Based on observation, interview, record review, and review of pertinent facility documentation, it was determined the facility failed to: a.) protect residents from the potential for significant medication errors by not following the standards of practice for the administration of medication, and b.) implement the facility policy for Medication Administration when 1 of 3 nurses (Licensed Practical Nurse) on 1 of 3 units (Garden) observed during a medication pass observation prepared and attempted to give high-risk medications to the wrong resident. On 02/22/23, the surveyor observed the Licensed Practical Nurse (LPN #1) attempt to administer six specific medications for lowering blood sugar and blood pressure, an anticoagulant (blood thinner), multivitamins, and a liquid protein supplement medication. LPN #1 did not follow the five rights of medication administration by identifying the correct resident with the correct medications. The five rights include the following: the right resident, the right drug, the right dose, the right route, and the right time. The surveyor intervened before the medications could be administered to Resident #49. Interviews with LPN #1 revealed it was her fourth week at the facility. She was oriented to the facility's medication administration system and completed a medication pass competency on 01/31/23 at the facility prior to an assignment on the Garden Unit medication cart. This incident posed a serious and immediate threat to all the residents on Garden Unit. The immediate jeopardy (IJ) began on 02/22/23 at 8:37 AM and continued until 02/23/23. The Assistant Administrator and Director of Nursing (DON) were notified of the IJ on 02/22/23 at 3:10 PM. The failure of LPN #1 to follow the five rights of medication administration in accordance with professional standards of nursing practice that must be used to reduce the risk of medication errors and harm (identifying a resident prior to administering medications) constituted an Immediate Jeopardy situation. The failure to identify a resident prior to administering medications was likely to cause serious injury, harm, impairment, or death to the residents on the Garden unit due to the risk associated with a resident receiving the wrong high-risk medications not prescribed to them by their physician or receiving a medication that may be associated with a medication allergy. An acceptable removal plan was received on 02/23/23 at 12:17 PM and verified by the survey team on 02/23/23 and throughout the remainder of the survey. This deficient practice was evidenced by the following: On 02/22/23 at 8:06 AM, the surveyor observed LPN #1 during medication pass on the Garden Unit. Resident #74, who was positioned by the bed near the window, did not have an identification (ID) band but was able to identify themself. LPN #1 then asked another nurse to identify Resident #74 by the resident's name. The surveyor observed LPN #1 open the Medication Administration Record (MAR) to prepare six (6) medications for Resident #74, which included the following: Amlodipine 5 milligrams (mg) (medication used to lower blood pressure), Atenolol 50 mg (medication used to treat high blood pressure and irregular heartbeat), Aspirin 81 mg (medication used to reduce risk of heart attacks), Eliquis 2.5 mg (Apixaban; medication used to thin the blood), PreserVision AREDS (multivitamins), and Dorzolamide HCl-Timolol (an eye drop medication to treat increased pressure in the eye). The surveyor observed LPN #1 bring a glucometer (device to measure blood sugar), glucometer strips, a lancet (a small sharp spring-loaded device used to perform a finger prick), an eye drop solution bottle, medication cup #1 containing the aspirin and medication cup #2 containing Amlodipine, Atenolol, Eliquis, and PreserVision tablets into the resident's room. At 8:14 AM, LPN #1 administered the eye drop medication, handed medication cup #1 to Resident #74, and instructed Resident #74 to chew the aspirin tablet. LPN #1 used the glucometer to check the resident's blood sugar level, which read 170 mg/dL (milligrams per deciliter). At this time, LPN #1 accidentally threw medication cup #2 into the garbage can while cleaning the resident's overbed table. The surveyor observed LPN #1 retrieve the medication from the garbage and exit the room to dispose of it. On 02/22/23 at 8:37 AM, the surveyor observed LPN #1 prepare six medications for Resident #74. LPN #1 prepared Amlodipine 5 mg, Atenolol 50 mg, Eliquis 2.5 mg, PreserVision, Prostat 30 ml (protein supplement), and insulin Lispro (medication to lower blood sugar) pen injector to 2 units. LPN #1 went inside the resident's room, but there were no residents inside the room. LPN #1 then checked the bathroom, and there was one resident (Resident #49) inside. LPN #1 waited outside the bathroom for the resident to exit. After assisting the resident in the bathroom, a Certified Nurse Assistant (CNA) wheeled Resident #49 from the bathroom to the resident's bedside, which was located near the door. The surveyor observed LPN #1 place the medication cups on the overbed table, take the insulin injector pen, and turn to Resident #49. The surveyor further observed that LPN #1 did not identify the resident by asking for their name, by reading the resident's ID band, or by requesting another staff to identify the resident. LPN #1 proceeded to pull Resident #49's shirt up to expose the abdomen to inject the insulin, which was ordered and prepared for Resident #74. The surveyor immediately stopped LPN #1 and asked her if this was the correct resident. The surveyor then observed LPN #1 check Resident #49's ID band, and LPN #1 stated, Oh, no. On 02/22/23 at 10:39 AM, the surveyor, in the presence of the survey team, discussed the medication pass concerns with the Director of Nursing (DON), Assistant Administrator, LPN/ Unit Manager (LPN/UM), and LPN #1. LPN #1 stated that the correct medication administration process was identifying the resident by checking the ID band. If the resident did not have an ID band, then you could get a CNA or another staff member to identify the resident. LPN #1 added that she could also look at the resident's picture on the electronic health record. LPN #1 stated that you should triple check for the rights of medication administration, including the right resident, the right drug, the right dosage, and the right route. LPN #1 further stated that during the medication pass observation, some of Resident #74's medications fell into the garbage and that once she poured the medications again that she became overwhelmed and confused. LPN #1 added that Resident #74 was originally in the room but had been taken out of the room to go to therapy. LPN #1 stated that she believed that Resident #49 was the resident she was originally working with and that her mind shifted to assisting Resident #49 because now, this was the only resident in the room. LPN #1 continued that she was about to give the resident an insulin injection, but she stopped because the surveyor interrupted her. LPN #1 confirmed that she did not check Resident #49's ID band as she should have. Review of Resident #74's admission Record (AR) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: hypertension (high blood pressure), type 2 diabetes mellitus (high blood sugar level), personal history of transient ischemic attack (interruption of blood flow to the brain), and cerebral infarction (a stroke). Review of Resident #74s February 2023 Order Summary Report (OSR) sheet revealed the following physician's orders: 1.) Amlodipine Besylate 5 mg one tablet by mouth one time daily for hypertension dated 05/05/2021, 2.) Atenolol 50 mg, one tablet by mouth every 12 hours for hypertension hold for heart rate less than 60 dated 07/17/2022, 3.) Eliquis (Apixaban) 2.5 mg, one tablet by mouth every 12 hours for DVT dated 06/19/2022, 4.) Aspirin chewable 81 mg one tablet by mouth two times a day dated 05/04/2021, 5.) PreserVision AREDS 2 oral capsule (Multiple vitamins with minerals) one capsule by mouth two times a day dated 02/09/2023, 6.) Prostat sugar-free one time a day for supplement give 30 ml dated 02/10/2023, 7.) Dorzolamide HCl-Timolol solution 22.3-6.8 mg/ml instill one drop in both eyes two times a day dated 05/05/2021, and 8.) Insulin Lispro (I unit dial) solution pen-injector 100 unit/ml, subcutaneously before meals and at bedtime dated 05/04/21, with the following sliding scale instructions: 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; and to call MD [medical doctor] if BS [blood sugar] is below 60 or above 450. Review of Resident #74's 2/09/2023 Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the resident had a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. Review of Resident #74's interdisciplinary care plan (IDCP), dated 09/11/21, revealed under a focus area of at risk for alteration in nutrition/hydration secondary to diagnoses of diabetes mellitus and hypertension. Review of Resident #49's AR indicated that the resident was admitted to the facility with diagnoses which included but were not limited to: heart failure, hypertension, type 2 diabetes mellitus, and unspecified dementia (loss of memory). Review of Resident #49s January 2023 OSR revealed the following orders to be administered at 9 AM: 1.) Memantine HCl (medication to treat memory loss) 10 mg, one tablet by mouth two times a day dated 01/15/2022, 2.) Metformin HCl (medication to lower blood sugar) 1000 mg, one tablet by mouth two times a day dated 01/18/2022, 3.) Trihexyphenidyl HCl (medication to treat involuntary movements) 2 mg, one tablet by mouth two times a day dated 02/01/2022, 4.) Amlodipine besylate 10 mg, one tablet by mouth once a day dated 01/15/2022, 5.) Lasix (Furosemide: medication to reduce extra fluid in the body) 20 mg by mouth one time a day dated 10/29/2022, 6.) Methenamine Hippurate (medication to treat infection of the urinary tract) 1 gram one tablet by mouth once a day dated 01/16/2022, 7.) Bengay ultra-strength external patch 5% (menthol topical analgesic) applied to left knee topically once a day dated 09/23/2022. There was no evidence from the corresponding OSR sheets for January 2023 that Resident #49 was receiving any of the same morning medications as Resident #74. Review of Resident #49's 01/21/23 Annual MDS reflected that the resident had a BIMS score of 9 out of 15, indicating that the resident had moderate cognitive impairment. Review of Resident #49's IDCP, initiated date 7/03/2021, revealed a focus area of impaired cognition function related to as evidenced by BIMS score during interview process, dementia. On 02/22/23 at 10:59 AM, in the presence of the survey team, the LPN/UM stated the process to identify a resident when administering medication to was to check the resident's ID band, get a nurse to identify the resident, or if the resident was alert and oriented have the resident identify themselves. The LPN/UM stated that safety was the most important thing in medication administration and that you could kill them if you give the wrong medication. The LPN/UM continued that she identified Resident #74 during the medication pass observation for LPN #1 and that Resident #49 was in the room the entire time. On 02/22/23 at 11:06 AM, the DON stated, in the presence of the survey team, that nurses administering medications were expected to identify the proper resident, check the picture in the electronic health record, and the resident's name band. The DON stated that giving the right medication to the right resident was to do no harm and not cause adverse effects. The DON stated that LPN #1 should have identified the correct resident before attempting to give medications. Review of the facility's policy titled Medication Administration-Policy, dated as reviewed/revised on 01/2023, provided by the DON revealed under Step 1 Identity Resident Step 5 Identify the resident by name and identification system (bracelet, photograph in PointClickCare (PCC), or with another staff member). Review of the facility's policy titled Insulin Administration dated 01/2023, provided by the DON, revealed under Procedure for administering insulin using an insulin pen 1. Performs the six rights and 3 point medication check. N.J.A.C. 8:39-11.2 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT#: NJ159023 Based on interviews, medical record review, and other pertinent facility documentation on [DATE], [DATE], and [DATE], it was determined that the facility failed to provide services to prevent Neglect of a resident (Resident #2). Resident #2 had a Physician's Order and a Plan of Care for a Full Code and a known diagnosis of Unspecified Chronic Obstructive Pulmonary Disease, Pulmonary Embolism without Acute Cor Pulmonale, and Shortness of Breath. On [DATE] at approximately 4:30 a.m., on the 11-7 shift, the Registered Nurse (RN) found Resident #2 unresponsive without a pulse and respirations in bed. The RN failed to place the air mattress in Cardiopulmonary Resuscitation (CPR) (an emergency procedure that can help save a person's life if their breathing or heart stops) mode to ensure a firm surface under Resident #2 when performing CPR and activate the Emergency Response System (ERS), which included: calling for other staff to assist, calling 911, getting the crash cart and (emergency supplies), getting the Automatic External Defibrillator (AED) and continuing CPR until the Emergency Medical Technicians (EMTs) arrived. According to the RN, she first saw Resident #2 at approximately 1:30 a.m. during her rounds, when the Resident was observed sleeping peacefully in bed. Resident #2 was not restless or struggling to breathe. Then at 4:30 a.m., she went into Resident #2's room to administer a nebulizer treatment when she saw that it looked like the Resident was not breathing. The RN shook Resident #2, did chest compressions, and got no response. The RN believed it would take 5-10 minutes to get another staff and told the Surveyors she didn't call 911 because the Resident was dead and did not call a code because she did not want to waste time. According to the Electronic Death Registration System (EDRS), the time of date for Resident #2 was 5:54 a.m. After pronouncing Resident #2's death, the RN notified the Director of Nursing (DON) on [DATE] at approximately 5:30 a.m.-5:40 a.m., advising her that Resident #2 had passed away. The DON spoke to the RN about the incident. However, the DON did not investigate how CPR was done on an air mattress, the ERS not being activated for CPR, or did not report the incident. In addition, the facility failed to follow its policy titled Abuse and Neglect Policy. The facility's failure to protect Resident #2 and other residents with Full Code status from Neglect and immediately in-service staff on how to activate the Emergency Response System when a resident is found unresponsive, without a pulse or respiration, placed Resident #2 and all full code residents at risk for an Immediate Jeopardy (IJ) situation. The RN continued to work on units with Full Code residents from [DATE] through [DATE], 40 hours a week, without being educated or in-service on the facility's CPR policy and ERS protocol. The RN was terminated on [DATE], the first day of the survey. The facility also failed to investigate the death of Resident #2 and notify the New Jersey (NJ) State Board of Nursing and the NJ Department of Health of the Neglect of Resident #2. This IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), the Director of Nursing (DON), and Social Worker (SW) on [DATE] at 7:25 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ began on [DATE] and continued through [DATE] when all staff were in-serviced and re-educated on the Emergency Response System and Neglect, ensuring all residents with Full Code status are safe and free from Neglect. On [DATE], the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, educating all staff on CPR, the ERS, Code Status, the Communication of STAT (urgent) situation, and Neglect. On [DATE], the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, educating all staff on CPR, the Emergency Response System, Code Status, the Communication of STAT (urgent) situation, and Neglect. This deficient practice was identified for 1 of 4 residents (Resident #2) and evidenced by the following: According to the admission Record (AR), Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Unspecified Chronic Obstructive Pulmonary Disease, Other Pulmonary Embolism without Acute Cor Pulmonale and Shortness of Breath. According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #2 had a Brief Interview of Mental Status (BIMS) score of 13/15, which indicated the Resident was cognitively intact. The MDS also showed Resident #2 needed extensive assistance with Activities of Daily Living (ADLs). A review of the Resident's Care Plan (CP) initiated on [DATE] revealed under Focus: that Resident #2 does not have an Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). Under Goal, showed Full Code status will be maintained through the review period. Under Interventions, included .Full Code date initiated [DATE] . A review of Resident #2's Order Summary Report (OSR) Order Date Range [DATE]-[DATE] revealed the following Physician Orders (POs): Air mattress-check placement and function q (every) shift, order date [DATE]. Full Code, order date [DATE]. A review of Resident #2's Treatment Administration Record (TAR) dated [DATE] -[DATE] revealed the above PO to check the function, and the placement of the air mattress was documented as done on [DATE] on the night shift by the RN. A review of Resident #2's Progress Notes (PNs) revealed the following: On [DATE] at 2:11 p.m., the Social Worker (SW) sat with the Resident to discuss living will/POLST/POA. The Resident has no interest in filling anything out at this time. The SW provided support and stressed the importance of having these documents. On [DATE] at 5:17 a.m., the PNs, written by the RN, revealed, Resident approached and attempt (ed) made to wake him/her for breathing TX (treatment) and meds (medications). Resident [was] unresponsive after chest compressions [were] done. Pronounced by RN, call, and [a] message left with Doctor [Physician], report given to the DON, messages left with both daughters. The Surveyor reviewed the Assignment Sheet (AS) dated [DATE] on the 11:00 p.m. -7:00 a.m. shift, which revealed there were three nurses: (1) RN and (2) Licensed Practice Nurses (LPNs) and (3) Certified Nursing Assistants (CNAs)on the Garden unit. The AS for the building revealed a total of 12 staff members: 6 nurses and 6 CNAs. However, there was no evidence of training provided at the time of the survey for staff working that night on the facility's ERS. There was also no camera footage for the incident, and the facility could not provide the Surveyor with the crash cart binder sign-off sheet for [DATE]. During an interview on [DATE] at 12:53 p.m., the SW stated she remembered Resident #2 if no Advance Directive, you [resident] are a Full Code. She continued, Full Code means full treatment: CPR, intubation, aggressive treatment, calling 911 .Resident #2 did not have an Advance Directive . the Resident was a Full Code. She indicated the Resident was always a Full Code. During a telephone interview on [DATE] at 9.51 a.m., when the Surveyor asked about the incident with Resident #2, the RN stated the following: the night of the incident at 1:30 a.m., I checked on him/her, the Resident was sleeping peacefully, not restless for struggling to breathe, so I thought he/she was asleep. At 4:30 a.m., I went in to give him/her a morning medication and a nebulizer breathing treatment. The RN explained that Resident #2 was not breathing, so I shook the Resident; I did chest compressions with no response, not even a tiny bit. I realized he/she was gone, no radial or apical pulse, no palpable pulse, I knew he/she was gone, he/she was dead. When the Surveyor asked the RN if anyone else was there, she replied, no, there was nobody else there with me. Nurses were doing med (medication) pass, and aides were doing their changes, so nobody was around. It was basically just me . His/her condition was poor; I don't think it would've helped. (Resident #2) wanted to be left alone, that's my opinion. When I found the patient [Resident] unresponsive, the Resident was a Full Code, to my knowledge. But I knew he/she was dead. The RN continued to say, even if (the Resident was) still breathing, by the time I got someone there, he/she would've been dead, there was no pulse, no gurgling, no sound, nothing, the Resident was totally cold. I did chest compressions immediately. She stated, If I went down [the] hall to get the code cart, it wouldn't have done any good. In the same telephone interview, when the Surveyor asked her if she had called 911, she stated, No, I didn't call 911 because he/she was already dead. If I had gotten the least bit of response from him/her, I would've called 911, but his/her condition was poor anyway. It takes time to call, and he/she was way down the hall. It would've taken 5-10 minutes to get somebody. I didn't know where Nurse [s] or aides were; they were in rooms doing changes. I didn't call 911 or any staff for help because he/she was dead. When the Surveyor asked the RN about an emergency code, and if she should have called a code, she replied, an emergency code is called as soon as you see the patient [resident] in distress. The RN said she did not call a code because he/she was dead, not wasting time, I did CPR on him/her. It didn't work because the Resident was dead. During an interview on [DATE] at 10:57 a.m., the Licensed Practical Nurse (LPN) working the Garden Unit on [DATE] on the 11:00 p.m. to 7:00 a.m. shift revealed that he had an emergency with one of his residents on the night of the incident. The LPN further stated he did not remember the name of the other Nurse he worked with that night but said that when he came out to the Nurse's station, the Nurse informed him that her Resident (Resident #2) had expired during the shift. The LPN stated, No, I didn't hear anyone yelling out for help or hear a STAT Code/Emergency called that night. The LPN said if a resident is a Full Code and found unresponsive, I will have to start CPR and alert someone to call 911 and get the crash cart. During an interview on [DATE] at 12:12 p.m., when the Surveyor asked the DON if a resident was unresponsive, what is done, she replied, Initially if a resident is unresponsive and Full Code, anyone should tap the person [Resident] anywhere on the body to see if [Resident] responds to stimuli. If (there is) no response, time is of the essence, yell for staff for assistance. She further stated as the primary Nurse, she would know the code status of the Resident, and if the Resident was a Full Code, she would start CPR, someone would call 911, and someone would bring the crash cart. Any staff can call 911 and bring the crash cart, all hands on deck. Usually, the Charge Nurse will be directing other staff members to get stuff. Time is of the essence; get things done as quickly as possible. In the same interview, when the Surveyor asked what happened with Resident #2 and the RN on [DATE], the DON stated, At about 5:30-5:40 a.m., I got a phone call from the RN; she advised me that Resident #2 had passed away, and I thanked her for letting me know. That was the end of the conversation. When I came into work, I made sure all the documentation was done, and that was the end of it. The DON continued to say, I did speak to the RN about what happened. She said she walked into Resident #2's room at about 1:45 a.m., and the Resident was sleeping during her rounds. Then she went in again [to the room] closer to 5:00 a.m. to administer meds (medications) and a nebulizer treatment, and then that's when she noted the Resident was unresponsive. She said she started CPR compressions, and it was futile, the man/lady was dead! Yes, that was it. In the same interview, when the Surveyor asked the DON if the RN yelled for help, she replied the RN told her, Yes, she yelled out for assistance, but she said nobody came. That was it. I did ask a few people in the building if they heard [someone] yell out for assistance, but they didn't hear anything. They were doing meds (medications) and giving care. I spoke to (3) other nurses, and they didn't hear anything. The DON continued, I don't remember if the RN told me she called 911. 911 is a given. When the Surveyor asked the DON if she investigated the incident for Resident #2, she replied, No, the death incident was not investigated. No, I did not go back and look to see if [the] procedure was followed. For [the] incident that night, the Nurse should've called 911 when she found patient [the Resident] unresponsive. On [the] phone system, we have a page all .when she [RN] was getting no response, she should've run out of the room and used the pager system to get help. Time is of the essence, and return to [the] Resident and continue CPR. During an interview on [DATE] at 1:11 p.m., when the Surveyor asked the Assistant Administrator (AA) if the RN followed the protocol for an emergency, she replied, if a resident was unresponsive and a Full Code, I expect the Nurse to call a code or start CPR on (their) own, yell for someone to come and help you, pick up the phone, call STAT (urgent) Code with (the) unit and room number. The RN was not following our protocol . During a telephone interview on [DATE] at 2:48 p.m., the Surveyor asked the Medical Director (MD) if a resident was found unresponsive with no pulse and not breathing, what is expected of the Nurse. The MD stated it would be expected for the Nurse to start CPR and activate the emergency code in the building. During a telephone interview on [DATE] at 3:00 p.m., the Licensed Practice Nurse (LPN) who worked on the night shift on [DATE] on another unit stated, [the] Nurse didn't call for assistance, I did not hear [a] call for help. I wasn't aware of anything. I said goodbye to the RN around 7:20 a.m. She said at the end of her shift, she had a patient [Resident] pass away, and that was it. She continued to say, a code is never a single person, a team effort, it's all hands on deck . I assumed when she told me a person [Resident] passed away, it was a do not resuscitate (DNR), I did not hear a code. According to the LPN, the overnight Nurse checks the crash cart to ensure nothing is expired; all is up to date, oxygen is full, suction is connected, and anything we need. It's checked every night, overnight, [on] a sign-out sheet kept in a binder with [the] crash cart. During a second interview on [DATE] at 3:48 p.m., the DON stated, if there's an air mattress, it can be pulled, [an] emergency pull activates the bed, [located] on the side of the bed for CPR mode. This Resident had an air mattress. The Nurse should have activated the bed for CPR mode. During a second telephone interview on [DATE] at 4:06 p.m., when the surveyors asked her how Resident #2's was done CPR, the RN stated, I gave the Resident CPR on his/her bed. When the Surveyor asked the RN if she did anything else before starting CPR, the RN said, No, I didn't do anything in the room, indicating she did not deflate the air mattress for CPR. On [DATE], the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, educating all facility staff on CPR, the Emergency Response System, Code Status, and the Communication of a STAT (urgent) situation. So, the noncompliance remained on [DATE] as a level D for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the following: The RN no longer works at the facility and all staff have been educated on the Emergency Response System and Neglect. A review of the facility policy titled Abuse and Neglect Policy dated [DATE] revealed the following: Under Policy Statement included Residents have the right to be free from abuse, Neglect, misappropriation, and exploitation. Residents will be notified about resident rights as well as promoting resident rights. Facility will develop and implement ongoing measures to prevent resident abuse by incorporating the seven attributes of abuse prevention in Long Term Care. Under Policy Interpretation and Implementation, indicated The Facility will protect all residents. All reports of suspected abuse will be investigated in a timely manner, with emphasis on the protection of the Resident after report of an incident and during the investigation. This policy will be accomplished through the following 7 elements: .3. Reporting of suspected abuse, All alleged abuse, Neglect, exploitation, mistreatment, injuries of unknown source and misappropriated resident property must be reported immediately to the Administrator - to local law enforcement and State agency, within 2 hours -serious bodily injury, within 24 hours-others .5. Investigation, every allegation of abuse, Neglect, exploitation, mistreatment, injuries of unknown source and misappropriated resident property must be thoroughly investigated .7. Report results, the results of the investigation must be reported to the Administrator and other officials, according to State law, and the State Survey Agency within 5 days of the incident .To assist our facility staff member in recognizing incidents of abuse, the following definitions of abuse are provided . Neglect is defined as, the failure of the facility, it's employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . N.J.A.C.: 8.39- 27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ159023 Based on observation, interviews, medical record review, and review of other pertinent facility documentation on [DATE], [DATE], and [DATE], it was determined that the facility failed to activate the Emergency Response System (ERS), which included: calling for other staff to assist, calling 911, getting the crash cart and (emergency supplies), getting the Automatic External Defibrillator (AED) and continuing Cardiopulmonary Resuscitation (CPR) (an emergency procedure that can help save a person's life if their breathing or heart stops) until the Emergency Medical Technicians (EMTs) arrived for a resident (Resident #2). Resident #2 had a Physician's Order and a Plan of Care for a Full Code and a known diagnosis of Unspecified Chronic Obstructive Pulmonary Disease, Pulmonary Embolism without Acute Cor Pulmonale, and Shortness of Breath. On [DATE] at approximately 4:30 a.m., on the 11-7 shift, the Registered Nurse (RN) found Resident #2 unresponsive without a pulse and respirations in bed. The RN failed to place the air mattress in CPR mode to ensure a firm surface under Resident #2 when performing CPR. According to the RN, she first saw Resident #2 at approximately 1:30 a.m. during her rounds, when the Resident was observed sleeping peacefully in bed. Resident #2 was not restless or struggling to breathe. Then at 4:30 a.m., she went into Resident #2's room to administer a nebulizer treatment when she saw that it looked like the Resident was not breathing. The RN shook Resident #2, did chest compressions, and got no response. The RN believed it would take 5-10 minutes to get another staff and told the Surveyors she didn't call 911 because the Resident was dead and did not call a code because she did not want to waste time. According to the Electronic Death Registration System (EDRS), the time of date for Resident #2 was 5:54 a.m. After pronouncing Resident #2's death, the RN notified the Director of Nursing (DON) on [DATE] at approximately 5:30 a.m.-5:40 a.m., advising her that Resident #2 had passed away. The DON spoke to the RN about the incident. However, the DON did not investigate how CPR was done on an air mattress, the ERS not being activated for CPR, or did not report the incident. In addition, the facility failed to follow its policy titled Emergencies. The facility staff failure to provide CPR correctly and activate the ERS when Resident #2 was found unresponsive, without a pulse or respiration, placed Resident #2 and all other residents who were a Full Code at risk for an Immediate Jeopardy (IJ) situation. The Surveyor identified the IJ on [DATE], Day 2 of the survey. This IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), the Director of Nursing (DON), and Social Worker (SW) on [DATE] at 7:25 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ began on [DATE] and continued through [DATE] when all licensed and unlicensed staff were in-serviced and re-educated on the Emergency policy and procedures for activating the ERS. On [DATE], the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, educating all staff on CPR, the Emergency Response System, Code Status, and the Communication of STAT (urgent) situations. This deficient practice was identified for 1 of 4 residents (Resident #2) and evidenced by the following: According to the admission Record (AR), Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Unspecified Chronic Obstructive Pulmonary Disease, Other Pulmonary Embolism without Acute Cor Pulmonale and Shortness of Breath. According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #2 had a Brief Interview of Mental Status (BIMS) score of 13/15, which indicated the Resident was cognitively intact. The MDS also showed Resident #2 needed extensive assistance with Activities of Daily Living (ADLs). A review of the Resident's Care Plan (CP) initiated on [DATE] revealed under Focus: that Resident #2 does not have an Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). Under Goal, showed Full Code status will be maintained through the review period. Under Interventions, included .Full Code date initiated [DATE] . A review of Resident #2's Order Summary Report (OSR) Order Date Range [DATE]-[DATE] revealed the following Physician Orders (POs): Air mattress-check placement and function q (every) shift, order date [DATE]. Full Code, order date [DATE]. A review of Resident #2's Treatment Administration Record (TAR) dated [DATE] -[DATE] revealed the above PO to check the function, and the placement of the air mattress was documented as done on [DATE] on the night shift by the RN. A review of Resident #2's Progress Notes (PNs) revealed the following: On [DATE] at 2:11 p.m., the Social Worker (SW) sat with the Resident to discuss living will/POLST/POA. The Resident has no interest in filling anything out at this time. The SW provided support and stressed the importance of having these documents. On [DATE] at 5:17 a.m., the PNs, written by the RN, revealed, Resident approached and attempt (ed) made to wake him/her for breathing TX (treatment) and meds (medications). Resident [was] unresponsive after chest compressions [were] done. Pronounced by RN, call, and [a] message left with Doctor [Physician], report given to the DON, messages left with both daughters. The Surveyor reviewed the Assignment Sheet (AS) dated [DATE] on the 11:00 p.m. -7:00 a.m. shift, which revealed there were three nurses: (1) RN and (2) Licensed Practice Nurses (LPNs) and (3) Certified Nursing Assistants (CNAs)on the Garden unit. The AS for the building revealed a total of 12 staff members: 6 nurses and 6 CNAs. However, there was no evidence of training provided at the time of the survey for staff working that night on the facility's ERS. There was also no camera footage for the incident, and the facility could not provide the Surveyor with the crash cart binder sign-off sheet for [DATE]. During an interview on [DATE] at 12:53 p.m., the SW stated she remembered Resident #2 if no Advance Directive, you [resident] are a Full Code. She continued, Full Code means full treatment: CPR, intubation, aggressive treatment, calling 911 .Resident #2 did not have an Advance Directive . the Resident was a Full Code. She indicated the Resident was always a Full Code. During a telephone interview on [DATE] at 9.51 a.m., when the Surveyor asked about the incident with Resident #2, the RN stated the following: the night of the incident at 1:30 a.m., I checked on him/her, the Resident was sleeping peacefully, not restless for struggling to breathe, so I thought he/she was asleep. At 4:30 a.m., I went in to give him/her a morning medication and a nebulizer breathing treatment. The RN explained that Resident #2 was not breathing, so I shook the Resident; I did chest compressions with no response, not even a tiny bit. I realized he/she was gone, no radial or apical pulse, no palpable pulse, I knew he/she was gone, he/she was dead. When the Surveyor asked the RN if anyone else was there, she replied, no, there was nobody else there with me. Nurses were doing med (medication) pass, and aides were doing their changes, so nobody was around. It was basically just me . His/her condition was poor; I don't think it would've helped. (Resident #2) wanted to be left alone, that's my opinion. When I found the patient [Resident] unresponsive, the Resident was a Full Code, to my knowledge. But I knew he/she was dead. The RN continued to say, even if (the Resident was) still breathing, by the time I got someone there, he/she would've been dead, there was no pulse, no gurgling, no sound, nothing, the Resident was totally cold. I did chest compressions immediately. She stated, If I went down [the] hall to get the code cart, it wouldn't have done any good. In the same telephone interview, when the Surveyor asked her if she had called 911, she stated, No, I didn't call 911 because he/she was already dead. If I had gotten the least bit of response from him/her, I would've called 911, but his/her condition was poor anyway. It takes time to call, and he/she was way down the hall. It would've taken 5-10 minutes to get somebody. I didn't know where Nurse [s] or aides were; they were in rooms doing changes. I didn't call 911 or any staff for help because he/she was dead. When the Surveyor asked the RN about an emergency code, and if she should have called a code, she replied, an emergency code is called as soon as you see the patient [resident] in distress. The RN said she did not call a code because he/she was dead, not wasting time, I did CPR on him/her. It didn't work because the Resident was dead. During an interview on [DATE] at 10:57 a.m., the Licensed Practical Nurse (LPN) working the Garden Unit on [DATE] on the 11:00 p.m. to 7:00 a.m. shift revealed that he had an emergency with one of his residents on the night of the incident. The LPN further stated he did not remember the name of the other Nurse he worked with that night but said that when he came out to the Nurse's station, the Nurse informed him that her Resident (Resident #2) had expired during the shift. The LPN stated, No, I didn't hear anyone yelling out for help or hear a STAT Code/Emergency called that night. The LPN said if a resident is a Full Code and found unresponsive, I will have to start CPR and alert someone to call 911 and get the crash cart. During an interview on [DATE] at 12:12 p.m., when the Surveyor asked the DON if a resident was unresponsive, what is done, she replied, Initially if a resident is unresponsive and Full Code, anyone should tap the person [Resident] anywhere on the body to see if [Resident] responds to stimuli. If (there is) no response, time is of the essence, yell for staff for assistance. She further stated as the primary Nurse, she would know the code status of the Resident, and if the Resident was a Full Code, she would start CPR, someone would call 911, and someone would bring the crash cart. Any staff can call 911 and bring the crash cart, all hands on deck. Usually, the Charge Nurse will be directing other staff members to get stuff. Time is of the essence; get things done as quickly as possible. In the same interview, when the Surveyor asked what happened with Resident #2 and the RN on [DATE], the DON stated, At about 5:30-5:40 a.m., I got a phone call from the RN; she advised me that Resident #2 had passed away, and I thanked her for letting me know. That was the end of the conversation. When I came into work, I made sure all the documentation was done, and that was the end of it. The DON continued to say, I did speak to the RN about what happened. She said she walked into Resident #2's room at about 1:45 a.m., and the Resident was sleeping during her rounds. Then she went in again [to the room] closer to 5:00 a.m. to administer meds (medications) and a nebulizer treatment, and then that's when she noted the Resident was unresponsive. She said she started CPR compressions, and it was futile, the man/lady was dead! Yes, that was it. In the same interview, when the Surveyor asked the DON if the RN yelled for help, she replied the RN told her, Yes, she yelled out for assistance, but she said nobody came. That was it. I did ask a few people in the building if they heard [someone] yell out for assistance, but they didn't hear anything. They were doing meds (medications) and giving care. I spoke to (3) other nurses, and they didn't hear anything. The DON continued, I don't remember if the RN told me she called 911. 911 is a given. When the Surveyor asked the DON if she investigated the incident for Resident #2, she replied, No, the death incident was not investigated. No, I did not go back and look to see if [the] procedure was followed. For [the] incident that night, the Nurse should've called 911 when she found patient [the Resident] unresponsive. On [the] phone system, we have a page all .when she [RN] was getting no response, she should've run out of the room and used the pager system to get help. Time is of the essence, and return to [the] Resident and continue CPR. During an interview on [DATE] at 1:11 p.m., when the Surveyor asked the Assistant Administrator (AA) if the RN followed the protocol for an emergency, she replied, if a resident was unresponsive and a Full Code, I expect the Nurse to call a code or start CPR on (their) own, yell for someone to come and help you, pick up the phone, call STAT (urgent) Code with (the) unit and room number. The RN was not following our protocol . During a telephone interview on [DATE] at 2:48 p.m., the Surveyor asked the Medical Director (MD) if a resident was found unresponsive with no pulse and not breathing, what is expected of the Nurse. The MD stated it would be expected for the Nurse to start CPR and activate the emergency code in the building. During a telephone interview on [DATE] at 3:00 p.m., the Licensed Practice Nurse (LPN) who worked on the night shift on [DATE] on another unit stated, [the] Nurse didn't call for assistance, I did not hear [a] call for help. I wasn't aware of anything. I said goodbye to the RN around 7:20 a.m. She said at the end of her shift, she had a patient [Resident] pass away, and that was it. She continued to say, a code is never a single person, a team effort, it's all hands on deck . I assumed when she told me a person [Resident] passed away, it was a do not resuscitate (DNR), I did not hear a code. According to the LPN, the overnight Nurse checks the crash cart to ensure nothing is expired; all is up to date, oxygen is full, suction is connected, and anything we need. It's checked every night, overnight, [on] a sign-out sheet kept in a binder with [the] crash cart. During a second interview on [DATE] at 3:48 p.m., the DON stated, if there's an air mattress, it can be pulled, [an] emergency pull activates the bed, [located] on the side of the bed for CPR mode. This Resident had an air mattress. The Nurse should have activated the bed for CPR mode. During a second telephone interview on [DATE] at 4:06 p.m., when the surveyors asked her how Resident #2's was done CPR, the RN stated, I gave the Resident CPR on his/her bed. When the Surveyor asked the RN if she did anything else before starting CPR, the RN said, No, I didn't do anything in the room, indicating she did not deflate the air mattress for CPR. On [DATE], the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, educating all facility staff on CPR, the Emergency Response System, Code Status, and the Communication of a STAT (urgent) situation. So, the noncompliance remained on [DATE] as a level D for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the following: The RN no longer works at the facility and all staff have been educated on the ERS, review and update Emergency Response System Policy, re-educated nursing staff on CPR and Emergency Response with emphasis placed on the immediate and effective calling of an emergency (STAT) situation, hands-on training, and drills. Residents' records/charts are updated to clearly indicate and identify Code Status or None-code Status. Training on safety precautions for CPR, such as deflating air mattresses and proper use of telephone and paging system to call STAT. Identify Residents who may be at risk by obtaining a list of all Residents who are Full Code, Crash cart review, AED review, and Demonstration of AED application, Demonstration of proper chest compression and hand placement, and notification to NJDOH, the Ombudsman, and NJ State Board of Nursing. A review of the facility's undated policy titled Emergencies included but was not limited to the following: Under Purpose: To provide nurses with information to enable them to identify emergency situations and intervene promptly in order to prevent negative resident outcome. Under Procedure: Step 1A. Regardless of the type of emergency, the following basis principles should guide nursing actions: 1. Maintain life functions as indicated (this may be determined by advanced directives, living will, or DNR). C. If it is determined by the RN or Supervisor that a resident is in need of emergency care due to a life-threatening problem, (i.e., sudden and unexpected cardiopulmonary arrest, Resident is choking and becomes unresponsive or persistent seizure activity, etc.) 1. Perform CPR 2. Notify Physician 3. Call family/significant other. N.J.A.C: 8:39-27.1(a)