**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility documentation, it was determined that the facility failed to clarify a physician's order for Paxlovid (an antiviral medication used to treat COVID-19, a deadly virus) for a vaccinated resident (Resident #4), for it to be administered within 24 hours for one of 14 residents reviewed for COVID-19 care. The original order was for Paxlovid to be administered for five days was faxed to the pharmacy on 10/22/23 but failed to include a dosage amount. This caused the pharmacy to contact the facility three additional times for clarification of the Paxlovid order. Resident #4 was provided a different antiviral medication on 10/25/23 (3 days later) and expired at the facility on 10/28/23. COVID-19 is known to be a highly infectious communicable disease which can lead to hospitalization and death. The facility had a positive confirmation of COVID-19 on 09/13/23, was currently still in an outbreak, and had been unable to mitigate the spread of the infection. The facility's failure to ensure Resident #4, who was at risk for severe outcomes from COVID-19, received the necessary treatment to avoid a worsening of their COVID-19 condition in a timely manner, including death, resulted in an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ situation on 11/17/23. The IJ continued from 10/22/23 until 11/20/23, once the survey team received an acceptable Removal Plan (RP), which was verified by the survey team on 11/20/23, removing the immediacy. The non-compliance remained on 11/21/23 for F684, with no actual harm with the potential for more than minimum harm that is not immediate jeopardy. The evidence was as follows: A review of the hybrid medical record revealed that Resident #4 had been readmitted on [DATE], with diagnoses which included but were not limited to; pneumonia, systemic inflammatory response syndrome (an inflammatory response to the whole body to harmful stressors), and hypertensive heart disease. A review of the most recent quarterly Minimum Data Set (MDS) an assessment tool used to facilitate treatment, dated 08/08/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 04 out of 15 indicating Resident #4 was cognitively impaired. Resident #4 continuously had an altered level of consciousness. Resident #4 required staff assistance for Activities of Daily Living (ADL). A review of the resident centered Care Plan (CP) included but was not limited to; a focus area date initiated 12/13/21 and revised 10/30/23, + (positive) COVID and may result to s/s (signs and symptoms) of respiratory distress. Interventions included Paxlovid as ordered dated 10/22/23. A review of the Progress Notes (PN) from 10/22/23 through 10/28/23, included the following: a note dated 10/22/23 at 21:52 (9:52 PM), Resident #4 had tested positive for COVID-19. A note dated 10/22/23 at 22:59 (10:59 PM), nonproductive cough and will continue to monitor and that Resident #4 was to start Paxlovid. A note dated 10/24/23 at 7:05 AM, nonproductive cough, resident is to start Paxlovid when available. A note dated 10/24/23 at 16:41 (4:41 PM), moist cough noted nonproductive. To start on Paxlovid. A note dated 10/25/23 at 16:03 (4:03 PM), lethargic, increased secretions, on supplemental oxygen for comfort. Will continue to monitor. A note dated 10/25/23 at 21:12 (9:12 PM), lethargic, Mulnupiravir (an antiviral medication used to treat COVID-19) D (day) 1/5 [1 of 5]. Pain medication administered for signs and symptoms of pain and discomfort. Nonproductive cough. Will continue to monitor. A note dated 10/26/23 at 13:54 (1:54 PM), lethargic noted with worsening of condition. Pain medication for generalized discomfort. Medication for increased secretions. A note dated 10/27/23 at 4:47 AM, labored breathing, pain medication administered for body discomfort, medication for increased respiratory secretions. A note dated 10/28/23 at 2:55 AM, unresponsive, absent respiration, no pulse, pronounced at 1:10 AM (deceased ). The PNs failed to document any rationale for the resident not receiving the Paxlovid, that the physician was notified and his response, or communication with the pharmacy. A review of the Physician's Orders Sheet (POS) revealed the following: a physician's order dated 10/17/23 for hospice evaluation related to dysphagia (difficulty in swallowing food or liquid). A telephone order dated 10/22/23 and not timed, for Paxlovid PO (by mouth) BID (twice a day) x (times) 5 days for COVID-19. Hold Eliquis (medication to keep the blood thin) x 5 days while on Paxlovid. TORB (telephone order read back) Dr [name redacted] / [name redacted Registered Nurse (RN) who signed the order] faxed and noted. An entry dated 10/23/23 and not timed, clarification of above order Paxlovid 150 mg (milligrams) TT (2 tablets) with 100 mg T (one tablet) BID x 5 days. TORB Dr [name redacted] to and was signed by the Director of Nursing (DON) RN. There was no indication that the clarified order had been faxed to the pharmacy or noted. A telephone order entry dated 10/25/23 and not timed, to D/C (discontinue) Paxlovid 150 mg 2 tabs with 100 mg 1 tab PO BID x 5 days and to begin Molnupiravir 200 mg 4 caps (capsules) po BID x 5 days Hold Eliquis [an anticoagulant] 2 days post completion of Molnupiravir. TORB Dr [name redacted], signed by the nurse and faxed and noted. A review of the Medication Administration Record (MAR) dated 10/2023, included a handwritten order for Paxlovid PO BID x 5 days DX (diagnosis) COVID-19. The MAR revealed the times 9 AM and 5 PM and indicated X on the dates of 10/23/23 and 10/24/23. There was no documentation on the back of the MAR regarding why the medication was not administered. On 11/17/23 at 1:39 PM, the DON was questioned about the above orders. The DON stated that there was no problem getting the Paxlovid. The DON further stated she was not aware of the situation with Resident #4 and that it was a delayed treatment. On 11/17/23 at 2:13 PM, the surveyor attempted to call the doctor three times with no success. On 11/17/23 at 3:00 PM, the DON was in the conference room in the presence of the survey team. The DON stated, there was a breakdown and that the nurse realized Paxlovid could not be crushed. She stated that the pharmacy made deliveries twice a day at 3:00 PM and midnight. The DON further stated that the Paxlovid was ordered 10/22/23, and that I don't know what happened. The DON stated that Resident #4 was administered a different medication on 10/25/23, she was not sure where the breakdown occurred, and she was just made aware of the situation when the surveyors informed her. On 11/17/23 at 3:12 PM, during a telephone interview, a pharmacist with the facility's contracted pharmacy, stated that Resident #4's Paxlovid order was received 10/25/23 and delivered to the facility on [DATE] at 2:52 PM. On 11/17/23 at 3:30 PM, during an interview with the surveyors, a Licensed Practical Nurse (LPN) #1 stated the process for medication orders would be to take the order, document it on the POS, fax the order to the pharmacy, and document it on the Medication Administration Record (MAR). LPN #1 stated there was never a delay obtaining medications. She further stated that if the medication was noted as not available, she would call the pharmacy to ensure the order was received, check if the medication was in the back up supply, and call the physician. She stated the information would be documented in the electronic medical record and endorsed to the next shift nurse. LPN #1 stated that if the information was not documented, it was not done, and that documentation was important for communication with all disciplines. LPN #1 further stated the if a medication was not available, the area on the MAR would be circled and a note would be made on the back of the MAR. Any blanks on the MAR would indicate that the medication was not administered. On 11/20/23 at 10:15 AM, the DON provided an email dated 11/17/23 at 4:52 PM, from the pharmacy representative (PR) which revealed the facility's inaction caused a delay in Resident #4 receiving the Paxlovid. The email included but was not limited to; 10/22 (2023) POS received for the Paxlovid on 10/22 at 8:31 PM. 10/23 (2023) the order was entered at 7:56 AM, set to profile at 11:34 AM, because clarification was needed whether it was for renal or regular dosing. Called the facility spoke with RN (DON) and was told will clarify and update. 10/24 (2023) Nurse [name redacted] (LPN #2) clarified the order at 2:53 PM that the order was for renally impairing dosing. The order was then un-profiled at 11:21 PM and moved to the batch for 11/24, order still needed clarification to DDI (drug dosing interaction per DON) with other meds (medications) the patient was on (Eliquis and Tamsulosin). 10/25 (2023) the order was moved to the batch for 10/25 (2023) at 12:45 AM. The pharmacy spoke with RN and clarified the other meds were being held for two days while the patient was on Paxlovid. The order was moved to the delivery batch and the label was also printed. The med was toted at 1:16 AM and was delivered to the facility at 5:15 AM. The DON stated that the nurses do not note the time an order was faxed. She stated she clarified the physician's order on 10/23/23, and noted it on the POS. She further stated she was not sure when she spoke to the doctor because it was not documented and that she was unsure what happened between the unclarified times. The DON stated that all the POS orders should have included times with the dates, but she did not realize they did not. On 11/20/23 at 10:44 AM, LPN #2 stated he recalled Resident #4 who was moved to the COVID-19 positive unit on 10/22/23 and was ordered Paxlovid. LPN #2 added that when faxing an order for Paxlovid, there were blood test results that needed to be relayed to identify if the resident needed a renal dose. LPN #2 stated he was not working 10/23/23, but when he returned to work on 10/24/23, he saw the order still needed clarification, so he contacted the pharmacy. LPN #2 stated that the medication had not been delivered until 10/25/23. On 11/20/23 at 12:22 PM, LPN #2 was interviewed again. LPN #2 stated that if a medication was not available, he must notify the physician and document to cover us and sometimes we need an alternative medication. He stated documentation should be done to make sure no side effects are happening to the resident. LPN #2 stated there was always delays with receiving medications from the pharmacy and that the DON knows. On 11/20/23 at 12:44 PM, the DON stated that she was not aware receiving medications from the pharmacy was a problem until the surveyors informed her. She stated when there was a problem, the staff could call the PR directly and that the LNHA was aware and had to call the PR at times. The DON stated that delays in receiving medications could cause a decline in a resident's medical condition. On 11/20/23 at 1:47 PM, the PR was at the facility and interviewed in the presence of the survey team. The PR stated that she was not a pharmacist but the representative and a nurse. The PR stated all events and communications would be documented in the pharmacy computer. She stated that included when a clarification of orders was done and when the pharmacy would be contacted by the facility to be asked about delays in receiving medications. The PR stated she reviewed the situation regarding Resident #4 not receiving the Paxlovid. The PR stated the first order on 10/22/23, was written incorrectly. A call was made on 10/23/23 to clarify but the facility did not clarify until 10/24/23. She stated that could cause problems with delays in medications. The PR further stated that the Internet at the facility was not good causing technical issues that impede communication and that the DON and LNHA were aware. On 11/21/23 at 9:55 AM, the PR provided email documentation of the events from the pharmacy computer. The communication revealed that the pharmacy contacted the facility on 10/23/23 at 11:34 AM, to clarify if the medication was for renal or regular dosing. The pharmacy again contacted the facility on 10/23/23 at 11:53 AM, spoke to the RN (DON) and again requested clarification. It was noted in that communication that the RN (DON) was to clarify and contact the pharmacy. There were no other communications from the facility until the pharmacy called again on 10/24/23 at 14:53 PM (2:53 PM), 27 hours later, and received clarification from LPN #2 that Resident #4 required renal dosing. A communication from the pharmacy on 10/25/23 at 00:19 AM (12:19 AM), was sent to clarify the drug interactions. The pharmacy spoke to an RN on 10/25/23 at 00:57 AM (12:57 AM) to clarify any drug interactions and at that time, the Paxlovid was ready to be sent to the facility. When the Paxlovid was delivered on 10/25/23, the nurse realized the medication could not be crushed due to Resident #4's diagnosis of dysphagia. On 11/21/23 at 10:30 AM, the DON reviewed the POS with the surveyor. The DON's telephone order transcription with the clarification of only the dosage amount which was not included in the original 10/22/23 order was documented. The DON's clarification on 10/23/23 did not clarify if Resident #4 was to receive renal or regular dosing. The order did not document if it was faxed to the pharmacy. The DON stated that the only way to verify if the telephone order she transcribed was received by the pharmacy was to check the pharmacy records. The DON acknowledged her transcribed order did not document that it was faxed to the pharmacy. When made aware that the pharmacy communication had no record of the telephone order she had transcribed, the DON had no additional information to provide. On 11/21/23 at 12:06 PM, Resident #4's physician (MD) was interviewed in the presence of the survey team. The MD stated that there were a lot of residents on Paxlovid at first (when COVID-19 began). He stated resident's being prescribed Paxlovid required blood tests to determine if a renal or regular dose was required. The MD stated his expectation was that if he ordered a medication, the resident would be administered that medication in less than 24 hours. The MD further stated that with Paxlovid you have to get it into the patient's mouth soon or it's no good. He stated that if not given within 24 hours, one of my patients died. The MD stated it was [name redacted Resident #4]. The MD next stated that if a resident does not receive their medication, it could cause worsening, even death and that Resident #4 wasn't that bad but had respiratory symptoms. A review of the facility provided, Abstract of Death Certificate Information date received 10/30/23, included but was not limited to; date pronounced dead 10/28/2023. Cause of death: a. Respiratory failure and b. COVID infection. A review of the facility provided, 1.0 Medication Shortages/Unavailable Medications revised 10/01/18, included but was not limited to; Policy: when medications are not received . for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. Procedure: F. When a missed dose is unavoidable: 1. Document missed dose on the MAR . a. initial and circle to indicate any missed dose. Document the explanation for the missed dose on the back of the MAR and indicate see nurses notes explanation 2. Document explanation of missed dose in the nurse's notes: b. notification of pharmacy and response. c. actions taken. A review of the facility provided, Physician Orders revised 08/01/2017, included but was not limited to; Purpose: ensure that all physician orders are complete and accurate. Policy: nursing will verify that physician orders are complete, accurate and clarified as necessary. Procedure: I. Telephone Orders. A. the licensed nurse will transcribe onto the POS the date, time and signature of the person receiving the order. c. the order will be faxed to the pharmacy. III. Medication orders will include the following: name of the medication; dosage; frequency; duration of the order; and the route and the condition/diagnosis for which the medication was ordered. VI. Order will include a description complete enough to ensure clarity of the physician's plan of care. A review of the facility provided, Telephone and Verbal Physicians Orders updated 01/29/2014, included but was not limited to; Purpose: to ensure accurate physicians and verbal and telephone orders. Policy: all telephone and verbal physician's orders are to be read back to the doctor. A review of the facility provided, Nursing Documentation dated 12/2020, included but was not limited to; Purpose: a key factor in our role and responsibility as patient care advocates. It provides a record of injury or potential injury and further observation, basis for implementation of measures to reduce risk of further occurrences and is critical to determine if the standard of care was rendered to a patient. Guidelines. When to chart: 1. Record nursing actions and individual responses as soon after they occur as possible. What to chart: 3. All injuries, illnesses, and unusual health situations until they are resolved. There should be entries on a regular basis until the problem is no longer present. 4. All contacts with the primary care prescriber: a. what information was relayed. c. if the contact is made by phone, document what was discussed and the results. d. document the plan for follow-up. 9. Any action you take in response to an individual's problem. A review of the facility's provided, Job Description Licensed Practical Nurse revised 04/2021, included but was not limited to; 2. Implements physician's orders timely and accurately. Document accurately and completely. 3. Reports physicians' orders that need clarification to RN (Registered Nurse) to obtain clarification. A review of the facility provided, Job Description Registered Nurse dated 06/22/2021, included but was not limited to; 3. Maintains acceptable standards of nursing practice and carries out physician orders. 10. Implements physician orders timely and accurately. Documents accurately and completely. A review of the facility provided, Job Description Registered Nurse dated 06/22/2021, included but was not limited to; 3. Maintains acceptable standards of nursing practice and carries out physician orders. 10. Implements physician orders timely and accurately. Documents accurately and completely. A review of the facility provided, Job Description Director of Nursing dated 03/25/2022, included but was not limited to; 1. Implements the objectives, policies, and standards of nursing practice. 3. Make frequent rounds on units to monitor the quality of care provided. 9. Establishes and maintains and effective system of medical records and ensure these are completed in a timely manner. 13. Confers with the nursing department staff. Provides guidance as needed. 20. Monitors nursing department for compliance with regulatory guidelines. 21. Ensures Matrix, MARS, TARS (Treatment Administration Record), falls and Incident reports and investigations are complete. NJAC 8:39-27.1; 29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REF: F600IJ Complaint #: NJ00164724 Based on interviews and record review, as well as the review of pertinent facility documents on [DATE], [DATE], and [DATE], it was determined that the facility failed to communicate the care needs and services to the Physician and related Practitioners of a change in the Resident's condition in accordance with the current standards of practice for a Resident who had a change in condition (CIC) for 1 of 3 residents (Resident #2) reviewed for significant CIC. On [DATE] at approximately 3:45 p.m., the Licensed Practical Nurse (LPN #1), who was at the nurse's station, did not respond immediately when Resident #2's roommate (Resident #1) reported that something might be wrong to Resident #2 in the Solarium. Instead, LPN #1 instructed the Quality Assurance Certified Nursing Assistant (QACNA) to check on Resident #2. QACNA went to check and found Resident #2 sitting in a wheelchair, verbally unresponsive. The QACNA performed a sternal rub, to which the resident did not fully respond. The QACNA immediately called the receptionist to call LPN #1 STAT [Immediately] for immediate assistance. When LPN #1 responded, Resident #2 was verbally unresponsive, and his/her head was leaning down towards the right side. Resident #2 was transferred to his/her bed and assessed by LPN #1 as having a petite mal seizure lasting approx. [approximately] 2 minutes, as documented by LPN #1 in the progress notes (PN) dated [DATE] at 6:29 p.m. Resident #2 remained in bed and closely monitored by a Certified Nursing Assistance (CNA #2) for safety. At approximately 3:59 p.m., LPN #1 instructed the QACNA to stay on the unit and wait until Registered Nurse (RN #1) assigned to the resident for the 4:00 p.m. to 12:00 p.m. shift arrived. LPN #1 left the building without notifying the resident's Primary Care Physician (PCP) of the first resident's seizure activity/CIC. At approximately 4:10 p.m., the QACNA checked on Resident #2 after LPN #1 left the building because RN #1 did not arrive. The QACNA found Resident #2 in bed, quiet, blank, staring, and verbally unresponsive. The QACNA immediately reported to the 3:00 p.m. to 11:00 p.m. shift Supervisor (LPN #2). Resident #2 had a second CIC. He/she was transferred to an Acute Care Hospital (ACH) and died on [DATE]. The facility's failure to immediately address Resident #2's seizure activity/CIC and notify the resident's PCP of the changes posed a likelihood of serious harm to the health and wellbeing of Resident #2 and potentially all other residents assigned to LPN #1 in an Immediate Jeopardy (IJ) situation. The IJ was identified and reported to the facility on [DATE] at 7:14 p.m. The IJ began on [DATE] and continued until [DATE]. The facility provided an acceptable removal plan on [DATE]. On [DATE], the Surveyor returned to the facility to ensure the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating staff. The non-compliance remained on [DATE] for no actual harm with the potential for more than minimal harm that is not an IJ. A review of cellphone text messages (CTM) provided to the Surveyor by the PCP on [DATE] at 2:55 p.m. reflected that on [DATE], the following text was received from LPN #1, at 4:22 p.m. [Resident #2] had a seizure lasting about two minutes FYI [for your information], at 5:01 p.m., the PCP responded and asked the LPN Anymore? At 5:15 p.m., the LPN responded, Yes, sent [him/her] to ER [emergency room]. The Surveyor conducted a telephone interview with the PCP on [DATE] at 2:44 p.m.; the PCP stated that he was first notified of the seizure activity/CIC through text message on [DATE] at 4:22 p.m. The PCP stated that the facility is expected to call him immediately if a resident has a CIC. The PCP explained that timing is very important and that something went wrong. The facility's policy titled CHANGE OF CONDITION, dated 12/2020, indicated under POLICY: All staff members shall communicate any information about resident status change to appropriate licensed personnel immediately upon observation. DEFINITIONS .Acute: a.) Sudden Onset b.) A marked change .Uncharacteristic: Any unusual a typical symptom that is not of the ordinary for a resident. PROCEDURE .6. Notification of physician, time, and date (month, day, and year) are to be documented in the nurse's notes. The licensed nurse must speak directly to the physician: you may not leave a message with the answering service or receptionist. The physician must call back . NJAC 8:39-13.1 (d) NJAC 8:39-27.1 (a) NJAC 8:39- 5.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00164724 Based on interviews, review of medical records (MRs), and other pertinent facility documents on [DATE], [DATE], and [DATE], it was determined that the facility failed to provide services necessary to prevent neglect of a resident (Resident #2) after a seizure activity/change in condition (CIC), follow the facility's policies titled CHANGE OF CONDITION and Abuse Prevention and Prohibition Program, and the LICENSED PRACTICAL NURSE job description. On [DATE] at approximately 3:45 p.m., Resident #2's roommate (Resident #1) went to the Nurse's station and reported to the Nurse that something might be wrong with [Resident #2]. The Nurse in charge (Licensed Practical Nurse - LPN #1) instructed the Quality Assurance Certified Nursing Assistant (QACNA) to check Resident #2 in the Solarium. The QACNA found Resident #2 sitting in a wheelchair, verbally unresponsive and responded to a sternal rub performed by QACNA. The QACNA immediately called the Receptionist to call LPN #1 STAT [Immediately] for immediate assistance because the resident was not responding fully. When LPN #1 responded, she observed Resident #2 was verbally unresponsive, leaning the head down to the right side and staring blankly. Resident #2 was then transferred to bed by the QACNA, CNA #2, and CNA #3 and assessed by LPN #1, who identified the Resident as having a petite mal seizure for approx. [approximately] 2 [two] minutes. Resident #2 remained in bed, and LPN #1 instructed the QACNA to notify a nurse and/or the Nursing Supervisor (NS) in case something happens to [Resident #2]. LPN #1 also assigned CNA #2 to remain outside the Resident's room to ensure that Resident #2 did not get out of bed. LPN #1 then left the building without reporting to a Registered Nurse (RN), the Director of Nursing (DON), and/or the NS of the Resident's seizure activity/CIC. In addition, LPN #1 instructed the QACNA to stay at the Nurse's station until the 4:00 p.m. - 12:00 a.m. nurse arrived. At Approximately 4:10 p.m., Resident #2 had another episode of a seizure/CIC; he/she was transferred to an Acute Care Hospital (ACH) and died on [DATE]. The facility's failure to immediately address Resident #2's seizure activity/CIC and notify the appropriate staff of the changes posed a likelihood of serious harm to the health and well-being of Resident #2 and potentially all other residents assigned to LPN #1 in an Immediate Jeopardy (IJ) situation. The IJ was identified and reported to the facility on [DATE] at 7:14 p.m. The IJ began on [DATE] and continued until [DATE]. The facility provided an acceptable removal plan on [DATE]. On [DATE], the Surveyor returned to the facility to ensure the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating staff. The non-compliance remained on [DATE] for no actual harm with the potential for more than minimal harm that is not an IJ. This deficient practice was identified for 1 of 3 residents (Resident #2) and was evidenced by the following: According to the facility admission RECORD (AR), Resident #2 was admitted on [DATE] and discharged on [DATE] with a diagnosis that included but was not limited to Seizures. The Minimum Data Set (MDS), an assessment tool, dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 12, which indicated the Resident's cognition was moderately impaired and the Resident needed extensive assistance with Activity of Daily Living. The MDS indicated that Resident #2 had Seizure Disorder. A review of the Care Plan (CP), initiated on [DATE], included Resident #2 was at risk for a fall due to a Seizure diagnosis. The intervention included but was not limited to Observing for response and providing a safe environment during a seizure episode. A review of the Progress Note (PN) documented by LPN #1, dated [DATE] at 6:29 p.m., revealed Resident #2 had a seizure activity at approximately 3:45 p.m. According to the PN, Resident #2 was at the Solarium in her/his wheelchair and had a petite mal seizure lasting approx [approximately] 2 minutes. The PN indicated that the Resident was transferred to his/her bed, yelling at the Nurse to stop taking his/her vital signs (VS) and to get her/him out of bed. The PN indicated Resident's VS were blood pressure (BP) 148/82, pulse rate (PR) 94 beats per minute (bpm), respiration (R) 20 bpm, temperature (T) 97.1 Fahrenheit (F), and oxygen saturation (OS) was 97%. The PN further indicated that Resident #2 had a seizure and needed to be kept in bed for safety and to monitor closely. The PN indicated that the resident's Primary Care Physician (PCP) was made aware of the episode. At approximately 4:15 p.m., the Resident had another seizure, and that appeared to be grand mal [seizure]. The PN revealed VS were BP 113/92, PR 44 bpm, R 30 bpm, oxygen saturation 87% (percent). Oxygen was placed on the Resident, and transport was arranged to the hospital while the Resident was being closely monitored by staff. Resident #2 was transported to the hospital at 5:00 p.m. The PN indicated that the PCP and residents' family members were notified. Further review of the PN showed no documented evidence that an RN and/or the NS was notified of the Resident's first seizure activity/CIC at 3:45 p.m. A review of the cellphone text messages (CTM) provided to the Surveyor by the PCP on [DATE] at 2:55 p.m. reflected that on [DATE], the following text was received from LPN #1, at 4:22 p.m. [Resident #2] had a seizure lasting about two minutes FYI [for your information], at 5:01 p.m., the PCP responded and asked the LPN Anymore? At 5:15 p.m., the LPN responded, Yes, sent [him/her] to ER [emergency room]. The Surveyor conducted a telephone interview with the PCP on [DATE] at 2:44 p.m.; the PCP stated that he was first notified of the seizure/CIC through text message on [DATE] at 4:22 p.m. The PCP stated that the facility is expected to call him immediately if a resident has a CIC. The PCP explained that timing is very important and that something went wrong. Review of the Transportation Company run sheet (TCRS) report, dated [DATE] at 4:28 p.m., the TCRS received a call from the facility and was dispatched for Unconscious/Fainting. The TCRS revealed the chief complaint was: Patient unresponsive, actively seizing. A second TCRS report, dated [DATE] at 4:29 p.m., revealed the TRCRS received a call at 4:29 p.m. and was dispatched for Convulsions/Seizure. The report further showed, PT [patient] is reported to have been seizing for 28 minutes as per staff at the facility. PT is noted to have stiff limbs and flickering eyes. PT is assessed and treated in [the] ambulance . A review of Resident #2's Hospital MR (HMR) dated [DATE] at 5:40 p.m. indicated that Resident #2 presented to the hospital in status epilepticus (A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes) and was seen immediately on presentation, intubated (insertion of a tube either through the mouth or nose and into the airway to aid with breathing, deliver anesthesia or medications, and bypass a blockage) for airway protection. A review of the EMPLOYEE WARNING REPORT (EWR), dated [DATE], written by the former Director of Nursing (DON), indicated that LPN #1 had a violation of misconduct and failed to perform her duty. The EWR further revealed the following: On [DATE] at 4:00 p.m., the Director of Nursing was notified by [Resident #1] that [Resident #2] needed help, the nurse [LPN #1] knew about it, and someone needed to check on her/him stat. The DON wrote on the EWR that she did not see anyone at the Nurse's station, and a CNA was sitting in a chair outside Resident #2's room. The CNA stated, She was watching the patient, who was actively having a tonic-clonic status epilepticus seizure. [LPN #1] was paged, and another CNA [QACNA] notified management that [LPN #1] had 'stepped out of the building to do something for her kids and would be right back' but asked her [CNA] to 'sit at the nurse station to wait for [RN #1]' which was the incoming Nurse. [LPN #1] did not notify nursing management that she was leaving the building at any time. There was no nursing coverage on the unit. The EWR further indicated that Resident #2 needed an immediate medical intervention, required oxygenation, and was sent to [ACH] for further evaluation and admitted to the ICU [intensive care unit]. The EWR indicated, [LPN #1] reported that [Resident #2] had a seizure at about 3:55 pm, and she left the building at exactly 4:00 pm .[LPN #1] further stated that she meant to call the nursing director [DON] to notify that she needed to leave the building but doesn't 'know what happened'. As a Licensed Practical Nurse at [facility], it is your duty to ensure that you make an effort to provide safe patient care to all patients and especially upon change in clinical condition. During this incident you showed failure to perform the duties of your job classification by knowingly leaving the facility after one of your assigned patients had a change in clinical condition and failure to notify your supervisor or management. Failure to provide safe patient care/conditions will result in disciplinary action up to and including termination. 2 DAY SUSPENSION to take place at this time. The EWR was signed by the former DON #1 on [DATE], and LPN #1 refused to sign the EWR. A review of LPN #1's statement, dated [DATE], revealed that on [DATE] at approximately 3:45 p.m., she was called by the QACNA in the Solarium because Resident #2 was having what appeared to be a petite mal seizure in his/her wheelchair. Resident #2 was transferred to bed by 3 CNAs (QACNA, CNA #2, and CNA #3). LPN #1 further indicated that immediately following the transfer, the patient [Resident #2] became more alert, talkative, and [her/his] usual argumentative self .I explained to [him/her that he/she] would need to stay in bed for the rest of the night and [he/she] should try to get some rest .At about 3:57 [p.m.]. I returned to the patient's room to check on [the Resident] again and observed [him/her] in bed with [his/her] eyes open .I returned to the desk, looked at my watch, and noted it was 3:59 [pm]. I picked up the desk phone to page a supervisor to inform them I'd be stepping out of the building when [QACNA] walked into my view. Distracted by [QACNA], I put the phone down and said to [QACNA], 'I need to step out. Would you sit here at the desk for a minute or two because [RN #1] should be here any second?' [QACNA] agreed and sat at the Nurse's station. On my way out of the building, I stopped in the lobby where I saw [LPN #2], a nursing supervisor, in the short A2 hallway .and I said to her, 'I am stepping out for a brief time. Do you need anything[?].' She said ok. I left the building and was back by 4:17 [pm] /4:18 [pm]. When I returned .they were sending [Resident #2] to the ER [emergency room] .I then went to check on the patient, who appeared to be having a seizure and had a non-rebreather. The EMTs eventually were on the unit, followed by the paramedics. They transferred [Resident #2] out at approximately 5 p.m. [5:00 p.m.] . The statement further revealed that on [DATE], at 2:15 p.m., DON #1 told LPN #1, .'you are here today because you left the building yesterday without telling anyone, left a patient in distress, and now [he/she] is in the hospital on a ventilator and will possibly die'. LPN #1 responded .that was not the truth, that the patient was NOT in distress, the patient was, in fact, stable, alert and her argumentative self. I also reminded her that I did NOT leave the building without telling 'anyone' and that I informed [QACNA] and was sure she was at the Nurse's station awaiting [RN #1's] arrival, which should have been within literally one or two minutes. I attempted to remind her about seeing [LPN #2] in the hallway, but she [DON #1] kept interrupting and would not give me much of an opportunity to speak. I also mentioned the patient has a long history of seizure disorder along with multiple other co-morbidities, and I had seen on Epic the patient was on a ventilator 'for sedation to properly medicate for seizure . LPN 1# explained in the statement, It is not uncommon practice to ask aid to sit at the desk while a nurse steps out. I also informed [LPN #2], the nursing supervisor, that I was stepping out .I can say with full certainty that there was absolutely NO DELAY in the care the patient received. In fact, when the patient [resident] was found to be having a second seizure, there was an aide sitting right outside the patient's [resident's] room watching [Resident #2]. I left the building at 3:59 p.m. with [QACNA] sitting at the desk and the patient alert and stable. There were [approximately] 6 other nurses in the building . Review of the investigation report (IR), conducted by the Administrator, dated [DATE]. The IR's conclusion was the nurse [LPN #1] had informed another nurse/nurse supervisor before stepping out of the building, that [LPN #1] put measures in place to keep watch of [Resident #2] by assigning an aide by the resident and instructing the aid to notify a nurse/nursing supervisor in case something happens to [Resident #2]. The IR did not indicate that LPN #1 informed LPN #2 and/or an RN of the Resident's first CIC before leaving the building. A review of the QACNA statement, dated [DATE], indicated, Around 3:35 p.m. I found [Resident #2] having a Seizure in the Solarium. I called [LPN #1] to come and check [Resident #2]. We put the Resident back to bed with the help of 3-11 [3:00 p.m. to 11:00 p.m.] aids .[LPN #1] checked [Resident #2] vitals, and [Resident #2] was talking at that time. [LPN #1] said vitals were good that's when we left the room. [CNA #2 and CNA #3] stay [stayed] with [Resident #2] .An aide stay [stayed] by the room. At that time, I went to the desk, and [LPN #1] asked me to stay and wait for [RN #1], which was around 4 p.m. [4:00 p.m.] . During an interview on [DATE] at 10:00 a.m., Resident #1 stated that on [DATE] at approximately 3:38 p.m. (unsure exact time), he/she found Resident #2 in the Solarium, breathing heavy, unresponsive, and right hand was dangling. Resident #1 further stated that he/she ran (with the rollator) to the Nurse's station and asked for help. According to Resident #1, QACNA and LPN #1 were at the Nurse's station, and Resident #1 notified them that Resident #2 was down. Call 911! Then, Resident #2 was transferred to bed. Resident #1 further stated that a few minutes later (unable to recall the time), he/she saw Resident #2's whole body shaking and immediately looked for help. Resident #1 further stated that he/she did not find staff at the Nurse's station; he/she went to the front to look for staff and found the former DON #1 in the dining room lobby and told her, [Resident #2] is down! According to Resident #1, the DON immediately went to see Resident #2. During an interview with QACNA on [DATE] at 12:22 p.m. The QACNA stated that she was at the Nurse's station with LPN #1 (who was on the phone) on [DATE] at approximately 3:30 p.m. to 3:40 p.m., Resident #1 came to the Nurse's station and reported that Resident #2 was down and needed help. The QACNA further stated that LPN #1 gestured to check Resident #2 in the Solarium. QACNA found Resident #2 sitting in a wheelchair, verbally unresponsive, leaning to the right side of the wheelchair. Resident #2 responded to sternal rub performed by QACNA. The QACNA immediately called the Receptionist to call LPN #1 STAT [immediately] for immediate assistance because the Resident was not responding fully. When LPN #1 responded, Resident #2 was verbally unresponsive. A few seconds later, Resident #2 started talking. According to the QACNA resident was transferred to his/her bed, and the LPN took the Resident's V/S. The QACNA stated that according to the LPN, VS was good, and there was no indication to call for a CODE. The QACNA left, and 2 CNAs stayed; the QACNA returned to the Nurse's station to continue her duty. The QACNA stated that LPN #1 checked on Resident #2 twice and said the VS were ok. A few minutes later, LPN #1 instructed QACNA to stay on the unit and wait until RN #1 arrived. LPN #1 then left the building. The QACNA checked on Resident #2 after LPN #1 left, while RN #1 did not arrive yet. The QACNA found Resident #2 in bed, quiet, looking straight but not verbally responsive. The QACNA immediately went to another wing (A2) to ask LPN #2 (3:00 p.m. -11:00 p.m. Nursing Supervisor) to check Resident #2. LPN #2 responded to the emergency along with a few licensed nurses. During an interview on [DATE] at 10:34 a.m. LPN #1 stated that on [DATE], she was at the Nurse's station with the QACNA when Resident #1 came to the Nurse's station. LPN #1 heard Resident #1 say, Something might be wrong with [Resident #2] in the Solarium. While on the phone with the pharmacy, LPN #1 instructed the QACNA to check on Resident #2. According to LPN #1, after a few seconds, she followed the QACNA to the Solarium. LPN #1 found Resident #2 in the Solarium sitting in the wheelchair, verbally unresponsive, head leaning down towards the right side, and Resident #2 looked different. The LPN further stated that the Resident was transferred to his/her bed with 3 CNAs (QACNA, CNA #2, and CNA #3). LPN #1 took Resident's VS. While performing VS, Resident #2 was fighting to get out of bed. The LPN further stated that she explained to the Resident that she/he had a seizure and needed to remain in bed for close monitoring. According to the LPN, I thought she/had a focal seizure that had a blank stare; I am not a doctor; I can't diagnose. The LPN further stated that when Resident #2 was being transferred to bed, Resident #2 was lethargic and did not verbally respond when called. LPN #1 stated a few minutes later. She instructed the QACNA to stay at the Nurse's station until RN #1 (Nurse from 4:00 p.m. to 12:00 p.m.) arrived. LPN #1 then left the unit, and on the way out, she saw the Nursing Supervisor (LPN #2), who told her, I have to step out for a minute. Do you need anything? LPN #2 responded, Fine, and left the building. LPN #1 confirmed that she did not endorse or report the Resident's CIC to the Nursing Supervisor or any facility staff because, according to LPN #1, the patient was ok to me, verbally and not in immediate danger to me, [Resident #2] went back immediately to normal. When I left, I told [QACNA] and [LPN #2] that I'm leaving. LPN #1 stated that she notified the PCP via text message. However, LPN #1 could not verify that the PCP was notified of the first CIC at approximately 3:45 p.m. LPN #1 confirmed that an LPN should report to an RN or the Resident's PCP to verify the assessment for any CIC. During an interview with the current Director of Nursing (DON #2) and the Administrator on [DATE] at 11:47 a.m., the DON stated that the standard of practice for CIC was for the LPN to evaluate the Resident's CIC, and LPN then reported to the RN to determine the CIC. The DON further stated that LPNs were not allowed to assess; the RN needed to verify and cosign the LPN's assessment. They both agreed that the facility's protocol for CIC was for the LPN to report to an RN. They further agreed that it was not their practice to leave a patient when there is CIC without reporting to the Nursing Supervisor. In addition, they also stated that the LPN should have asked another licensed nurse to monitor the CIC instead of a CNA. Review of the Licensed Practical Nurse job description, dated 4/2021, included under PRIMARY FUNCTIONS .7. Notes changes in condition of residents .Notifies Supervisor of findings . The facility's policy titled CHANGE OF CONDITION, dated 12/2020, indicated under POLICY: All staff members shall communicate any information about Resident status change to appropriate licensed personnel immediately upon observation. DEFINITIONS .Acute: a.) Sudden Onset b.) A marked change .Uncharacteristic: Any unusual a typical symptom that is not of the ordinary for a resident. PROCEDURE: 1. The Resident's change of condition shall be reported immediately to the nursing supervisor .6. Notification of Physician, time, and date (month, day, and year) are to be documented in the Nurse's notes. The licensed Nurse must speak directly to the Physician: you may not leave a message with the answering service or Receptionist. The Physician must call back .8. Serious conditions call for nursing assessment skills and expertise to move the Resident to acute care surroundings, then the Resident shall be transferred to an acute care hospital, emergency transport service. This decision shall be made by the nursing supervisor in the situation that the patient's condition is so acute that time does not permit waiting for the Physician's response. 9. Director of Nursing and Administrator are to be immediately notified of a serious change of condition .12. Any persistent or recurrent condition change shall be placed on the patient's care plan with appropriate approaches to care until the problem is resolved . The facility's policy titled Abuse Prevention and Prohibition Program, dated [DATE] is indicated under Policy I. Each Resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property . NJAC 8:39-13.1 (a) NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT#: NJ00164724 REF: F600IJ Based on interviews, review of medical records (MRs), and other pertinent facility documents on [DATE], [DATE], and [DATE], it was determined that the facility failed to follow the professional standards of nursing practice to a.) notify the Primacy Care Physician (PCP), b.) the policy titled, CHANGE OF CONDITION, and c.) the LICENSED PRACTICAL NURSE (LPN) job description. On [DATE] at approximately 3:45 p.m., the LPN left a resident (Resident #2) unattended and in the care of Certified Nursing Assistants (CNA) during seizure activity/change in condition (CIC). Resident #2's roommate (Resident #1) went to the Nurse's station and reported to the Nurse that something might be wrong with [Resident #2]. The Nurse in charge (LPN #1) instructed the Quality Assurance Certified Nursing Assistant (QACNA) to check Resident #2 in the Solarium. The QACNA found Resident #2 sitting in a wheelchair, verbally unresponsive and responded to a sternal rub performed by QACNA. The QACNA immediately called the Receptionist to call LPN #1 STAT [Immediately] for immediate assistance because the Resident was not responding fully. When LPN #1 responded, she observed Resident #2 was verbally unresponsive, leaning the head down to the right side and staring blankly. Resident #2 was then transferred to the bed by the QACNA, CNA #2, and CNA #3 and assessed by LPN #1, who identified the Resident as having a petite mal seizure lasting approx [approximately] 2 minutes. Resident #2 remained in bed, and LPN #1 instructed the QACNA to notify a nurse and or the Nursing Supervisor (NS) in case something happens to [Resident #2]. LPN #1 also assigned CNA #2 to remain outside the Resident's room to ensure that Resident #2 did not get out of bed. LPN #1 then left the building without reporting to a Registered Nurse (RN), the Director of Nursing (DON), and/or the NS of the Resident's seizure activity/CIC. In addition, LPN #1 instructed the QACNA to stay at the Nurse's station until the 4:00 p.m. - 12:00 a.m. nurse arrived. At Approximately 4:10 p.m., Resident #2 had another episode of a seizure /CIC; he/she was transferred to an Acute Care Hospital (ACH) and died on [DATE]. The facility's failure to immediately address Resident #2's seizure activity/CIC and notify the appropriate staff of the CIC posed a likelihood of serious harm to the health and wellbeing of Resident #2 and potentially all other residents assigned to LPN #1 in an Immediate Jeopardy (IJ) situation. The IJ was identified and reported to the facility on [DATE] at 7:14 p.m. The IJ began on [DATE] and continued until [DATE]. The facility provided an acceptable removal plan on [DATE]. On [DATE], the Surveyor returned to the facility to ensure the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating staff. The non-compliance remained on [DATE] for no actual harm with the potential for more than minimal harm that is not an IJ. This deficient practice was identified for 1 of 3 residents (Resident #2) and was evidenced by the following: Reference: New Jersey Board of Nursing Law 45:11-23, revised on [DATE]. 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 .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. The Surveyor conducted a telephone interview with the PCP on [DATE] at 2:44 p.m.; the PCP stated that he was first notified of the seizure/ CIC through text message on [DATE] at 4:22 p.m. The PCP stated that the facility is expected to call him immediately if a resident has a CIC. The PCP explained that timing is very important and that something went wrong. During an interview on [DATE] at 10:34 a.m. LPN #1 stated that on [DATE], she was at the Nurse's station with the QACNA when Resident #1 came to the Nurse's station. LPN #1 heard Resident #1 say, Something might be wrong with [Resident #2] in the Solarium. While on the phone with the pharmacy, LPN #1 instructed the QACNA to check on Resident #2. According to LPN #1, after a few seconds, she followed the QACNA to the Solarium. LPN #1 found Resident #2 in the Solarium sitting in the wheelchair, verbally unresponsive, head leaning down towards the right side, and Resident #2 looked different. The LPN further stated that the Resident was transferred to his/her bed with 3 CNAs (QACNA, CNA #2, and CNA #3). LPN #1 took Resident's VS. While performing VS, Resident #2 was fighting to get out of bed. The LPN further stated that she explained to the Resident that she/he had a seizure and needed to remain in bed for close monitoring. According to the LPN, I thought she/had a focal seizure that had a blank stare; I'm not a doctor; I can't diagnose. The LPN further stated that when Resident #2 was being transferred to bed, Resident #2 was lethargic and did not verbally respond when called. LPN #1 stated a few minutes later. She instructed the QACNA to stay at the Nurse's station until RN #1 (Nurse from 4:00 p.m. to 12:00 p.m.) arrived. LPN #1 then left the unit, and on the way out, she saw the NS (LPN #2) and told her, I have to step out for a minute. Do you need anything? LPN #2 responded, Fine, and left the building. LPN #1 confirmed that she did not endorse or report the Resident's seizure activity/CIC to the Nursing Supervisor or any facility staff because, according to LPN #1, the patient was ok to me, verbally and not in immediate danger to me, [Resident #2] went back immediately to normal. When I left, I told [QACNA] and [LPN #2] that I'm leaving. LPN #1 stated that she notified the PCP via text message. However, LPN #1 could not verify that the PCP was notified of the first seizure activity/CIC at approximately 3:45 p.m. LPN #1 confirmed that an LPN should report to an RN or the Resident's PCP to verify the assessment for any CIC. During an interview with the current DON (DON #2) and the Administrator on [DATE] at 11:47 a.m., the DON stated that the standard of practice for CIC was for the LPN to evaluate the Resident's CIC, and the LPN then reported to the RN to determine the CIC. The DON further stated that LPNs were not allowed to assess; the RN needed to verify and cosign the LPN's assessment. They both agreed that the facility's protocol for CIC was for the LPN to report to an RN. They further agreed that it was not their practice to leave a patient when there is a CIC without reporting to the NS. In addition, they also stated that the LPN should have asked another licensed nurse to monitor the CIC instead of a CNA. The facility's policy titled CHANGE OF CONDITION, dated 12/2020, indicated under POLICY: All staff members shall communicate any information about Resident status change to appropriate licensed personnel immediately upon observation. DEFINITIONS .Acute: a.) Sudden Onset b.) A marked change .Uncharacteristic: Any unusual a typical symptom that is not of the ordinary for a resident. PROCEDURE: 1. The Resident's change of condition shall be reported immediately to the nursing supervisor .6. Notification of Physician, time, and date (month, day, and year) are to be documented in the Nurse's notes. The licensed Nurse must speak directly to the Physician: you may not leave a message with the answering service or Receptionist. The Physician must call back .8. Serious conditions call for nursing assessment skills and expertise to move the Resident to acute care surroundings, then the Resident shall be transferred to an acute care hospital, emergency transport service. This decision shall be made by the nursing supervisor in the situation that the patient's condition is so acute that time does not permit waiting for the Physician's response. 9. Director of Nursing and Administrator are to be immediately notified of a serious change of condition .12. Any persistent or recurrent condition change shall be placed on the patient's care plan with appropriate approaches to care until the problem is resolved . NJAC 8:39-13.1 (a) NJAC 8:39-27.1 (a)