Careone At Wayne

Provide safe and appropriate respiratory care for a resident when needed.

Complaint #400262 Based on observation, interview, record review of medical records, and pertinent facility documentation, it was determined that the facility failed to ensure that the physician's orders were followed according to the standard of clinical practice.

This deficient practice was identified for one of the residents (Resident #3), who was reviewed for respiratory care.This deficient practice was evidenced by the following: On 10/29/25 at 9:46 AM, the surveyor observed Resident #3 in bed awake, alert, wearing a nasal cannula (NC) connected to the oxygen (O2) from a wall outlet (a device that supplies oxygen) at 3 (three) lpm (liters per minute). On 10/29/25 at 11:02 AM, the surveyor observed the resident in bed awake on O2 via NC at 3 lpm connected to the wall outlet. On the same day, the surveyor showed up at the Licensed Practical Nurse (LPN) Resident #2 O2 at 3 lpm.

The LPN stated that the oxygen order was 2 lpm, but the actual oxygen liters the resident is getting is above 2 lpm.

The LPN added that it is not supposed to be above 2 lpm, then the LPN adjusted the resident's liters of oxygen to 2 lpm. On 10/29/25 at 12:10 PM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #3, which revealed the following: A review of the admission Record (an admission summary) (AR) reflected that Resident #3 was admitted with diagnoses that included but were not limited to shortness of breath (SOB) and congestive heart failure (CHF - the heart cannot pump blood well enough to give the body a regular supply).

There was no Minimum Data Set (MDS) (an assessment tool used to facilitate the management of care) in the hybrid medical records for Resident #3 A review of the Order Summary Report (OSR) showed an active order for oxygen at 2 (two) lpm via nasal cannula continuously, every shift, with the start date of 10/29/25. A review of Resident #3's Care Plan (CP) report initiated on 10/28/25, focused on at-risk for respiratory impairment related to CHF.

Interventions included, but were not limited to, administering oxygen per physician order. On 10/29/25 at 1:16 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss the above concern; however, no further information was provided. A review of the facility policy titled Oxygen Administration, revision date on October 2010, revealed the following under Steps in the Procedure 8.

Turn on the oxygen.

Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. NJAC 8:39-25.2(c)3

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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