRD. Additional review of the investigation file revealed that the police and the DEA (Drug Enforcement Administration) were notified. It did not reveal evidence that the Board of Nursing had been notified. On 02/22/24 at 8:45 AM, in the presence of the survey team, the Regional Director of Clinical Services (RDCS), confirmed that the facility did not report the LPN/S to the Board of Nursing because they did not have concrete proof she took the medications, but she (the LPN/S) was the only one who had access to all of the carts (medication carts). She then stated that the DEA and the police were notified. On 02/22/24 at 10:48 AM, the RDCS, the Regional Director of Operations (RDO), DON#1 and the Licensed Nursing Home Administrator (LNHA) met with the survey team to review the above-mentioned investigation. The RDCS, who confirmed at the time of the incident she was the DON #2, acknowledged that the investigation was completed and reported to the Department of Health, the police, and the DEA. She stated that it is fair to say yes we believe that [name redacted] (the LPN/S #1) was the common denominator, she had access to all the carts but I did not send a report to the BON. The RDCS stated that the purpose of reporting to the BON was so that they are aware of a situation, something that that nurse did, so they could investigate it. The administrative team all acknowledged that the incident should have been reported. On 02/23/224 at 10:22 AM, the DON provided the survey team with the incident report, dated 12/18/22 at 12:00 PM. Review of the report, revealed Agencies/People Notified: State Agency (DEA), Office of Ombudsman, Department of Health, and Physician. On 2/22/24 at 1:50 PM the LNHA provided the survey team with copy of a report that the above incident was submitted to the BON, dated 2/22/24. A review of the facility's policy Incident and Accidents revised 7/17/23, revealed: Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member. Policy Explanation: The purpose of incident reporting can include Alert risk management and/or administration of occurrences that could result in claims or further reporting requirements; Meeting regulatory requirements for analysis and reporting incidents and accidents. Compliance Guidelines: 4. Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse policy. 8. The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events. A review of the facility's policy Abuse, Neglect and Exploitation revised 7/2023, revealed: VII. Reporting/Response: A. the facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, .all other required agencies. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. A review of the facility's policy Controlled Substance Administration & Accountability revised 5/20/23, revealed Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. 9. Discrepancy Resolution: e. Any discrepancies which cannot be resolved must be reported immediately as follows: iii. The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities. NJAC 8:39-13.4(c)(2)(v)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure the medication error rates were not 5% or greater. During the morning medication administration observation on 2/20/24, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 37 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 5.41%. This deficient practice was identified for one (1) of four (4) residents, Resident# 83, that was administered medications by one (1) of the two (2) nurses that were observed. The deficient practice was evidenced by the following: On 2/20/2024 from 9:23 AM to 9:40 AM, during the medication administration, the surveyor observed the Licensed Practical Nurse (LPN) prepare and administer medications to Resident # 83 which included: (i) Icosapent Ethyl (a medication used along with a proper diet to help lower fats [triglycerides] in the blood.) oral capsule one (1) gram (GM) (ii) Darolutamide (an oral tablet for prostate cancer that has not spread to other parts of your body) oral tablet 300 milligrams (MG). The surveyor asked the LPN if the resident had breakfast and the LPN stated, the resident has not eaten yet. The LPN opened up resident's room door to show the surveyor that his/her breakfast tray was on the tray table, which was positioned away from the resident's bed and further stated, the resident is waiting for [his/her] wife to bring [him/her] breakfast from home. At 10:00 AM, the surveyor reviewed Resident #83's Electronic Medication Administration Records (eMARs), which included special directions for these medications: (i) Icosapent Ethyl- Give 1 capsule by mouth two times a day for HLD (hyperlipidemia [high lipids]). Give with meals. (ii) Darolutamide Oral tablet 300 MG- Give 2 tablet by mouth two times a day for prostate cancer. Please ensure given 12 hrs. (hours) apart and with food in the stomach and also with food. At 1:25 PM, the surveyor asked the LPN when the resident ate last and the LPN stated, the resident had food last night. At that time the surveyor requested the LPN to review the eMARs and read the directions for the above medications, Give with meals and Please ensure given 12 hrs. apart and with food in the stomach and also with food. After reviewing the directions, the LPN stated, I should've HOLD the medications. A review of facility's policy, Medication Administration, revised on 5/30/23, included the following: 14. Administration medication as ordered in accordance with manufacturer specifications. a. Provide appropriate amount of food and fluids. A review of an undated policy titled PharmACCURATE Medication Pass, which was provided by the Director of Nursing on 2/23/24, included the following instructions under the subsection titles, Medication Timing: -Medication ordered with food may be administered up to 15 minutes after a meal or given with 4 ounces of milk and 2 graham crackers (or similar items). -Applesauce is not food. -Medication ordered with meals should be given with the meal (i.e., Metoprolol). -Milk and crackers do not constitute a meal. N.J.A.C 8:39-29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ159278, 159279, 159280 Based on interviews and record review, as well as review of pertinent facility documents on 12/20/22, 12/21/22, and 12/22/22 it was determined that the facility failed to report injury of unknown origin to the New Jersey Department of Health (NJDOH) and to follow the facility policy on Abuse Investigation and Reporting for 2 of 6 residents (Resident #1 and Resident #3). This deficient practice is evidenced by the following: 1. According to the admission RECORD (AR) form, Resident #1 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: Dementia and Anxiety Disorder. The Minimum Data Set (MDS), an assessment tool dated 10/7/22, showed that Resident #1's cognition was severely impaired and required extensive assistance from staff in Activities of Daily Living (ADL). The care plan (CP), undated, revealed that Resident #1's cognition was impaired, forgetful, and had a diagnosis of Dementia. The facility's investigation report (IR) dated 10/17/22 at 10:22 am indicated that the facility investigated an incident involving Resident #1. The IR revealed that Certified Nursing Assistant (CNA #1) saw Resident #1's right shoulder, forearm, wrist, and hand were swollen during care and reported to the nurse on duty. The IR further revealed that the NP assessed Resident #1 and ordered an Xray of the shoulder, humerus, wrist, and hand and the Xray result was pending. The IR indicated the Resident was unable to explain what happened and there were no witnesses. On 12/18/22, the IR concluded by the Director of Nursing (DON) that there was no evidence of intentional mishandling. Included in the IR was a written statement from CNA #1 which indicated that she notified the nurse when she observed the swollen of right shoulder and wrist. Also included in the IR was a written statement for Registered Nurse (RN #1) verified she was notified by CNA #1 of the Resident's change in status. The RN indicated the Resident was confused and unable to express what happened. A Physician's progress note (PPN) dated 10/17/22 at 8:38 am, documented by the NP revealed that Resident #1 was evaluated for the right arm pain and edema and other medical problems. The PPN further showed that Resident's right arm was swollen, and the Resident was complaining of pain. Review of the Radiology Results Report (RRR) indicated that on 10/17/22 at 3:38 pm, X-ray was performed to Right Humerus, Right Wrist, Right Clavicle, Right Hand, and Right Shoulder to ruled out fracture. The PPN dated 10/18/22 indicated that it was unclear if Resident #1 had a fall and that the result of the X-ray was negative for fracture. Review of Resident #1's progress note (PN), on 10/17/22 at 5:36 pm, documented by RN #1 reflected the incident on the IR. The surveyor conducted an interview with CNA #1 on 12/21/22 at 1:53 pm. The CNA confirmed what she wrote on her aforementioned statement. She remembered the Resident was leaning on the right side, she assisted the Resident to the bathroom. When she removed the Resident's gown, she noticed the Resident's right shoulder was bigger than before, and that the Resident was complaining of pain. CNA #1 further stated that she was unable to explained how it happened and the Resident was unable to tell her what happened to the right shoulder. The surveyor conducted an interview with RN #1 on 12/22/22 at 1:53 pm. The RN confirmed what she wrote on her aforementioned statement. RN #1 stated that she immediately reported the incident on 10/17/22 to the Director of Nursing (DON) and did not report it to the NJDOH. During the post survey telephone interview with the NP on 12/28/22 at 2:08 pm, the NP stated that she received a report from one of the nurses stating that Resident #1's right shoulder and arm was swollen, Resident #1 was cooperative and was not agitated during the assessment, Resident #1 had pain when she/he lifted her/his arm. The NP further stated that an Xray was ordered to make sure that there was no fracture to Resident's right shoulder, she was unable to conclude what happened to the right shoulder without the Xray result. The surveyor conducted an interview with the DON on 12/21/22 at 3:51 pm. The DON confirmed the incident was not reported to the NJDOH because it was a known origin and the CNA was able to explain what happened. The DON further stated that the Resident acquired the injury from leaning on the right side. The DON confirmed that if a resident was unable to explain, the facility will report to the NJDOH within 2 hours. 2. According to the AR form, Resident #3 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: Hemiplegia, Hemiparesis, and Amnesia, The MDS, dated [DATE], revealed that Resident #3's cognition was moderately impaired and required extensive assistance from staff in ADL. The CP, undated, indicated that the Resident was at risk for complications, injury related to anticoagulant therapy and behaviors. The CP further revealed that Resident #3 had impaired cognition and forgetful. The facility's IR dated 10/24/22 at 11:00 am, revealed that the facility investigated an incident involving Resident #3. The IR indicated that the Hospice CNA (CNA #3) reported a discoloration next to Resident's right eye. The investigation further indicated that Resident #3 was unable to explained what happened and there was no witness to explain how the discoloration next to the Resident's eye happened. The IR noted the incident was reported to the NJDOH on 10/27/22 at 1:11 pm which was not according to their policy. Additionally, the IR included a verbal statement from Licensed Practical Nurse (LPN #1) dated 10/24/22 signed and documented by the DON. The statement indicated that LPN #1 reported a discoloration to Resident #3's right eye. On 10/24/22 LPN #1 also stated that on 10/21/22 Resident #3 threw his/her breakfast tray on the floor, fluids flew in the air. The Resident was flailing his/her arms and bumped his/her face where the discolorations was located. A PN dated 10/21/22 at 3:23 pm, documented by LPN #1 indicated that CNA #4 (who was passing breakfast tray on 10/21/22) reported that Resident #3 threw breakfast tray on the floor and the Resident was agitated. LPN #1 walked into the room and asked Resident #3 what happened, the Resident did not say what happened and asked the LPN to leave the room. The PN had no documented evidence that the Resident was having behavior episode as indicated on the statement by DON on 10/24/22. The surveyor conducted an interview with the DON on 12/21/22 at 3:51 pm, the DON confirmed the aforementioned IR and verbal statement from LPN on 10/24/22. The DON stated that incident was not reported to the NJDOH because it was a known origin and added that LPN #1 was able to explain what happened on 10/21/22. The DON confirmed that if a resident was unable to explain how it happen, the facility will report the occurance to the NJDOH within 2 hours. During the post survey telephone interview with LPN #1 on 12/27/22 at 1:27 pm. The LPN stated that on 10/21/22 in the morning, when CNA #4 was passing tray, the CNA reported that the Resident became agitated, threw breakfast tray on the floor and all over the place. LPN #1 further stated that she did not witness that Resident threw the tray, when she walked into the room the tray was already on the floor, Resident #3 was calm and had asked the LPN to leave the room. The LPN confirmed what she documented on the PN dated 10/21/22 at 3:23 pm. During the post survey telephone interview with CNA #4 on 12/27/22 at 2:14 pm. The CNA stated that on 10/21/22, Resident #3 refused breakfast and reported to LPN #1. CNA #4 further added that the Resident was agitated, however, the Resident did not swing his/her hands and did not hit his/her face. The surveyor conducted an interview with the Administrator on 12/22/22 at 1:31 pm, who stated that injuries of unknown origin must be investigated according to policy and are to be reported within 2 hours to NJDOH. The facility's policy titled Accidents and Incidents - Investigating and Reporting, dated 7/2017 showed All accidents or incidents involving residents . occurring on our premises shall be investigated and reported to the administrator . The facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021 showed . residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restrain not required to treat the residents symptoms .8. identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within time frames required by federal requirements . NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C# NJ100159278, 159280 Based on interviews, medical record review, and review of other pertinent facility documents on 12/20/22, 12/21/22, and 12/22/22, it was determined that the facility staff failed to consistently document in the Documentation Survey Report the Activities of Daily Living (ADL) status and care provided to the resident. In addition, the facility staff failed to follow the facility's policy titled Guidelines for Charting and Documentation for 4 of 4 residents (Resident #1, #2, #3, and #4) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnosis that included but was not limited to Dementia. The Minimum Data Set (MDS), an assessment tool, dated 10/7/22, revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated that the Resident's cognitive status was severely impaired. The MDS also indicated that the Resident required extensive assistance from staff for ADLs. The surveyor reviewed the Documentation Survey Report (DSR), an ADL record documented by the Certified Nursing Assistant (CNA) during their assigned shift for September 2022. The DSR revealed the following: The DSR forms had assigned ADL care tasks which included but were not limited to Bed Mobility, Behavior Symptoms, Dressing, Personal Hygiene, Skin Observation, Toilet Use, Transferring, Turning and Repositioning, and Eating and percentage of amount eaten. Review of Resident #1's ADL record included an area for the CNAs to document the Resident's self-performance and support provided by staff. There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shifts on 9/1/22, 9/4/22, 9/11/22, 9/18/22, and 9/25/22. Evening shifts on 9/24/22. Night shifts on 9/2/22, 9/12/22, 9/16/22, 9/21/22, 9/26/22, and 9/30/22. Eating and percentage of amount eaten for breakfast and lunch on 9/1/22, 9/4/22, 9/11/22, and 9/25/22. Additionally for breakfast on 9/18/22, and dinner on 9/24/22. Review of Resident # 1's Progress Notes revealed no documentation of the aforementioned ADL care. 2. According to the AR, Resident #2 was admitted to the facility on [DATE] with diagnosis that included but was not limited to Hypertension. The MDS dated [DATE], revealed a BIMS score of 15 which indicated that the Resident's cognitive status was intact. The MDS also indicated that the Resident required extensive assistance from staff for ADLs. Review of Resident #2's ADL record in the DSR form for October 2022 revealed the following: There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shifts on 10/25/22 to 10/28/22, and 10/31/22. Evening shifts on 10/14/22, 10/23/22, 10/24/22, 10/26/22, 10/28/22, and 10/31/22. Night shifts on 10/12/22, 10/17/22, 10/20/22, and 10/22/22. Eating and percentage of amount eaten for breakfast and lunch on 10/25/22 to 10/28/22, and 10/31/22. Additionally for dinner on 10/3/22, 10/23/22, 10/24/22, 10/26/22, 10/28/22, and 10/31/22. Review of Resident # 2's PN revealed no documentation of the aforementioned ADL care. 3. According to the AR, Resident #3 was admitted to the facility on [DATE] with diagnosis that included but was not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction. The MDS dated [DATE], revealed a BIMS score of 12 which indicated that the Resident's cognitive status was moderately impaired. The MDS also indicated that the Resident required extensive assistance from staff for ADLs. Review of Resident #3's ADL record in the DSR form for December 2022 revealed the following: There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shifts on 12/4/22, 12/7/22, 12/9/22, 12/13/22, and 12/16/22. Evening shifts on 12/4/22, 12/9/22, and 12/18/22. Night shifts on 12/3/22, 12/5/22, 12/10/22, 12/17/22 and 12/19/22. Eating and percentage of amount eaten for breakfast and lunch on 12/4/22, 12/7/22, 12/9/22, 12/13/22, and 12/16/22. Additionally for dinner on 12/4/22, 12/9/22. Review of Resident # 3's PN revealed no documentation of the aforementioned ADL care. 4. According to the AR, Resident #4 was admitted to the facility on [DATE] with diagnosis that included but was not limited to Alzheimer's Disease with Late Onset. The MDS dated [DATE], revealed that BIMS was zero and rarely understood which indicated that the Resident's cognitive status was severely impaired. The MDS also indicated that the Resident required extensive assistance from staff for ADLs. Review of Resident #4's ADL record in the DSR form for November 2022 revealed the following: There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shifts on 11/13/22 and 11/20/22. Evening shifts on 11/4/22, 11/9/22, 11/13/22, 11/14/22, 11/17/22, 11/20/22, 11/28/22, and 11/29/22. Night shifts on 11/1/22, 11/6/22, 11/7/22, 11/10/22, 11/14/22, 11/16/22, 11/19/22, 11/21/22, and 11/29/22. Eating and percentage of amount eaten for breakfast on 11/13/22 and 11/20/22, and for lunch on 11/4/22, 11/9/22, 11/13/22, 11/14/22, 11/17/22, 11/20/22, 11/28/22, and 11/29/22. Additionally for dinner on 11/1/22, 11/6/22, 11/7/22, 11/10/22, 11/14/22, 11/16/22, 11/19/22, 11/21/22, 11/21/22, and 11/29/22. Review of Resident # 4's PN revealed no documentation of the aforementioned ADL care. During an interview with the surveyor on 12/21/22 at 1:53 PM, CNA #1 stated that CNAs are responsible for entering the ADL care provided to residents in the POC kiosk and must be completed by the end of the shift. During an interview with the surveyor on 12/22/22 at 12:10 PM, CNA #2 stated that CNAs are responsible for documenting the ADL care into the kiosk. She further stated that all tasks must be answered as these reflected the resident's status and the ADL care provided. She could not explain why there were blanks in the sampled resident's ADL records but stated that they should have been completed. During a telephone interview with the surveyor on 12 /22/22 at 12:35 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that CNAs are expected to complete the ADL care in the kiosk at the end of their shift. She stated that it was her responsibility to ensure that the tasks are documented timely and accurately, however, she could not explain why there were blanks in the ADL records for the sampled residents. During a conference with the DON and Administrator on 12/21/22 at 4:00 PM, the DON stated that CNAs are expected to document the ADL care provided to the residents into the kiosk by the end of their shift. The DON could not explain why there were blanks in the sampled Resident's ADL records but stated that they should have been completed. Review of the Job Description titled Certified Nursing Assistant under Main Duties revealed Support the facility's philosophy of care .Carry out assignments for resident care including (but not limited to) a.) bathing b.) dressing .e.) feeding .Complete assignment .at the end of every shift. Review of the facility's policy titled Guidelines for Charting and Documentations indicated The purpose of charting and documentation is to provide: 1. A complete account of resident's care .the progress of the resident's care. 3. The facility a tool for measuring the quality of care provided to the resident. 5. Assistance in the development of a Plan of Care .under General Rules for Charting and Documentation indicated 6. Document assessments, interventions, treatments, etc 7. Chart all entries legibly. 8. All entries must reflect the date, the time, and the signature and title of the person recording the data. NJAC 8:39-35.2 (a)(g)1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical records and review of facility documentation, it was determined the facility failed to document on the Care Plan (CP) a residents use and refusal of a hearing aid. This deficient practice was identified for 1 of 25 residents, (Resident #25) reviewed for CP. On 11/15/21 at 9:16 AM, the surveyor observed Resident #25 lying in bed, eyes closed. The resident did not respond to the surveyors greeting. On 11/16/21 at 9:59 AM, the surveyor observed the Certified Nursing Aide (CNA) enter the resident's room. The CNA spoke loudly to the resident. On 11/16/21 at 12:38 PM, the surveyor observed Resident #25 in their room sitting in a wheelchair. The surveyor did not observe any hearing aids in either of the resident's ears. On 11/17/21 at 11:55 AM, the surveyor observed the resident in bed and did not observe any hearing aids in either ear. On 11/17/21 at 12:40 PM, the surveyor observed the resident in bed with lunch next to the bed. The surveyor observed no hearing aids in either ear. On 11/18/21 at 8:42 AM, the surveyor observed the resident in bed with breakfast next to the bed. The surveyor observed no hearing aids in either ear. Resident #25 was admitted to the facility with diagnoses which included but were not limited to difficulty in walking; dementia without behavioral disturbance; foot drop both feet; chronic kidney disease and altered mental status. Review of the, Nursing admission Screening/History, dated 8/27/21, revealed Resident #25 had a right hearing aid in use. Review of the admission Minimum Data Set (MDS - an assessment tool), dated 7/16/21, revealed Section B, B0300 - that Resident #25 used a hearing aid or other hearing appliance; and that the resident required extensive assistance of a staff member for dressing and personal hygiene. The most recent Quarterly MDS, dated [DATE], revealed Section B, B0300 - that Resident #25 used a hearing aid or other hearing appliance; that the resident scored an 08 Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment; and that the resident required extensive assistance of a staff member for dressing and personal hygiene. Review of the facility provided 24 hour Report Sub-Acute Unit 1st Floor, revealed Resident #25's clinical needs which did not include hearing aids. Review of Resident #25's facility provided, Personal Effects Inventory, effective 7/10/21, revealed the resident had a hearing aid for Rt (right) ear in box. Review of Resident #25's facility provided, Personal Effects Inventory, effective 8/3/21, revealed the resident had a left hearing aid with batteries. Review of Resident #25's CP revealed a focus area of hard of hearing initiated 7/20/21 and revised on 7/20/21 with four interventions listed as follows: 1) speaker to adjust tone of voice, 2) speaker to face resident when speaking, 3) speaker to repeat as needed, and 4) speaker to talk to resident in quiet setting. Review of Resident #25's current CP provided by the facility, revealed a focus area of hard of hearing initiated 8/27/21 (after readmission to the facility) with interventions that included but were not limited to hearing aide to right ear initiated on 11/18/21. On 11/16/21 at 9:59 AM, the CNA caring for Resident #25 stated that the resident was hard of hearing so the staff would speak loudly. The CNA further stated the resident had glasses but she was not aware of any hearing aids. On 11/16/21 at 12:38 PM, Resident #25 stated she/he had hearing aids but was not sure where they were or why they were not at the facility. The CNA entered the room and was interviewed at that time. The CNA stated that if a resident had hearing aids, the nurses would keep them in the medication cart and put them in the residents ears. On 11/17/21 at 9:07 AM, Resident #25's family member was interviewed via telephone and stated that the resident had a right hearing aid at the facility but the staff never applied the hearing aid. The family member further stated that they never see the resident wearing the hearing aid but never remembered to ask staff why she/he was not wearing it. On 11/17/21 at 10:18 AM, the Registered Nurse (RN) caring for the resident stated that if a resident was able to put the hearing aids in themselves, they would keep their own hearing aids in the bedside table. The RN stated if the resident was unable, the nurses would keep the hearing aid in the medication cart and get an order to apply them. The RN stated the nurse would sign for the hearing aid on the medication administration record or the treatment administration record. The RN stated that there were only two residents she was aware of with hearing aids but did not mention Resident #25 as being one of them. On 11/17/21 at 10:24 AM, the Licensed Practical Nurse Unit Manager (LPN/UM) of the resident's unit, stated alert residents keep their own hearing aids but residents who were not alert would have the hearing aids locked in the medication cart. The LPN/UM stated there was no log or accountability sheet kept for hearing aids and the hearing aids would not be documented unless the staff were to put them in the resident's ear. The LPN/UM stated if a resident was hard of hearing, the family would have to request an appointment to have that checked and that he was unaware of any resident on the unit with hearing aids. On 11/18/21 at 8:46 AM, the LPN MDS nurse stated she documented on the 11/4/21 MDS and would have obtained MDS information from the residents if able, the staff, the resident medical record and the Social Worker. The LPN MDS nurse stated Resident #25 was hard of hearing and that she was able to interview the resident. LPN MDS nurse documented the resident use of a hearing aid. On 11/18/21 at 8:49 AM, a second MDS nurse stated she documented on the admission MDS and that she would have obtained the information from the hospital records, staff and resident. The second MDS nurse stated Resident #25 had a right hearing aid. On 11/18/21 at 8:51 AM, the LPN MDS nurse stated the hearing aid should have triggered and been added to the CP. She further stated it would be the responsibility of the nurse, unit manager and MDS to enter the hearing aid on the CP. The LPN MDS nurse reviewed the initial CP and the most recent CP in the presence of the second MDS nurse and the surveyor and acknowledged that the hearing aids were never entered on the CP. The LPN MDS nurse added the intervention of the hearing aid at the time the surveyor brought it to her attention. On 11/18/21 at 8:55 AM, the LPN/UM stated the nursing staff should refer to the 24 hour report, the CP, and the MDS to know what type of care a resident needed. The LPN/UM, in the presence of the surveyor, reviewed Resident #25's admission and stated the staff should be encouraging the use of the hearing aid instead of just speaking loudly to the resident. The LPN/UM acknowledged the 24 hour report should have had the hearing aids on the clinical information but did not. The LPN/UM and the surveyor went to Resident #25's room to locate the hearing aids but the LPN/UM was unable to locate them. On 11/18/21 at 9:04 AM, the LPN/UM and surveyor approached the second RN who was caring for Resident #25 that day. The second RN showed the LPN/UM and surveyor the resident's hearing aids locked in the medication cart. The second RN stated the last time she tried to apply the resident's hearing aid was a few months ago and eventually the resident removed it. The second RN stated she had not tried again to put the hearing aid in. The second RN stated she was not sure if she had documented the resident refused the hearing aid at that time and stated she might have told someone but was unsure. The second RN stated the hearing aid should have been on the CP. On 11/19/21 at 11:19 AM, in the presence of the survey team, the facility regional nurse stated that the resident had a habit of taking out her/his hearing aids frequently. The facility was unable to provide documentation of the refusals by the resident. The surveyor asked if the residents refusal of the hearing aid should have been documented on the care plan? The Director of Nursing (DON) stated yes. On 11/19/21 at 11:23 AM, the Licensed Nursing Home Administrator stated that the hearing aides should have been documented on the care plan. Review of the facility provided, Care Plan-Baseline, policy revised 12/16, revealed the following: a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The interdisciplinary team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including but not limited to initial goals based on admission orders; physician orders; dietary orders; therapy services; and social services. Review of the facility provided, Care Plans, Comprehensive Person-Centered, revised 12/16, included but was not limited to the following. A comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The interdisciplinary team, resident and family or legal representative, develops and implements a comprehensive, person-centered care plan. The care plan interventions are derived from a thorough analysis of the information gathered in the comprehensive assessment. The care planning process will facilitate resident and/or representative involvement; and include an assessment of the resident's strengths and needs. The comprehensive person-centered care plan will (included but was not limited to) the following: describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; incorporate risk factors; reflect the resident's expressed wishes regarding care and goals; identify the professional services that are responsible for each element of care; and aid in preventing or reducing decline in the resident's function level. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). Assessments are ongoing and care plans are revised as information about the residents and the residents' conditions change. The resident has the right to refuse to participate in medical and nursing treatments. Such refusals will be documents in the resident's clinical record in accordance with established policies. NJAC 8:39-11.2(d),(e)(1),(f),(g),

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 11/10/21 at 10:28 AM, the surveyor observed Resident #93 sitting in a chair in the hallway with a walker nearby. The surveyor attempted to interview the resident, but the resident was unable to understand the surveyor and spoke another language. The surveyor reviewed the medical record for Resident #93. A review of the resident's Transfer/Discharge Report revealed that the resident was admitted to the facility on [DATE] with diagnoses that included dementia (impairment of the brain function), chronic kidney disease (chronic condition of the kidney leading to renal failure), congestive heart failure (chronic condition in which the heart does not pump blood as well as it should) and hypertension (a condition in which the force of the blood against the artery walls is too high resulting in a high blood pressure). A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/21/21, reflected that the resident had a brief interview for mental status (BIMS) score of 12 out of 15, indicating that the resident had an intact cognition. A review of the October and November 2021 electronic Medication Administration Record (EMAR) for Resident #93 reflected the physician's order (PO) dated 10/14/21 for Clonidine (a medication used to treat high blood pressure) 0.2 milligrams, give one tablet by mouth every eight (8) hours for HTN. Hold for systolic blood Pressure (SBP) (the maximum or top number of the blood pressure measurement) less than 160. In addition, the EMAR reflected the administration of the Clonidine on the following dates and times with the corresponding SBP results that were less than 160: on 10/17/21 at 2:00 PM for a SBP of 138. on 10/19/21 at 10 PM for a SBP of 134. on 10/20/21 at 2 PM for a SBP of 148. on 10/20/21 at 10 PM for a SBP of 118. on 10/29/21 at 2 PM for a SBP of 138. on 10/30/21 at 2 PM for a SBP of 140. on 11/7/21 at 10 PM for a SBP of 144. on 11/8/21 at 10 PM for a SBP of 132. on 11/10/21 at 2 PM for a SBP of 128. on 11/12/21 at 10 PM for a SBP of 145. On 11/16/21 at 8:49 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who reviewed the resident's EMAR and verified that a check mark indicated that the medication was administered. The UM/LPN added that if a medication was not administered there would be a code number documented on the EMAR to indicate that the medication was held and thought there may also be a progress note. Another review of the resident's EMAR revealed that all the dates listed above had a check mark and there was no code numbers entered that corresponded to the medication being held. A review of the electronic progress notes (EPN) on the above dates and times revealed that there was no EPN indicating that the Clonidine was held. On 11/15/21 at 11:26 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that the resident spoke some English at times but was confused. The CNA added that there had been times that the resident would get upset and would not speak any English and would only speak in another language. The CNA added that there was several staff members that spoke the same language as the resident. On 11/15/21 at 12:46 PM, the surveyor interviewed the Housekeeper (HK) who stated that she spoke the same language as Resident #93 and was called at times to interpret when the resident became upset. The HK explained that the resident forgets why they had to come to the facility and that was what was causing distress. The HK stated that the resident does understand some English and can make needs known to the staff but speaks in another language. On 11/16/21 at 11:29 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who verified her initials on the EMAR for the administration of Clonidine on 10/19 at 10 PM, 10/20 at 10 PM and 11/10 at 2 PM listed above. The LPN stated that she thought that she had not administered the medication. The LPN added that the computer system was difficult to strike out or change that the medication was not administered. The LPN stated that she would have to review and was unable to speak to the EMAR documentation of the Clonidine being administered. Further review of the resident's medical record revealed that there was no EPN on the above dates and times indicating that there was an error on the EMAR, and that the Clonidine was not administered. On 11/16/21 at 11:37 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses were able to document in the electronic system if a medication was held or there was a change in a PO. The DON added that she would have to review the resident's EMAR for the Clonidine administration. On 11/17/21 at 8:39 AM, the surveyor, in the presence of the survey team, interviewed the physician (MD) who stated that he was very familiar with the resident and stated that the resident had fluctuating blood pressures (BP) and was asked to speak with the survey team. The MD added that the nurses frequently called him about the resident's BP and has instructed the nurses to administer the Clonidine even if the SBP was less than 160. The MD added that the resident was clinically assessed and had no concern with the Clonidine administration. The MD was unable to verify the specific dates or times that he gave permission for the Clonidine to be administered for a SBP less than 160. The MD also acknowledged that when the nurses called him, and he gave permission there should have been documentation in the resident's progress notes to indicate the discussion. Further review of the resident's medical record revealed that there was no EPN documenting that the physician was contacted regarding the Clonidine. In addition, there was no documentation of a change in the PO for Clonidine on the above dates and times to allow the Clonidine to be administered when the SBP was less than 160. On 11/17/21 at 9:30 AM, the surveyor interviewed the DON who stated that after reviewing the resident's EMAR for the Clonidine administration, she completed a Quality Assurance review with the nurses. The DON added that the nurses frequently called the physician but had not documented in the chart. On 11/17/21 at 12:20 PM, the surveyor interviewed the Registered Nurse (RN) who stated that she was familiar with Resident #93 because she administered medications to the resident. The RN added that she had to take a BP prior to administering the Clonidine and if the SBP was less than 160 then the medication should be held and documented in the EMAR. The RN acknowledged that she had signed the EMAR on 10/17 at 2 PM and 10/29 at 2 PM for the administration of Clonidine when the SBP was less than 160. The RN stated that she had made a mistake. The RN added that the physician was aware of the resident's fluctuating BP. On 11/18/21 at 1:28 PM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone. The CP acknowledged that the nurses were to follow a PO accordingly and to follow a hold order as instructed. The CP stated that the nurses frequently called the MD and would take a PO over the phone. The CP acknowledged that a PO would have had to be documented. The CP stated that the EMAR system allowed for documentation of medications being held and the nurses could also document in the EPN if there was a problem with medication administration. The CP also stated that he does review the EMAR for accurate medication administration according to a hold order. The CP added that if the documentation indicated that the medication was inaccurately being administered then he would notify nursing. On 11/19/21 at 12:01 PM, the survey team met with the Licensed Nursing Home Administrator, DON, Regional Clinical Nurse, and a DON from a sister facility. There was no further information provided regarding not following the standard of practice for the administration of Clonidine for the above listed dates and times. A review of the facility policy dated as revised April 2021 for Administering Medications provided by the DON reflected that medications were to be administered as prescribed. The policy also reflected that if vital signs (important medical signs that indicate the status of the body's life sustaining functions such as BP) were necessary then the vital signs were to be checked/verified prior to administering medications. In addition, the policy reflected that if a medication was withheld, refused or given at another time other than the scheduled time then the electronic health record would be appropriately documented. NJAC 8:39- 11.2(b), 29.2(d) Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility staff failed to: a) consistently follow a physician order for the application of a hip protector (device to minimize risk of injury in the presence of fall), b.) ensure that a resident's hearing aid used to facilitate communication was applied as ordered by the physician, and c.) accurately following a Physician's Order (PO) to hold a medication (Clonidine) according to blood pressure results. This deficient practice was identified for three of 25 resident's, (Resident #27, #50, and #93) reviewed for professional standards of nursing practice. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. According to the facility admission Record, Resident #27 was admitted to the facility with diagnoses which included Dementia and a history of right hip arthroplasty the surgical reconstruction or replacement of a joint). The significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 08/11/2021, revealed that the resident had impaired cognition and needed assistance with all activities of daily living (ADLs). The MDS indicated the resident was at risk for falls. Review of the Progress Notes revealed that Resident #27 sustained a fall at the facility on 09/12/2021. Review of the November 2021 Physician Order Sheet (POS) included a PO dated 09/01/2021 for Resident #27 to have a hip protector on at all times. The hip protector was to be removed during hygiene and checked for skin integrity. Review of the November 2021 Treatment Administration Record (TAR) confirmed the order and was plotted to be checked by all three shifts (7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM - 7:00 AM). During a tour of the 200 Unit on 11/10/2021 at 9:00 AM, the surveyor observed Resident #27 in bed. The resident attempted to get out of the bed unassisted with his/her feet on the floor mat. The surveyor alerted the staff who went in and assisted Resident #27 back to bed. On 11/10/2021 at 12:27 PM, the surveyor observed Resident #27 in bed. Resident #27 removed the bed covers and was calling for help. The surveyor observed that Resident #27 did not have the hip protector on. On 11/15/2021 at 8:51 AM, the surveyor observed the resident in bed, positioned on the left side, calling out for help, and no hip protector was in place. On 11/15/2021 at 10:07 AM, the surveyor observed Resident #27 in bed partly covered with blankets, the Certified Nursing Assistant (CNA) was at bedside and was assisting the resident with the breakfast meal. Resident #27 did not have a hip protector on. At that time the surveyor interviewed the CNA who stated that Resident #27 was totally dependent on staff for all care. The surveyor returned to the resident's room at 12:27 PM, and observed Resident #27 in bed dressed for the day. The surveyor inquired about the hip protector. The CNA went to the resident's room with the surveyor and verified that Resident #27 did not have a hip protector on. The CNA accompanied the surveyor to the linen room and showed the surveyor a bin with several hip protectors available for use. The CNA told the surveyor all residents on fall precautions were to have hip protectors on. An interview with the nurse at 11:37 AM, revealed that the CNAs were responsible to apply the hip protectors and the nurses would signed the TAR. The nurse acknowledged that she did not verify that the hip protector had been on before signing the TAR. The surveyor requested a copy of the 11/2021 TAR for review. Review of the TAR indicated that on the following dates, 11/09, 11/10, 11/15 and 11/16, the nurses had signed that the hip protector was on despite the surveyor observation and staff verification with that the hip protector was not on the resident. 2) On 11/10/2021 at 9:08 AM, the surveyor observed Resident #50 seated in his/her wheelchair eating breakfast, Resident #50 did not have his/her hearing aids on. According to the facility admission Record, Resident #50 was admitted to the facility with diagnoses which included dependence on supplemntal oxygen, high blood pressure, and pain in left knee. A review of Resident #50's Physician Order Sheet (POS) dated 11/2021 reflected a PO dated 07/31/2021 for bilateral hearing aid to be applied every morning and evening shift. The order also indicated to remove bilateral hearing aids at bedtime. On 11/15/2021 at 11:45 AM, the surveyor observed the resident resting in bed and the resident's hearing aids were not on. The surveyor interviewed the resident's CNA who stated that Resident #50 was alert and could communicate his/her needs. On 11/17/2021 at 09:17 AM the surveyor observed Resident #50 sitting in the chair eating breakfast and the hearing aids were not on. On 11/17/2021 at 11:20 AM, the surveyor conducted an interview with the resident's representative who stated that the resident was very alert and able to communicate. The family member stated that he/she was very involved with the care and the resident required hearing aids on to be able to communicate. The resident representative expressed concerns over the staffs failure to ensure that the hearing aids were on. The resident representative indicated that during visits, the staff had to be reminded to apply the hearing aids in the morning. On 11/17/2021 at 11:56 AM, the surveyor again went to the room and observed the resident did not have his/her hearing aids in place. The surveyor interviewed the resident's primary nurse at 12:57 PM who stated that the hearing aids were applied when the resident was out of his/her room. The surveyor reviewed the November 2021 POS and the resident's PO for the hearing aides with the nurse and the order read, Apply hearing aid in the morning and removed at HS [Hour of sleep ]. The nurse did not have any comment. During a conference meeting on 11/18/2021, the facility was made aware of the above concerns. During a conference meeting on 11/19/2021 at 11:30 AM, the Director of Nursing (DON) indicated that staff should ensure that the hearing aids were in place before signing the TAR.

Based on observations, interview, record review and review of the pertinent facility documentation it was determined the facility failed to: a.) ensure that oxygen tubing was appropriately labeled and dated, b.) the nasal canula was stored in a way to prevent bacterial microbial growth, c.) the oxygen humidification bottle was checked to ensure the appropriate water level for humidification, and d.) the facility followed their Policy and Procedure for Oxygen Administration. This deficient practice was identified for three of four residents, (Resident #11, Resident #27, and Resident #50) reviewed for respiratory care and was evidenced by the following. 1. A review of Resident #11's admission Record indicated Resident #11 was admitted with diagnoses which included but were not limited to Alzheimer's disease with late onset, adult failure to thrive, acute congestive heart failure and shortness of breath. Review of the resident's Physician Order Sheet (POS) dated 11/2021 revealed a physicians order dated 07/15/2021 for oxygen to be administered via nasal cannula as needed for shortness of breath (SOB) or oxygen saturation less than 91% as needed related to acute respiratory failure with hypoxia. On 11/09/2021 at 10:15 AM, the surveyor observed Resident #11sitting in a wheelchair in the his/her room. Resident #11 did not speak to the surveyor. The oxygen concentrator machine was observed next to the wheelchair. The surveyor observed that the oxygen tubing was in direct contact with the floor. On 11/10/2021 at 9:01 AM, the surveyor observed the oxygen tubing and the nasal cannula in direct contact with the floor. On 11/15/21 at 10:07 AM, the surveyor observed the oxygen concentrator machine running and titrated at four liters per minute via nasal cannula. The surveyor further observed that the oxygen tubing was dated 11/14/2021 and was in direct contact with the floor in the resident's room. Additionally, the nasal cannula was not protected and was observed on the floor in the resident's room. On 11/16/21 at 9:34 AM, the surveyor observed Resident #11 seated in the wheelchair in his/her room. The oxygen tubing and nasal cannula were both observed on the floor and dated 11/14/2021. During an interview with the Licensed Practical Nurse (LPN) on 11/15/2021 at 10:30 AM, the LPN stated that Resident #11 was on hospice and very confused. The LPN further stated that Resident #11 removed the nasal cannula all the time. The surveyor observed the LPN enter the resident's room and place the oxygen tubing on the concentrator. A review of the resident's Care Plan revised 11/09/2021 reflected that the resident did not have a focus care area for the use of oxygen. 2. A review of Resident #27 admission Record revealed that the resident was admitted to the facility with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), unspecified dementia, and dependence on supplemental oxygen. Review of the resident's POS dated 11/2021 revealed an physicians order dated 09/13/2021 for oxygen to be administered at two liters via nasal cannula continuous every eight hours as needed. On 11/09/21 at 11:25 AM, the surveyor observed the oxygen tubing and the nasal cannula on the floor in the resident's room. The tubing was dated 11/04/2021. The surveyor further observed that there was no water in the humidifier bottle. On 11/15/21 at 10:07 AM, the surveyor observed the oxygen flowing at two liters per minute via nasal cannula. The Hospice Aide (HA) was observed in the room. The oxygen concentrator machine was on and running. The nasal cannula was observed on the floor mat. The HA stated that Resident #27 kept removing the nasal cannula. At that time, the surveyor observed the HA remove the nasal cannula from the floor mat and placed it on the resident's bed. The surveyor observed that the nasal cannual and humidification bottle were labeled and dated 11/15/2021. On 11/16/21 at 9:01 AM, the surveyor observed Resident #27 in bed. The oxygen concentrator was observed to be running. Resident #27 did not have the nasal cannula on. The nasal cannula was observed on the bed rail. Resident #27 did not have her/his socks on. Resident #27's feet were purplish in color. Resident #27 was calling out. The surveyor left the room, located the nurse and informed her that Resident #27 needed help and was calling out. At 9:09 AM, the surveyor observed the nurse enter the room and apply the nasal cannula that was on the bed rail. The surveyor observed Resident #27 in bed with the oxygen flowing two liters. The nasal cannula was dated 11/15/2021. During an interview with the LPN on 11/16/2021 at 12:30 PM, the LPN stated that regarding the oxygen tubing being on the bed rails revealed that Resident #27 was very confused. The LPN further stated that Resident #11 removed the nasal cannula all the time. The LPN stated that the 11:00 PM - 7:00 AM nurses were responsible for changing the nasal cannula and the humidifier bottle. On 11/17/21 at 12:05 PM, the surveyor requested the policy for respiratory care. The Director of Nursing (DON) told the surveyor she would look for the policy. The DON further stated, It was the facility's practice to store the nasal cannula in a plastic bag when not in use. This interview contradicted the surveyors observations. There was no plastic bag hung on the concentrator machine or in the room to store the nasal cannula when not in use. A review of the resident's undated Care Plan reflected a focus area that the resident had refused care and oxygen therapy. The goal of the resident's Care Plan reflected that the resident's behaviors would not interfer with his/her activities of daily living. The interventions in the resident's Care Plan included to allow the resident to express self, have consistency with caregivers, and reassure the resident. 3. A review of Resident #50 admission Record revealed that Resident #50 was admitted to the facility with diagnoses which included congestive heart failure, acute kidney failure and dependence on supplemental oxygen. Review of the resident's November 2021 POS revealed an physician's order dated 08/23/2021 for oxygen at two liters via nasal cannula to be administered as needed for oxygen saturation less that 92%. On 11/09/2021 at 12:30 PM, the surveyor observed the oxygen on and flowing at two liters nasal cannula, there was no water in the humidifier bottle. The surveyor further observed that the oxygen tubing was not labeled and dated. On 11/10/2021 at 9:08 AM, the surveyor observed Resident #50 seated in a wheelchair, eating breakfast. The oxygen concentrator was running. The nasal cannula was observed on the bed rail. The oxygen tubing was observed on the floor. On 11/15/2021 at 8:20 AM, the surveyor observed Resident #50 in bed resting. The oxygen was running at two liters via nasal cannula. The surveyor observed that the oxygen tubing was not labeled or dated. On 11/15/21 at 11:45 AM, the surveyor observed Resident #50 sitting in his/her wheelchair leaning forward. The resident reported feeling lousy and wanted to go back to bed. The surveyor observed that the oxygen tubing was not labled or dated and the nasal cannula was observed placed on the oxygen concentrator.The surveyor further observed that there was no bag attached to the oxygen concentrator machine to store the nasal cannula. On 11/17/21 at 12:05 PM, the surveyor shared the above observations with the Director of Nursing (DON) and inquired about a policy for respiratory care treatment. The DON told the surveyor she would look for the policy. The DON also stated, It was the facility's practice to store the nasal cannula in a plastic bag when not in use. There was no plastic bag hung on the concentrator machine or in the room to store the nasal cannula when not in use during observations on the following dates: 11/09/2021, 11/10/2021,11/15/2021 and 11/16/2021. On 11/18/2021 the facility was asked to provide any in-services and further information regarding Oxygen therapy. No further information was provided during the conference meeting on 11/19/2021. The facility policy titled, Oxygen Administration revised October 2021, indicated that the purpose of this procedure is to provide guidelines for safe oxygen administration. The procedure contained 17 steps that staff were to follow with oxygen administration. Steps 8 of the procedure indicated the following: Be sure there is water in the humidifying bottle if needed and that the water level is high enough that the water bubbles as oxygen flows through. Steps 10 of the procedure read, Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. Steps 11 Periodically re-check water level in humidifying jar, change tubing and supplies weekly. The Oxygen Administration Policy and Procedure did not include how the oxygen supplies would be stored when not in use. NJAC 8:39-11.2(b); 27.1(a)

**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 store, label and dispose of medications. This deficient practice was noted in 4 of 8 medication carts and 1 of 2 medication room refrigerators inspected and was evidenced by the following: On [DATE] at 11:02 AM, the surveyor inspected the Subacute Unit medication cart #4 in presence of a Licensed Practical Nurse (LPN #1). The surveyor observed an open vial of Admelog Insulin and an open Admelog insulin pen that were not dated when opened. The surveyor interviewed LPN #1 who stated that the Admelog pen and vial should have been dated when opened. On [DATE] at 11:05 AM, the surveyor inspected the Subacute medication room refrigerator in the presence of a Registered Nurse (RN#1). The surveyor observed two opened vials of Influenza Vaccine that were not dated when opened. The surveyor interviewed RN #1 who stated the Influenza vaccine should have been dated when opened. On [DATE] at 11:10 AM, the surveyor inspected the Subacute Unit medication cart #2 in the presence of LPN #2. The surveyor observed one unopened bottle of Xalatan eye drops, one unopened Basaglar Insulin pen and one unopened Humalog Insulin pen that were not dated and were stored in the medication cart and not stored in the refrigerator. The surveyor also observed one Basaglar Insulin pen without a resident's name on it and one opened Basaglar insulin pen with an expiration date of [DATE] written on it. The surveyor interviewed LPN #2, who stated that an expired Basaglar insulin pen should have been removed from stock and discarded. Also that any medication without a resident's name should have been removed from active medication stock. LPN #2 also stated that the unopened bottle of Xalatan, Basaglar Insulin pen and Humalog Insulin pen should have been stored in the refrigerator until opened. On [DATE] at 11:15 AM, the surveyor inspected the Subacute Unit medication cart #3 in the presence of RN #2. The surveyor observed an unopened Basaglar Insulin pen and an unopened Humalog Insulin pen that was not dated and and stored in the medication cart instead of the refrigerator. The surveyor interviewed RN #2, who stated that the unopened Basaglar and Humalog Insulin pens should have been stored in the refrigerator until opened. The surveyor also observed an opened Basaglar Insulin pen and an opened Admelog Insulin pen that were not labeled with residents names. RN #2 stated that the Basaglar and Admelog Insulin pens without a resident's name should have been removed from active medications. On [DATE] at 12:00 PM, the surveyor inspected the Pavilion Unit medication cart in the presence of LPN #3. The surveyor observed an opened bottle of UTI-STAT supplement that had an open date of [DATE] and was expired. The surveyor interviewed LPN #3, who stated that UTI-Stat supplement was expired and should have been removed from stock. A review of Manufacturer's Specifications for the above medication revealed the following: 1. Admelog Insulin vial once opened had a 28-day expiration date. 2. Admelog Insulin pen once opened had a 28-day expiration date. 3. Influenza Vaccine vial once opened had a 28-day expiration date. 4. Humalog Insulin pen once opened had a 28-day expiration date. 5. Basaglar Insulin pen once opened had a 28-day expiration date. 6. Xalatan eye drops once opened had a 42-day expiration date. 7. Unopened Basaglar Insulin pen should be stored in the refrigerator. 8. Unopened Humalog Insulin pen should be stored in the refrigerator. 9. Unopened Xalatan eye drops should be stored in the refrigerator. 10. UTI-Stat bottle once opened had a 90-day expiration date. On [DATE] at 10:40 AM, the facility Administrator told the surveyor that they have no facility policy for dating and labeling of medication. The Administrator stated that each medication cart contained information regarding insulin dating and storage. NJAC: 8:39-29.4 (a) (h) and (d)