Every finding on record at Childrens Specialized Hospital Toms River

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure professional standards of practice for nutrition were implemented for a resident who required nutrition support via a gastrostomy (g-tube; surgical opening where a tube is placed in the stomach to provide nutrition bypassing chewing and swallowing) to ensure a.) an enteral feeding tube order included a rate per hour in which the formula was infused via a feeding pump for consistency to decrease potential complications and b.) a nutrition assessment was completed for a resident upon re-admission to the facility. This deficient practice was identified for 1 of 1 residents reviewed for tube feedings (Resident #5), and was evidenced by the following:On 3/23/26, the surveyor reviewed the medical record for Resident #5. A review of the face sheet (an admission summary) reflected that the resident was admitted to the facility with cerebral palsy (neurological disorder affecting movement, muscle tone, and posture caused by abnormal brain development or damage before, during, or shortly after birth). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/18/26, reflected that the resident had no speech, rarely understood or understands, and had highly impaired vision with no glasses. The MDS also revealed that the resident had upper and lower extremity impairment on both sides and received more than 51% of their total calories via a g-tube. A review of the physician's orders (PO) included the following PO's: A PO dated 8/19/25, for tube feeding bolus (a method for delivering nutrition through a feeding tube by a syringe either pushing or gravity to administer formula that generally lasts 15-20 minutes and done three to six times a day) five times a day at 2:00 AM, 5:00 AM, 10:00 AM, 4:00 PM, and 9:00 PM. A PO dated 11/18/25, to administer 130 milliliters (mL) of Neocate Splash (nutrition formula) with 150 mL of water for a total volume of 280 mL via a g-tube at 5:00 AM, 10:00 AM, 4:00 PM, and 9:00 PM. The order specified bolus feeding for a duration of three hours. The order also included to administer 90 mL of water at 2:00 AM. A review of the Care Plan (CP) included a focus area dated 5/14/25, for altered nutrition and hydration. Interventions included to administer tube feeding: Follow procedures for feeding: including assessment, flushing, and changing feeding equipment to optimize delivery. A review of the quarterly Nutrition assessment dated [DATE], included the resident received 130 mL of Neocate Splash plus 150 mL of water four times a day ran over three hours. The resident's weight has remained stable since last quarter which was appropriate, and their body mass index (BMI; measure of body fat based on height and weight) remained elevated, but it was not recommended to reduce their caloric intake to avoid the risk of nutrient deficiencies or skin breakdown.The resident's weight and tube feeding tolerance will continue to be monitored. A review of the resident's past three months of weights were as follows: 3/1/26: 56.54 pounds (lbs.)1/29/26: 55.66 lbs.12/1/25: 54.78 lbs. On 3/24/26 at 8:16 AM, the surveyor observed Resident #5 in their room in a wheelchair. The resident was alert but non-verbal. The surveyor observed a feeding pump (a medical device used to deliver precise amounts of liquid formula or nutrition into a patient's gastrointestinal tract (stomach or intestines) through a feeding tube that is set to a specific feeding rate (mL per hour) and volume). At that time, the Registered Nurse (RN #1) was in the resident's room, and informed the surveyor that she was an Agency nurse who was scheduled to accompany the resident to school that day. RN #1 stated that it was her first time assigned to the resident, but she was informed that the resident received tube feedings at a rate of 93 mL per hour for three hours via a g-tube. On 3/25/26 at 8:57 AM, the surveyor interviewed the Registered Dietitian (RD), who stated that she completed full nutrition assessments on residents every quarter. The RD stated that Resident #5 received nothing by mouth (NPO) and was administered Neocate Splash via a g-tube. The surveyor asked if the resident had a feeding pump, and the RD stated no, that the resident received gravity bolus feedings three times a day with a water flush at 2:00 AM. On 3/24/26 at 8:57 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who was Resident #5's assigned nurse. LPN #1 stated that the resident received all their medications and nutrition via a g-tube. LPN #1 stated that Neocate Splash was administered via a feeding pump. The surveyor asked what rate the feeding pump was set to, and LPN #1 stated that she would have to check. LPN #1 stated that the resident was not administered a morning feeding by her, that the nurse who accompanied the resident to school would provide the feeding. LPN #1 stated that the resident did not receive bolus feedings and that the resident tolerated their feedings. At that time, LPN #1 reviewed the resident's PO in the presence of the surveyor and stated that the order specified bolus which meant via a [feeding] pump. LPN #1 stated that the feeding lasted three hours so you divided the total volume administered by the duration of the feeding, so the rate should be 93 mL per hour. The surveyor asked if the order should specify the rate, and LPN #1 stated that generally their orders specified how many hours to run the feeding, and the nurse divided the hours to determine the rate. On 3/24/26 at 9:04 AM, the surveyor re-interviewed the RD, who stated that a bolus feeding was when formula was provided at an intermittent time. The RD stated that you could run a bolus feeding through a feeding pump, and it was not a gravity feed as stated previously. The surveyor asked what rate the formula feeding was administered at, and the RD stated that she would have to ask the nurse. The surveyor asked who was responsible for the resident's nutrition and accuracy of their feedings, and the RD acknowledged that she was. The surveyor asked what was the importance of the rate, and the RD stated it was the amount of formula administered per hour that was determined for the resident's tolerance. The RD acknowledged that the order should specify the rate, and the nurses should not be dividing the total volume of the feeding by the duration to determine the rate. At that time, the surveyor requested all nutrition assessments from the resident's admission in May of 2025. On 3/24/26 at 10:14 AM, the Informatics Nurse (IN), in the presence of the Director of Nursing (DON) and the RN Clinical Nurse Educator, questioned the surveyor which nutrition assessments they requested. The surveyor stated since the resident's admission in May of 2025. The IN stated that the resident was discharged from the facility in April of 2025 to the hospital, and the resident was re-admitted to the facility in May of 2025, and that the resident had a RD assessment in the hospital the day before being re-admitted to the facility. The IN continued that the facility did not conduct a nutrition assessment until August of 2025, which was their quarterly assessment. On 3/24/26 at 10:15 AM, the surveyor asked the DON and the RN Clinical Nurse Educator if the facility conducted assessments upon readmission to the facility, and the RN Clinical Nurse Educator stated that per the facility's policy, they would do a screening on the resident. The RN Clinical Nurse Educator stated the facility was unable to locate the resident's screening from their May 2025 admission. At that time, the surveyor gave the DON and the RN Clinical Nurse Educator the resident's PO and asked them to interpret the resident's feeding. The RN Clinical Nurse Educator stated that the resident was receiving a bolus feeding via a feeding pump with a total volume of 280 mL. The surveyor asked what the determined rate was, and the RN Clinical Nurse Educator stated that you would divide the total volume by the duration to determine the rate. The DON stated at that time that there was nowhere in the order to put the rate. The surveyor asked if the facility had the ability to add comments to the order, and the DON acknowledged that there was. On 3/24/26 at 11:05 AM, during a follow-up interview with the RD, stated assessments were completed on residents upon admission and re-admission. The RD stated that she completed a brief admission note to go over the diet order and then completed the assessment within seven days. The RD confirmed that the RD at the facility needed to complete the nutrition assessment to determine any changes since their last admission, and that you did not use a hospital assessment. The RD stated that she started at the facility in September of 2025, which was after Resident #5's re-admission. A review of the Nutrition Assessment completed by the Hospital RD, dated 5/12/25, included that the resident received 130 mL of Neocate Splash with 125 mL of water for a total of 255 mL four times a day at 6:00 AM, 11:00 AM, 4:00 PM, and 9:00 PM. The Hospital RD indicated that the feedings were bolus running via a feeding pump at a rate of 85 mL per hour for three hours. A review of the Pediatric History and Physical completed at the facility by Resident #5's Physician, dated 5/14/25, included the resident was re-admitted to the facility after a prolonged stay at the hospital for sepsis (the body's life-threatening response to an infection). The resident was now back at the facility with a new feeding regimen. Assessment and Plan.New feeding as outlined: mix 130 mL of Neocate Splash with 125 mL of water (total volume 255 mL). The feeds were to run over three hours at a rate of 85 mL per hour with two hours off between feeds. A review of the quarterly Nutrition assessment dated [DATE], included that the resident was admitted to the facility on [DATE], and was dependent on g-tube feedings for nutrition and hydration needs. The assessment recommended to change the resident's g-tube feedings to 130 mL of Neocate Splash plus 150 mL of water for a total volume of 280 mL ran over three hours at 5:00 AM, 10:00 AM, 4:00 PM, and 9:00 PM. The assessment did not include the rate at which the formula should be administered per hour. A review of the quarterly Nutrition assessment dated [DATE], included to continue with the g-tube feedings of 130 mL of Neocate Splash with 150 mL of water four times a day. The assessment did not include the rate the formula should be administered. A review of the quarterly Nutrition assessment dated [DATE], indicated to continue current g-tube regimen. The assessment did not include the rate per hour the feedings were administered at. On 3/24/26 at 12:00 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON and informed them of the concerns. No additional information was provided. A review of the facility's PC - Nutritional Screening Assessments and Monitoring of Care (Policy & Procedure), dated effective 1/23/25, included An Initial Nutrition Assessment will be completed by the RD within three days of admission for any patients screened at increased nutritional risk on the Nursing admission Assessment or during chart review. An Initial Nutrition Assessment will be completed by the RD within seven days of admission for any patient screened at potential risk on the chart review. A review of the facility's PC - Gastrostomy/Jejunostomy Management and Care policy dated effective 1/14/26, included Feeding/Medication Administration.Label feeding bags with patient identifiers, date/time and initial staff that hung it. If utilizing a feeding tube bag, label must have formula name and rate of infusion on it. NJAC 8:39-17.2(d); 27.1(a)

Based on observation, interview, and review of other facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 09/10/2024 at 07:50 AM, the surveyors observed the Director of Maintenance (DOM) in the kitchen area. The DOM had a mustache and beard. The DOM was not wearing a beard restraint. When interviewed at that time by the surveyor the DOM said while in the kitchen he should have on a beard restraint. On 09/10/2024 from 8:03 AM to 8:37 AM, the surveyors, accompanied by the Swing [NAME] (SC), observed the following: 1.) In the meat refrigerator there was a metal tier rack with twenty 3-ounce bowls of pears, 3 trays of 3-ounce bowls of gelatin, 1 tray of 3-ounce bowls of applesauce with no open or expiration date. There was a tray of fourteen plated brownies dated 09/06/2024. The SC said she was going to throw away the pears, gelatin, applesauce and brownies. The SC also said the items should be labeled and have an expiration date. 2.) In the meat refrigerator there was 1 case of frozen hot dogs. One bag was opened, exposed to air, and not labeled with an open or expiration date. At that time, the SC said she was going to throw the bag of exposed hotdogs away. 3.) In the produce / milk refrigerator there was a bag of unopened coleslaw with an expiration date of 08/23/2024. The SC said she was going to throw the coleslaw away. 4.) In the dry storage area, there was 15 loose coffee lids exposed to air. The SC said the coffee lids should not be exposed to air and she was going to throw them away. 5.) In the freezer, there was 1 bag of breaded nuggets that was opened and exposed to air. The bag was not labeled with an open or expiration date. The SC said she was going to throw the bag of breaded nuggets away. On 09/10/2024 at 8:40 AM during an interview with the surveyors, the Director of the Kitchen (DOK) said that the DOM should have worn a beard restraint while in the kitchen area. He also said metal tier racks should be labeled and dated. A review of the undated facility policy titled, Employee Sanitary Practices, revealed under number 1 that all employees shall wear hair restraints (hairnet, hat, and/or bead restraint) to prevent hair from contacting exposed food. A review of the undated facility policy titled, Labeling and Dating, revealed under procedure: 1.) That any newly opened perishable food items will have an Opened On date and a Use By date. Will be discarded after 7 days. 2.) That leftover cooked food products will have a Use By date and will be discarded after 3 days. 5.) That all foods are to be stored in an airtight manner and not exposed to open air. 6.) That food items will be discarded upon expiration. A review of the undated facility policy titled, Storage Areas, revealed under procedure number 13 that leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. A review of the undated facility policy titled, Storage Areas, revealed under procedure frozen foods that all foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. A review of the undated facility policy titled, Storage Areas, revealed under procedure number 5 that all foods are to be stored in an airtight manner and not exposed to open air. A review of the undated facility policy titled, Deliveries, revealed under procedure number 4 that perishable food will be properly covered, labeled, and dated. N.J.A.C 8:39-17.2 (g)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to provide a clean environment for 2 of 7 occupied resident rooms. The deficient practice was evidenced by the following: On 09/10/2024 at 09:41 AM during the initial tour, the surveyor entered room [ROOM NUMBER] which was occupied by residents. At that time, the surveyor observed an unpackaged, oral syringe on the floor, an unpackaged nutritional formula bag left on a bed occupied by a resident, and residue stains on the floor. On 09/11/2024 at 08:59 AM, the surveyor entered room [ROOM NUMBER]. At that time, the surveyor observed the closed-top trash bin partially open with disposable gowns visible over the brim of the bin. On 09/12/2024 at 08:53 AM, the surveyor entered room [ROOM NUMBER]. At that time, the surveyor observed a bedside table. The surveyor observed disposable gloves and two tissues left on top of the table. On the same date at 08:54, the surveyor entered room [ROOM NUMBER]. At that time, the surveyor observed the closed-top trash bin partially open with disposable gowns visible over the brim of the bin. On 09/12/2024 at 11:06 AM during an interview with the Environmental Services Director (ESD), the surveyor asked how often are trash cans emptied. The ESD replied, Each time they [Environmental Service Employees] visit the rooms. He also said that environmental service employees do not work overnight. Lastly, he said that rooms are cleaned twice daily. On the same date at 12:36 PM during an interview with the ESD, the surveyor asked who is responsible for cleanliness when Environmental Services leave for the day. The EVD replied, Shared responsibility. A review of the facility-provided policy titled, IC Cleaning and Disinfection of Room Following Discontinuation of Transmission Based Precautions dated 1/1/2024 revealed under, Policy that, To maintain a clean environment for patients/residents and minimize the risk of patient/resident and healthcare personnel exposure to potentially infectious microorganisms. The patient care environment throughout the facility will be maintained in a state of cleanliness that meets professional standards in order to protect patients/residents and healthcare personnel from potentially infectious microorganisms. S 8:39-31.4 (a)

Based on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to: a.) assure that a pressure relieving device was in place to prevent the development of a pressure ulcer b.) timely notify the physician regarding the resident change in skin condition consistent with professional standards of practice and c.) accurately document a skin assessment. This deficient practice was identified for 1 of 1 resident, (Resident #9) reviewed for pressure ulcer care and was evidenced by the following: A review of Resident #9's Admission Record indicated that the resident was admitted to the facility with diagnoses which included but was not limited to encephalopathy (a broad term for any brain disease that alters brain function or structure) and right distal femur fracture. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of a resident's care dated 04/05/23, indicated that Resident #9 had severe cognitive impairment and required total care with all aspects of activities of daily living. The MDS indicated that the resident was at risk for the development of pressure ulcers. The MDS further indicated that the facility was not utilizing pressure relieving devices for the resident's wheelchair or bed. The surveyor reviewed the undated Interdisciplinary Plan of Care (CP) which indicated that the resident was at high risk for impaired skin integrity. The CP did not include interventions such as an antipressure cushion for the resident's wheelchair to prevent the reoccurrence or development of a pressure ulcer. On 06/12/23 at 08:42 AM, the surveyor observed the resident sitting up in a wheelchair. The resident appeared to be sitting on a positioning cushion. The resident was not able to be interviewed due to decreased cognition and was not verbal. On 06/12/23 at 09:05 AM, the surveyor reviewed Resident #9's electronic medical record (EMR) and according to the physician order history on the EMR a treatment was ordered by the physician on 06/10/23 at 16:42 for saline/Mepilex application to a sacral wound. On 06/13/23 at 09:21 AM, the surveyor interviewed the Registered Nurse (RN #1) who stated that she had been employed in the facility for approximately [AGE] years. RN #1 stated that the Certified Nursing Assistant (CNA) reported to the nurse on 06/13/23 that Resident #9 had some redness on the left heel and that Physical Therapy (PT) was notified and adjusted the resident's boot. The RN then added that the resident had developed a stage 2 skin opening (pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis to include intact or ruptured blisters) on the sacral area and that the nursing staff was applying dressings to the area every 12 hours. She stated that the wound was discovered on 5/29/23. The RN showed the surveyor the Skin and Wound Assessment (SWA) sheet dated 06/13/23, which indicated that the wound was located on the resident's coccyx area and measured 0.2 centimeters (cm) x 0.2 cm. RN #1 further stated that two (2) nurses assessed that the wound was a stage 2 pressure area. She then stated that a skin assessment was completed for Resident #9 every 12 hours. RN #1 stated that the PT should have been notified to see if the wheelchair was the cause of the breakdown or if there was a positioning issue, but she was not sure if that was done. She then reviewed the SWA dated 05/29/23 and explained to the surveyor that the wound was discovered by RN #2 on 05/29/23 and provided the surveyor with RN #2's name. RN #1 then stated that according to the SWA the wound was not measured upon discovery, but that the wound should have been monitored and measured every 12 hours. She stated that the treatment was being administered every 12 hours. RN #1 could not explain to the surveyor why the physicians order was dated 06/10/23 when the wound was discovered on 05/29/23. On 06/13/23 at 09:41 AM, the surveyor interviewed the PT who stated that she had been employed by the facility for [AGE] years. The PT explained the process the occurred when residents in the facility developed wounds. The PT explained that when a wound was discovered, the nurse would measure the wound and a treatment would be ordered by the physician. The PT continued to explain that there was a team approach that happened to investigate the cause of the wound. She stated that some wounds were caused by mechanical issues, and some were caused by physical issues. She explained that when she was notified that any resident had developed a wound, she would look at seating to see if the chair was causing the issue or if the resident required extra cushioning such as an anti-pressure device (chair cushion used for treating or preventing pressure ulcers). She continued to add that the nurses would be responsible to find out if the resident needed a new mattress. She stated that she was made aware that Resident #9 developed a coccyx wound. She stated that the antipressure roho cushions that were currently in stock in the facility, were too big. She revealed that she was only told yesterday (06/12/23) that Resident #9 had a stage two coccyx wound and she explained that she needed to order the chair cushion. She indicated that she had not yet sent the email to order the cushion. On 06/13/23 at 10:04 AM, the PT provided the surveyor with a copy of an email dated 06/13/23 at 09:59 AM, that indicated that the PT attempted to contact a provider requesting the need for a low profile antipressure cushion to be delivered to the facility for Resident #9. On 06/13/23 at 10:10 AM, the surveyor interviewed the Registered Nurse/Assistant Nurse Manager (RN/ANM) who stated that she had been employed in the facility for 4 years. The RN/ANM explained to the surveyor what her responsibilities included. She explained that she acted as the Director of Nursing (DON) when DON was not available. She added that she made sure resident appointments were scheduled, organized the unit, and made sure that the unit was flowing right. She continued to explain that each shift nurse was responsible to monitor a wound's condition, assure that there were no signs and symptoms of infection and perform measurements of the wound. The RN/ANM stated that Resident #9's wound was not measured when the wound was discovered on 05/29/23 and that there was not a description of the wound documented on the SWA on 05/29/23. The RN/ANM also confirmed that there was not any documentation that the physician was notified at that time or that the responsible party was notified. She stated that she would have to investigate it and get back to the surveyor. On 06/13/23 at 10:18 AM, the surveyor interviewed the Registered Dietician (RD) who stated that she had been employed in the facility for [AGE] years and explained that if a resident developed an in-house pressure ulcer, then she should have been notified. She stated that she was notified of Resident #9's coccyx wound last Friday on 6/13/2023. She indicated that she was notified through the supervisor's report. She stated that she was very familiar with Resident #9 and would not be changing the resident's feeding and that the resident's nutritional needs were being met through the feeding tube. She continued to add that that she did not feel that the facility acquired wound was caused by malnutrition. She stated that the resident's formula was very high in protein and that his/her weight was stable. She stated that the wound could have been caused by other reasons such as positioning issues, however that was to be determined by the PT. On 06/13/23 at 11:45 AM, the surveyor interviewed the Director for Professional Development and Research who was also a Registered Nurse. She explained the facility process if a resident developed a facility acquired pressure ulcer. She indicated that two clinicians were to assess and stage the pressure ulcer and treatment was then ordered. She also stated that as soon as a pressure ulcer was identified that an intervention to prevent further deterioration of the skin should have been put in place as soon as possible. On 06/13/23 at 12:28, the RN/ANM provided the surveyor with copies of the resident's medical records to the surveyor for review. On 06/14/23 at 09:20 AM, the surveyor reviewed the SWA dated 05/29/23 which indicated that Resident #9 developed a stage 1 pressure area on the coccyx (near the buttocks). The surveyor did not observe that there were any measurements of the wound nor any physical description of the wound documented on the SWA. The surveyor then interviewed the Registered Nurse (RN #2) who discovered the wound. RN #2 stated that she was notified by a CNA on 5/29/23 that Resident #9 had a wound on the coccyx area. She stated that there was an area of skin on the coccyx that was just red and was not open. She stated that she notified the Registered Nurse/ Charge Nurse (RN/CN) and that together both RN #2 and the RN/CN assessed the wound and determined that the wound was a stage 1. She did admit to not measuring the wound and confirmed that she should have measured the wound so that there was a baseline. She added that she completed the Situation Background and Recommendation (SBAR) - Change in condition assessment and a wound assessment. She stated that she did not update the CP with interventions. She revealed that the resident did not have an anti-pressure device on his/her wheelchair at the time that the wound was discovered. She stated that she did not call the physician about the wound and that she was not sure who called the physician. She continued to explain that the nurses applied a treatment to the wound but did not obtain a physician's order until later. RN #2 could not explain why if a wound developed on 05/29/23, there was not a physician's treatment order until 06/10/23. She could not speak to the process regarding putting interventions in place that would have prevented further deterioration of the skin. RN#2 further stated that she had not implemented interventions since she has been working in the facility. On 06/14/23 at 09:40 AM, the surveyor attempted to telephone interview the RN Charge Nurse that assessed Resident #9's wound on 05/29/23 however there was no answer. The surveyor left a message. On 06/14/23 at 11:13 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she had been employed at the facility for eight years. The DON explained that if a pressure injury was discovered that two nurses were required to assess the wound, measure it and then stage the wound. The DON continued to explain that the nurses were to notify the provider (physician) to inform them that there was a change in the status of the resident's skin. The DON explained that the provider should have been notified so that the plan of care could have been edited and the physician could have provided additional orders. She then stated that if the wound was related to positioning or an orthotic that the resident wore, then the nurses would notify the PT for lower body and Occupational Therapist (OT) for upper body, to see if modifications had to be done to the orthotic or if any additional interventions needed to be obtained. She stated that the PT oversaw the rehabilitation technician build the resident's wheelchair. She stated that PT would recommend an anti-pressure cushion. She continued to explain that children grow and may need wheelchair modifications to accommodate growth. She stated that any changes in a resident's skin condition would be documented on the SWA. She continued to add the facility's SBAR form was a change in condition form that was formulated to be able to communicate a change in the resident's condition and to communicate recommendations. The DON reviewed the SBAR note that was completed on 05/29/23, regarding Resident #9's facility acquired pressure ulcer. She stated that the form was not complete to include that the parent or guardian was notified or that the physician was notified that the resident had a change in condition. The DON stated that the PT should have been notified the day that a new wound was discovered. The DON stated that the wound was a re-occurring wound. She stated that her expectation would be that the PT would have been notified about the resident's development of a wound within 24 hours. She stated that if the physician ordered an ointment to be applied to the wound, the facility would have been required to obtain a physician's order but since the treatment was only a dressing, the facility was not required to obtain a physician's order. The DON explained why the resident did not have an antipressure device on his/her wheelchair from 05/26/23 until 05/31/23. She explained that on 05/26/23 the resident came home from school with his/her chair cushion in a bag. She stated that the cushion had a strong odor, such as a bowel movement odor. She stated that the resident usually had a strong body odor. She explained that the cushion had to be cleaned and deodorized. She further revealed that while the cushion was being cleaned and deodorized, the facility did not have a replacement cushion to put onto the resident's chair. The resident developed a pressure area on 05/29/23 during the time that the antipressure cushion was not available. On 06/14/23 at 11:55 AM, the surveyor reviewed the PT LTC productivity minutes dated 05/31/23 at 16:00 hrs (04:00 PM) which indicated that the resident was without an anti-pressure cushion and was not sitting on a cushion from 05/26/23 until 05/31/23. On 06/15/23 at 08:10 AM, the surveyor observed the wound on Resident #9's coccyx area. The surveyor observed a very small pinpoint opening and the surrounding area slightly red. The DON stated that the area was a small layer of skin that the facility was being extra cautious of, so they treated it as a wound to prevent further skin breakdown. The DON further stated that it was a reoccurring skin issue that the resident had, so it was not necessary to call the physician and notify the physician of the open area at that time because the physician was already aware of it and that they were going to round with the physician the next day. On 06/15/23 at 10:30 AM, the DON stated that she was not disputing the surveyor findings and had no additional information to provide. The surveyor reviewed the facility policy, Pressure Injury Prevention and Management, dated 01/01/2023, which indicated that nursing, in collaboration with the healthcare team, would assess and manage skin integrity for all patients throughout their stay. The prevention procedure indicated that pressure relieving surfaces/specialty beds as clinically appropriate. Documentation of pressure injury prevention and pressure relieving devices and support surfaces (cushions, beds, boots, etc.). The policy also indicated that pressure injuries were assessed with each ordered dressing change and documentation should be as followed: Pressure ulcer description and size. The policy also indicated that the facility was to communicate to the provider, any new areas of skin breakdown and concern. Initiate appropriate nutritional referrals and notify the provider as soon as a pressure ulcer is identified. Patient and family education concerning pressure ulcer care and pressure injury prevention. NJAC 8:39-27.1(e)

Based on observation, interviews and review of facility documentation it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination, and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and was evidenced by the following: On [DATE] at 09:46 AM, in the presence of the Director of Nutritional Services (DNS), the surveyor toured the kitchen and observed the following: 1.) In the walk-in refrigerator #1, there was a rolling metal rack with a tray containing yellow cut squash that was uncovered and exposed to air. The DNS acknowledged the tray was uncovered and stated that it was important to make sure prepped foods were covered to protect from debris and contamination. 2.) In the walk-in freezer #2, on a metal rack, there was an opened 10 pound box marked beef [NAME] which contained an opened clear package of eight beef [NAME] that were wrapped with clear plastic wrap with no open or use by dates. The DNS acknowledged that he was unsure when the package was opened and stated that it was important to date the food items when they were opened to ensure they were not expired. 3.) In the dry storage room, there was half a loaf of brown sliced bread, the DNS identified the bread as raisin bread, that was wrapped in clear plastic wrap with no label or use by dates. The DNS acknowledged the bread was not wrapped correctly and stated that the package should have had an opened or use by date. 4.) In the kitchen there was a meat slicer that was covered with a dark plastic bag. The DNS stated that once the slicer was used that it was cleaned and covered with the plastic bag. The DNS removed the plastic bag and there was white and tan debris on the base and tan debris on the arm of the slicer which the DNS removed with his finger. The DNS acknowledged the debris and stated that it should not have been there and that it was important to keep the equipment clean for infection control. 5.) In the prep area there was one large box containing a roll of clear plastic wrap film that was opened, uncovered and exposed to air. There was one large box containing a roll of aluminum foil that was opened, uncovered and exposed to air. The DNS stated that the plastic wrap and the foil were used to cover food and acknowledged that it was important to keep them covered to avoid getting dust or debris on them. 6.) On a clean rack under a prep area there was a rack that contained one green plastic cutting board with a large amount of tan debris and black smudges. There was one white plastic cutting board with gouges, and black and brown debris. The DNS stated they were used for food prep and that they were cleaned and sanitized after each use. The DNS stated they were clean then moved the cutting boards to the dishwashing area. 7.) At the grill, there was a cook observed cooking hamburgers who had a moustache and beard stubble with no facial hair restraint. The cook acknowledged that he was not wearing a beard guard and that he probably should have been. The cook stated that it was important to keep all hair covered so that hair did not fall into the food. During an interview with the surveyor at that time, the DNS stated the hairnet policy included that everyone in the kitchen had to wear a hair restraint such as a hairnet or hat and that beard guards were to be worn for those with beards. When the surveyor inquired as to whether the cook should have been wearing a beard guard, the DNS stated, I suppose. On [DATE] at 12:39 PM, the surveyors met in the conference room with the Licensed Nursing Home Administrator and the Director of Nursing who were made aware of the kitchen observations. A review of the undated facility policy, General Food Preperation and Handeling [sic], revealed Procedure: 2. Food Storage, b. Food is covered for storage. 3. Food Preparation, e. cutting boards are washed and sanitized after each use. 5. Equipment, a. all food service equipment should be cleaned, sanitized, dried, and reassembled after each use. b. plastic-ware or dishware that has lost its glaze or is chipped or cracked must be disposed of. A review of the undated facility policy, Storage Areas, revealed Procedure: 8. c. Food should be dated as it is placed on the shelves. 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. 14. Refrigerated Food Storage: f. All foods should be covered, labeled and dated. 15. Frozen Foods: d. All foods should be covered, labeled and dated. A review of the undated facility document, Proper Hair Restraint, revealed, Food employees shall wear hair restraints, such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting: exposed food, clean equipment, and utensils. NJAC 8:,d+[DATE].2(g)

Based on observation, interview, and review of medical record it was determined that the facility failed to assure that 1 of 3 residents, (Resident #17) reviewed for respiratory care was administered a nebulizer (a medication delivery system for aerosolized inhaled medication) treatment appropriately. This deficient practice is evidenced by the following: A review of the Admission record reflected that Resident #17 was admitted in April of 2023 with diagnoses that included but were not limited to failure to thrive, tracheostomy (a surgical opening in the neck which allows air to fill the lungs) status, stridor (high pitched sound during breathing usually caused by an obstruction in the airway), paralysis of vocal cords and larynx, personal history of other diseases of the respiratory system, preterm newborn, and gestational age 36 completed weeks. A review of Long Term Care Orders, revealed a physician order for the medication, Albuterol Sulfate 2.5 mg/inhaled BID (twice a day) and Budesonide 0.25 mg/inhaled BID. A review of the paper Medication Administration Record (MAR) dated 06/13/23 -06/16/23 revealed an physician order dated 06/05/23, for Albuterol Sulfate 2.5 mg (milligram)/3 ml (milliliter) neb (nebule) inhaled BID SCH (scheduled) and Budesonide 0.25 mg/2 ml nebule inhaled BID SCH. A review of the June 2023 electronic MAR revealed that Albuterol Sulfate 2.5 mg inhaled was administered on 06/13/23 at 08:54 AM. The record also revealed that Budesonide 0.25 mg inhaled was administered on 06/13/23 at 08:54 AM. On 06/13/23 at 08:52 AM, Resident #17 was observed supine in bed with a tracheostomy intact and had an audible moist cough. On 06/13/23 at 08:53 AM, two staff members arrived at the resident's bedside with a medication cart. The surveyor interviewed the Licensed Practical Nurse (LPN) who stated she was the orientee and that the Registered Nurse (RN) was the orienter. The LPN approached the resident's bedside and the RN stood next to the end of the bed at the medication cart. The LPN suctioned the resident's trach and then attached a nebulizer, with a connected medication cup filled with clear liquid, to the tracheostomy (trach) collar and the other end attached to oxygen tubing. The LPN then placed the trach collar over the resident's trach. The trach collar was observed to have two green loose fitting elastic straps attached to each side of the collar. On 06/13/23 at 08:59 AM, the LPN and the RN left Resident #17's room with the medication cart and entered another room. The surveyor remained in the resident's room. On 06/13/23 at 09:02 AM, the surveyor observed Resident #17's trach collar connected to the nebulizer treatment with the trach collar resting on the resident's left shoulder. The trach collar was not covering the trach. On 06/13/23 at 09:04 AM, the surveyor observed Resident #17's trach collar connected to the nebulizer treatment with the trach collar resting on the resident's left shoulder. The trach collar was not covering the trach. The resident was holding the nebulizer in his/her hands. On 06/13/23 at 09:08 AM, the surveyor observed Resident #17's trach collar connected to the nebulizer treatment with the trach collar resting on the resident's left shoulder. The trach collar was not covering the trach. The resident was holding the nebulizer in his/her hands. On 06/13/23 at 09:11 AM, the LPN and the RN returned to Resident #17's bedside. At that time, the surveyor interviewed the LPN and the RN. The RN stated that it was the nurse's responsibility to administer the breathing treatments if there was no respiratory therapist working. The LPN stated the process for administering a nebulizer treatment was that the medication got added to the nebulizer medication cup which was connected to the trach collar and was also connected to the oxygen tubing. The surveyor inquired if the trach collar was in place over the trach when the nurses returned to the resident's room. The LPN stated, No, it was on the side, so I tightened it a bit more to keep it in place. The surveyor inquired as to how the nurse would have known how much medication was given if the trach collar was not covering the trach. The LPN stated she did not know and that she would tighten the green straps (that are connected to the trach collar) to keep the trach collar in place. The LPN further stated that it was important to ensure the collar was in proper position so that the resident received the proper dose of medication. On 06/13/23 at 09:16 AM, the surveyor interviewed the Assistant Unit Manager (AUM) who stated that it was the nurse's responsibility to administer nebulizer treatments when there was not a respiratory therapist working. The AUM acknowledged that the resident would not have received the full ordered medication dose if the trach collar was resting on his/her shoulder and that the collar would have needed to be closer to the trach. The AUM stated that it was important for the trach collar to have been secured and have stayed in place with the medication cup upright during the medication administration so that the resident received the physician ordered dose and that the nurse should have stayed at the bedside to ensure the collar stayed in place. On 06/13/23 at 12:14 PM, via phone the surveyor interviewed the Respiratory Therapist (RT) who stated that the RT would have administered respiratory treatments but that she worked 4:00 PM to 12:30 AM on Monday through Friday and that sometimes there were per diem (as needed) RTs from 06:00 AM until 10:00 AM. The RT stated that if no RT was working that it was the nurse's responsibility to administer nebulizer treatments. The RT stated that when a resident had a trach and was ordered a nebulizer treatment that the trach collar was positioned over the trach stoma (opening in neck.) The surveyor informed the RT of the nebulizer administration observation and the RT stated that the trach collar should not have been resting on the resident's shoulder and that she would have stayed and watched the resident and would not have left the room while the medication was being administered because it would not have been known how much medication the resident received. The RT further stated that it was important to ensure the trach collar was in place over the trach stoma when administering a nebulizer treatment so that the resident got the ordered medication. On 06/14/23 at 11:54 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the RT was primarily responsible for providing respiratory treatments but that the RTs were not available at all times so it would have been the nurse's responsibility to administer nebulizer treatments. The DON stated that the trach collar was like a bow tie and got positioned in front of the trach which could have been loosened or tightened with the connected elastic band. The surveyor informed the DON of the nebulizer administration observation and the DON stated that the trach collar should not have been resting on the resident's shoulder and that it was too loose and navigated to his/her shoulder and was not administering the nebulizer treatment to him/her. The DON further stated that it was important to make sure the trach collar was over the trach stoma when the nebulizer was administered because it was an inhaled treatment and it would have ensured the resident received the respiratory treatment. A review of the facility policy, PC-Aerosol Administration, effective date 1/1/2023, revealed, Procedure: 11. a. Initiate treatment using age and condition appropriate method. i. Age and ability to cooperate will affect treatment method used. b. Via trach collar: iv. Make sure trach collar is placed securely over tracheostomy tube. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to ensure an enteral feeding pump set (bags that are designed to be used with feeding pumps) were set up according to manufacturer's directions, to minimize the risk of contamination during the administration of enteral feedings for 2 of 10 sampled residents (Resident #14 and #18). This deficient practice was evidenced by the following: 1. During the initial tour on 7/27/21 at 10:14 AM, the surveyor observed a tube feeding pump set connected to Resident #18's gastrostomy tube (GT), (a tube inserted through the belly that brings nutrition directly to the stomach). The top cap of the pump set was opened and exposed the nutritional formula to potential contamination. On 7/29/21 at 08:02 AM, the surveyor observed the tube feeding pump set connected to resident #18's GT. The top cap of the pump set was opened and exposed the nutritional formula to potential contamination. On 8/2/21 at 09:21 AM, the surveyor observed Resident #18's pump set top cap was opened and exposed the nutritional formula to potential contamination during active tube feed administration. According to medical record Resident #18 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Annual Minimum Data Set (MDS), an assessment tool dated 05/12/21, revealed Resident #18 had a feeding tube. A review of the Long Term Care Orders dated 4/28/2021 revealed Resident #18 had the following tube feed orders: [MEDICATION(S)] [NAME] with Fiber, full strength, 35 milliliters (ml) per hour via GT, start drip 2100 (9:00 PM) and stop drip 0300 (3:00 PM). [MEDICATION(S)] [NAME] with Fiber, full strength, 120 ml twice daily via GT at 1000 and 1400 (2:00 PM) with 30 ml water to feeds. [MEDICATION(S)] [NAME] with Fiber, 2/3 strength, 120 ml via GT twice daily at 0600 and 1800 (6:00 PM). During an interview on 7/29/21 at 8:44 AM, Registered Nurse (RN #1) stated, The nutritional bag doesn't have to be closed but it is preferred. 2. On 7/29/2021 at 12:14 PM, Resident #14 was observed lying in bed receiving an enteral feeding. The surveyor observed the top cap on the enteral feeding bag opened and the nutritional formula was exposed to potential contamination. According to the quarterly MDS, dated [DATE] Resident #14 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further revealed in section K that resident #14 had a feeding tube. A review of the Long Term Care Orders for Resident #14 revealed the following physician orders: 5/4/2021: Vital 1.5 300 ml plus 120 ml water and 30 ml sugar free prostat (a liquid protein supplement) at 110 ml per hour via jejunostomy tube (JT), a soft plastic tube placed through the skin of the abdomen into the midsection of the small intestine, start drip at 2300 (11:00 PM) and end drip at 0300. In addition, Resident #18 has the following order, dated 7/22/2021: Vital 1.5 237 ml. Add 120 ml of water to each feed and run over 60 minutes at 0600, 1200, and 1800 (6:00 PM). Add 15 ml sugar free prostat to each feed. During an interview on 7/29/2021 at 12:25 PM, RN #2, who was assigned to care for Resident #18, stated the following: The bag should be capped as best practice during tube feed administration. The most concern would be that you do not want any contaminants in the feeding. You want it closed as best practice. During an interview on 8/3/2021 at 8:31 AM, with the Registered Dietitian (RD), the RD, when questioned concerning the administration of enteral feedings being delivered with the cap of the pump set open the RD responded, I would expect that the bag would be closed during administration of an enteral feeding but that is more of a nursing thing. When questioned whether the manufacturer directions for the enteral pump set setup should be followed the RD stated, Yes, I would follow the manufacturer's instructions. During an interview on 8/3/2021 at 9:31 AM, the Director of Nursing (DON), the DON stated, We are aware that the manufacturer recommends that the bag be closed and that is our policy. I think we aren't closing the bags appropriately and they are coming open. We are going to in-service our staff for consistency in this procedure. A review of the manufacturer Tube Feeding Pump Set directions revealed the following under Directions, 1. Fill bag with desired amount of formula. 2. Close and hang bag . NJAC 8:39-27.1 (a)

Based on observation, interview, medical record review and review of other facility documentation, it was determined that the facility failed to apply bilateral upper extremity splints based on the person-centered care plan for 1 of 2 residents reviewed for limited range of motion, (Resident #13). This deficient practice was evidenced by the following: On 07/27/21 at 10:48 AM, during the initial tour, the surveyor observed Resident #13 in the activities room with splints on his/her right and left arms. On 07/28/21 at 01:15 PM, the surveyor observed Resident #13 in his/her room seated in a wheelchair. There were no splints on his/her right and left arms at this time. On 7/29/21 at 12:31 PM, the surveyor observed Resident #13 in his/her room seated in a wheelchair. There were no splints on his/her right or left arms. According to the medical record, Resident #13 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Long Term Care orders with a date of 7/28/21, revealed under OT (Occupational Therapy) Modalities (treatments) Splinting. A review of Resident #13's care plan revealed under the problem section, Impaired joint mobility. Under the goals section, Maintain ROM (Range of motion), (Resident #13) will maintain PROM (Passive Range of Motion) through exercises and splinting as needed as noted by sustained PROM in LUE (Left upper extremity) wrist and hand. The interventions in the care plan included to Apply upper extremity splint. Type of splint: LUE White dorsal volar splint (splints that extend from the middle of the forearm to the top crease in the palm. RUE (Right upper extremity) Tan Ulnar splint. Wearing schedule: 0700-1000, 1200-1500 (3:00 PM), 1600-1900 (4:00 PM-7:00 PM). During an interview on 07/29/21 at 12:33 PM, Registered Nurse (RN #2) stated, they (the splints) should be on in response to the surveyor's question about why Resident #13 does not have the splints on. RN #1 confirmed the order for the splints in the Electronic Medical Record. At that time, RN #2 confirmed that Resident #13 did not have splints on his/her right and left arms. RN #2, with the help of another staff member, applied the splints to Resident #13. A review of a facility policy titled, Splinting Procedure with a reviewed date of 7/21, revealed under the Purpose statement, To Promote appropriate alignment of body/joints and to prevent loss of ROM. Under the Procedure section, A wearing schedule will be established by the therapist and communicated to the primary nurse and assistants, as well as Nursing will be responsible for monitoring splints and informing therapists if there are any problems. N.J.A.C 8:39-27.1 (a)

Based on record review and interviews, it was determined that the facility failed to create a plan for managing new admissions and readmissions in accordance with the Centers for the Disease Control (CDC)'s guidance for the isolation and monitoring of residents with an unknown COVID-19 status; and failed to utilize full personal protective equipment (PPE) for residents with an unknown COVID-19 status. This had the potential to affect 20 of 20 residents during the COVID-19 pandemic. This deficient practice was evidenced by the following: On 07/09/2020, a review was completed of a facility document titled, [DIAGNOSES REDACTED]-CoV-2/COVID-19 Pandemic Plan for Long Term Care, dated 06/23/2020. The document defined four different Cohorts related to COVID-19. Cohort 1 was for residents who tested positive for COVID-19. Cohort 2 was for residents who had tested negative but had been exposed to known positive residents. Roommates of symptomatic residents may already be exposed; it is generally not recommended to separate them given spatial limitations. Cohort 3 was noted to identify residents who had tested negative and had no exposure. Cohort 4 was used to identify residents with unknown COVID-19 status. Cohort 4 was noted to include residents that travel to an outside healthcare facility (which are not part of the RWJBH (Robert Woods Johnson Barnabas Health) system. This document also noted in the section titled, Transmission-Based Precautions, that all recommended COVID-19 PPE should be used for all residents who are: COVID PUI. PPE required included a N95 respirator, eye protection, gown, and gloves. On 07/09/2020 at 9:00 AM, an interview was completed with Nurse #1. Nurse #1 said new admissions or readmissions would be quarantined for 14 days and the staff would follow standard precautions (surgical masks and gloves). If it's an outside appointment that isn't part of RWJ, that would be Cohort 4, meaning the resident would be placed in Cohort 4 upon return. If they go to a RWJ facility, we don't feel like they have been exposed and they would just be monitored. Nurse #1 clarified that residents returning from an RWJ facility could be placed in any (including Cohort 3) room with other residents. On 07/09/2020 at 9:39 AM, an interview was completed with the Director of Nursing (DON) and the Administrator. The DON was asked what residents would be considered a Person Under Investigation (PUI) for COVID-19. She stated a PUI would be anyone who was being tested for symptoms. The provider would decide if a test was needed. It's not based on symptoms. When asked about classifying new admissions from facilities outside the RWJ network, the DON said that if the COVID-19 status was not known, the resident would be placed in Cohort 4. They are in their room for 14 days. They are on standard precautions. She clarified that the only PPE used would be a surgical mask. When asked about residents who were admitted from within the RWJ system, she stated, If they come from within our organization, we would know their status (COVID-19) and they wouldn't be required to have the 14-day isolation. We wouldn't do a repeat test on them. An interview was completed with the Director of Patient Safety (DPS) on 07/09/2020 at 12:10 PM. The DPS was asked about the procedure for new admissions. She stated that all new admissions were placed in Cohort 4 for 14 days. We prefer they are put in a private room (without roommates), but they may be in with other children. We use standard precautions (surgical masks) but pull a curtain for some environmental control. (Cohort 4) don't need full PPE unless they need something that may cause aerosolizing like suctioning. The DPS said that was the same practice in place before the COVID-19 pandemic. She also stated that if a resident went out to an appointment at an RWJ facility, We don't worry about exposure because of the process in place at the facilities. If a resident went to an out of network facility, they would be placed into Cohort 4 when they return, but no residents were tested unless they had symptoms. She also stated that any resident admitted from an RWJ facility would have already had a test before the admission. A follow up interview was completed with the Administrator on 07/09/2020 at 1:55 PM. The Administrator said the document they used to create their Pandemic Plan came from the State Department of Health. The document, says Cohort 4 is for new admissions if status is unknown. If they come from one of our centers, we know their status. He said those residents would be placed in Cohort 3 and that there was no guidance that new admissions would be considered PUI. An interview was completed with the Infection Preventionist (IP) on 07/09/2020 at 1:55 PM. The IP said when residents return from being out of the facility, or when they are admitted , no testing was done. We have confidence in the systems we (RWJBH) have. For residents who come from outside our system, we monitor them for 14 days and put them in a quarantine room or a room by themselves. The only PPE required are surgical masks. A review of the New Jersey Department of Health's document titled, Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities, dated 05/11/2020, indicates, When testing capacity is available and facility spacing permits, patients/residents should be organized into the following cohorts: .d) Cohort 4 - New or Re-admissions: This cohort consists of all persons from the community or other healthcare facilities whose COVID-19 status is unknown. This cohort serves as an observation area where persons remain for 14 days to monitor for symptoms that may be compatible with COVID-19. Furthermore, the document indicates, Regardless of cohort, all staff should adhere to Standard Precautions and any necessary Transmission-Based Precautions according to clinical presentation and diagnosis, when caring for any patients/residents. Full Transmission-Based Precautions and all recommended COVID-19 PPE should be used for all patients/residents who are: - COVID-19 PUI - Exposed to a COVID-19 HCP (healthcare personnel) PUI - Exposed to any COVID-19 positive person - On a wing/unit (or facility wide), regardless of presence of symptoms, when transmission is suspected or identified. According to the Centers for the Disease Control's guidance titled, Responding to Coronavirus (COVID-19) in Nursing Homes, dated 04/30/2020, indicated, Considerations for new admissions or readmissions to the facility, Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. - All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. - Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. -New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. NJAC: 8:39-13.1 (c)

Based on observation, interview and document review, it was determined that the facility failed to maintain 1.) kitchen equipment in a manner to minimize microbial growth and cross contamination, 2.) the nourishment room on the pediatric unit in a clean and sanitary manner, and 3.) the storage of bottles and equipment used to make pediatric nutrition formula in a manner to minimize microbial growth and cross contamination for 7 out of 7 residents who received on-site prepared nutrition formula. This deficient practice was evidenced by the following: On 09/13/19 at 8:28 AM, the surveyor, accompanied by the Dietary Director (DD), completed a tour of the kitchen and observed the following: A meat slicer was covered and identified as clean by the DD. There was food debris on the base and blade of the slicer. A large blender, identified as clean by the DD, was stored upright with the lid on. The lid was removed, and the blender was visibly wet inside. At 9:04 AM, the tour continued in the pediatric unit nourishment room and the following was observed: Two brushes identified as bottle cleaning brushes were soiled and stored directly on top of the sink. The two compartment sink, identified as being used in the bottle cleaning process, was visibly soiled throughout and contained a dark gelatinous type substance in and around both of the drains. The following was observed in a cabinet labeled, Formula Containers N Lids, and identified by the DD as containing clean formula containers: Nine, two-quart bottles. Two were visibly wet and all had a white residue inside the bottles. One, one-liter cup that was labeled with Resident #6's name, contained white residue and other debris inside. Four, one-quart bottles were visibly wet inside and three of the four bottles contained white residue inside. One, one-pint bottle contained residue inside. At 9:13 AM, the Administrator joined the tour. The Administrator and DD were interviewed regarding who was responsible for the cleanliness of the nourishment room. Neither provided information regarding the responsibility for the cleanliness of the nourishment room. At 9:36 AM the surveyor, Administrator and Director of Nursing (DON) observed the nourishment room. The DON confirmed that the formula containers are rinsed out in the sink that contained the debris. On 09/16/19 at 8:27 AM, the surveyor conducted a telephone interview with the Registered Dietitian, regarding the nourishment room. The RD stated the blender is used for pediatric formula preparation and that it should not have been stored wet. She also stated that the bottles should have been dry from being stored overnight and they should not have been wet. She further stated that some of the formulas are difficult to remove from the containers and the brushes were used to scrub the containers. She stated the brushes should have been put through the dish machine for cleaning and stored in the drawer, and not on top of the sink. Review of the undated Food Preparation Appliances policy indicated that small appliances (such as mixers and food processors) will be cleaned and sanitized after each use. The policy also revealed that the appliances should be air dried. Review of the Clinical Nutrition Services, Preparation of Formulas policy, dated revised 4/2019, revealed that all equipment reused for formula preparation is passed through a commercial dish machine and each blender is stored in a tightly knotted plastic bag. At 9:16 AM, the surveyor, in the presence of the survey team, interviewed the Administrator regarding the cleaning policy for the nourishment room. The Administrator stated it is sort of a blended policy between housekeeping and dietary and no specifics were provided. NJAC 8:39 17.2(g)

Based on observation, interview and record review, it was determined that the facility staff failed to follow the facility infection control policy for a resident on modified contact precautions. This deficient practice was identified for 1 of 2 residents reviewed for infections, Resident #6, and was evidenced by the following: On 09/11/19 at 12:46 PM, the surveyor observed a stop sign posted outside of Resident #6's room. The sign revealed that the resident was on Modified Contact Precautions. There were gloves, gowns and masks observed outside of the resident's room. The sign revealed that at bedside, a gown should be worn whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces, or equipment in close proximity to the patient. The sign indicated to don a gown upon entry into the resident's room or cubicle. When interviewed, the staff stated that the resident was currently at an off campus school. According to the Resident Registration Form and Interdisciplinary Plan of Care (IDPC), Resident #6 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), an assessment tool used to facilitate care dated 9/4/19, revealed that Resident #6 had a Brief Interview of Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. The Long Term Care orders revealed a Physician order, dated 03/28/19, for Modified Contact Precautions for [CONDITION(S)] (an antibiotic resistant organism). A Progress Note, dated 08/29/19 and signed by the Advanced Nurse Practitioner revealed Resident #6 had [CONDITION(S)] colonization of the nares (nostrils) and was on Modified Contact Precautions. On 09/12/19 at 2:29 PM, the surveyor interviewed the Behavior Analysts (BA) while positioned outside of the rear of the facility and awaiting the return of Resident #6 from school. The BA stated the resident was deaf and has a private nurse that accompanies the resident to and from school each day. The surveyor observed the mini van arrive back to the facility with Resident #6. The surveyor observed the BA walk to assist Resident #6. The surveyor observed the BA tie Resident #6's shoe and assist the resident off of the van along with the contracted nurse. The staff, including the contracted nurse were observed walking the resident into the facility. The BA was interviewed regarding any special precautions for the resident and she stated the the resident is on modified contact precautions only if he/she urinates, defecates or vomits and gloves and a gown are worn only when the resident is given medications. At 2:43 PM the surveyor interviewed the contracted nurse who accompanied the resident to and from school. The contract nurse stated that she assists the resident on and off the toilet while at school and she wore gloves during care. She further stated that she is not aware of any other precautions for the resident while at school or upon arrival back to the facility. On 09/13/19 at 2:40 PM, the surveyor observed Resident #6 arrive from school in a minivan. The BA and a Recreation Childlife Assistant (RCA) attended to the resident upon arrival in the minivan. The contract nurse was observed holding the Resident's hand and the BA and RCA provided close supervision for the resident while the resident walked into the building and toward the resident's room. A review of the Infection Control Precaution Guidelines Policy # IC-05, Effective Date: 9/07, Reviewed: 12/18, reflected that Modified Contact Precautions requires the following Personal Protective Equipment: a. Wear gloves whenever touching the patients intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). Don gloves upon entry into the room or cubicle. b. Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Additionally, the policy revealed that the duration for precautions for patients who are colonized or infected for MRDO's remained undefined. Colonization from [CONDITION(S)] can persist for may months and patients with colonized [CONDITION(S)] may have precautions discontinued when [CONDITION(S)] can no longer be recovered from the original site of infection/colonization and nares cultures are negative on three consecutive cultures obtained at least a wear apart. (Note: Be sure to order nasal culture for [CONDITION(S)], not [CONDITION(S)] screen.) On 09/12/19 at 1:24 PM, the surveyor, in the presence of the survey team, interviewed the facility Infection Preventionist (IP) by telephone, and in person, the Director of Patient Safety (DOPS). The IP stated the Modified Contact Precautions are used for patients that are allowed outside of their rooms and if a patient has [CONDITION(S)] in the nares, the patient will be placed on Modified Contact Precautions. She further stated that unless someone is providing direct care to a patient, they are not required to do anything when entering the room. When asked about the Modified Precaution Sign indicating that gloves must be worn upon entry into the room or cubicle, she stated gloves do not have to be worn when entering the room, although the sign indicated that gloves should be worn. She continued and stated the that gloves do not need to be worn unless there is direct contact with body fluids. She continued to state that the Modified Contact Precautions do not transfer for the children who attend school, although the sign, nor the policy does not reflect guidelines for children who regularly attend off campus activities. The DOPS stated there is a disconnect between the sign and what we should actually be doing. On 9/16/19 at 8:48 AM, the surveyor, in the presence of the survey team interviewed the Administrator, IP and Senior Regulatory and Accreditation Specialist (SRAS). The IP stated that Resident #6 has colonized [CONDITION(S)] of the nares and the current infection control policies have been approved by the infection control committee. She further stated that the current sign was not part of the approval process for the infection control policies. The surveyor requested cultures related to the MRDO for Resident #6. At 10:00 AM the surveyor, in the presence of the survey team and facility Administrator, interviewed the IP, who stated that there were no [CONDITION(S)] cultures available for the resident for two years due to the resident being on another antibiotic for acne. The Infection Prevention and Control Committee Meeting Minutes, dated 12/18/18, revealed the Policies for Review and Approval, included the IC-05 Infection Control Precautions Guideline with no changes indicated and the committee approved all. NJAC 8:39-19.1(b)

Based on observation, interview and record review, it was determined that the facility failed to consistently administer medications in accordance with the manufacturer's specifications, printed cautionary information and professional standards for medication administration. This deficient practice was identified for 2 of 5 residents reviewed for medication administration, Residents #11 and #12, as evidenced by the following: 1. During a medication pass observation of Resident #11 on 8/9/17 at 8:11 a.m., the surveyor observed the Registered Nurse (RN) prepare medications for the resident which included an asthma treatment of [REDACTED]. The surveyor observed that the RN did not rinse/clean the resident's mouth after the Flovent inhaler administration. On 8/9/17 at 8:11 a.m. the surveyor interviewed the RN. The RN confirmed the need to clean the resident's mouth with a wet sponge after each nebulizer/inhaler administration. Review of the resident's Medication Detail Sheet for the Fluticasone Propionate indicated to Rinse mouth after use to prevent fungal infection. On 8/9/17 at 11:00 a.m. the surveyor reviewed the 4/16 facility policy on Medication Administration Procedure - Aerolized Medication provided by the DON. The policy revealed to have patient rinse mouth or provide oral hygiene care if inhaled steroids were administered. Further review of the manufacturer's Full Prescribing information provided by the DON revealed that after inhalation, the resident should rinse his/her mouth with water to reduce the risk of oropharyngeal candidiasis (an infection of the mouth). On 8/10/17 at 10:38 a.m., the DON confirmed the need for providing oral hygiene/care with the use of a toothette (an oral sponge applicator) after each nebulizer/inhaler administration. 2. During a medication pass observation of Resident #12 on 8/9/17 at 8:50 a.m., the surveyor observed the RN prepare medications for the resident which included an asthma treatment of [REDACTED]. The surveyor observed that the RN did not rinse/clean the resident's mouth after the Flovent inhaler administration. On 8/9/17 at 8:11 a.m. the surveyor interviewed the RN. The RN confirmed the need to clean the resident's mouth with a wet sponge after each nebulizer/inhaler administration. Review of the resident's Medication Detail Sheet for the Fluticasone Propionate indicated to Rinse mouth after use to prevent fungal infection. On 8/9/17 at 11:00 a.m. the surveyor reviewed the 4/16 facility policy on Medication Administration Procedure - Aerolized Medication provided by the Director of Nursing (DON). The policy revealed to have patient rinse mouth or provide oral hygiene care if inhaled steroids were administered. Further review of the manufacturer's Full Prescribing information provided by the DON revealed that after inhalation, the resident should rinse his/her mouth with water to reduce the risk of oropharyngeal candidiasis (an infection of the mouth). On 8/10/17 at 10:38 a.m., the DON confirmed the need for providing oral hygiene/care with the use of toothette (an oral sponge applicator) after each nebulizer/inhaler administration. NJAC 8:39-29.4(b)2

C# NJ Based on interview, review of the medical records, and pertinent facility documentation on 10/3/16 and 10/21/16, it was determined that the facility failed to maintain 1:1 monitoring of Resident #1 and protect 1 of 4 sampled residents that was cognitively impaired (Resident #2) from physical abuse and/or potential further abuse from Resident #1. Resident #1, was in an agitated state during the beginning of the shift on 8/23/16, the Security Officer sat with Resident #1 until he calmed down and went to bed. Several hours later, Resident #1, who was Care Planned for 1:1 monitoring while awake, woke up in an agitated state and was able to enter Resident #2's room unattended and punch Resident #2 in the face/head four times. The lack of 1:1 monitoring of Resident #1 on 8/23/16, posed a serious and immediate threat to Resident #2 as well as all other residents, and was identified on 10/21/16 as an Immediate Jeopardy situation. The Immediate Jeopardy was identified as Past Non-Compliance (PNC) for 8/23/16, and corrected when the facility provided an acceptable plan of correction. This deficient practice is evidenced by the following: The surveyor reviewed the medical records on 10/3/16 and 10/21/16. 1. According to the Registration Form, Resident #1 was admitted to the facility on [DATE]. According to the Nursing Kardex, Resident #1 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), an assessment tool dated 8/23/16, indicated that the resident was cognitively intact and required extensive assistance with activities of daily living (ADLs). The Patient's Plan of Care-[MEDICAL CONDITION] dated 9/10/10, identified social and emotional deficits from poor impulse control. In addition, high risk for injury related to poor impulse control was identified on 9/10/10. Interventions included but were not limited to the following: security and all staff to follow hand-off procedures and to be sure awake patient had 1:1 supervision. Staff will continue to monitor Resident #1's behavior near children that leave often or have visitors often, and remain within arms' length when he was near other residents and staff. All 1:1's must be no further than one arms length from Resident #1, when passing a resident the 1:1 was located between the resident and Resident #1. On 12/4/15, the Patient's Plan of Care-[MEDICAL CONDITION] was updated to include implementation of AM 1:1 staff to engage (Resident #1) upon awaking till school (Monday-Friday) and all day till bed on weekends and when off from school. 2. According to the Registration Form, Resident #2 was admitted to the facility on [DATE]. According to the Nursing Kardex, Resident #2 had [DIAGNOSES REDACTED]. The annual MDS, an assessment tool dated 7/12/16, indicated that the resident was cognitively impaired and required extensive assistance with ADLs. 3. According to the Registration Form, Resident #3 was admitted to the facility on [DATE]. According to the Nursing Kardex, Resident #3 had [DIAGNOSES REDACTED]. The annual MDS, an assessment tool dated 7/12/16, indicated that the resident was cognitively impaired and required extensive assistance with ADLs. On 8/24/16. the New Jersey Department of Health (NJDOH) received a Reportable Event Record/Report (FRE) from the facility. The report indicated that on 8/23/16, Resident #1 entered Resident #2's room at approximately 6:30 a.m. and hit Resident #2 who was in bed asleep. The report further indicated that Certified Nursing Assistant (CNA #1) was in the room providing care to an unsampled resident. The curtain was pulled when the CNA #1 heard someone enter and looked and saw Resident #1 hitting Resident #2. CNA #1 immediately removed Resident #1 from the room and summoned for additional help. In addition, the report stated that Resident #1 had a behavioral plan and had an assigned 1:1 during his waking hours beginning at 7 a.m. until he went to school. On 8/23/16, Resident #1 got up early and left his room and entered Resident #2's room and hit him. Resident #1 was removed from the area and the Security Officer was summoned to stay with Resident #1 until the 1:1 arrived at 7 a.m. Review of all events in progress and team meeting held to identify action plan for change in his patterns. An attached detailed timeline summary indicated that on 8/23/16 at midnight, Resident #1 was agitated with the nurse, attempted to punch her, walked to the nurse's station and threw objects, communicated, Call mom. Resident #1 eloped from the nurse and attempted to leave the facility by walking down the hallway towards the exit. Resident #1 was redirected to remain in the building. Resident #1 continued to throw objects and attempted to hit staff. The nurse held Resident #1 in a basket hold for his and others' safety. Once released, Resident #1 punched the glass window. The Security Officer was called and Resident #1 was placed in a basket hold until he calmed down. Resident #1 remained sitting on the floor with the Security Officer for 20 minutes until he calmed down. The attached detailed timeline summary further indicated that on 8/23/16 at 5:45 a.m., Resident #1 was found out of his room and shaking Resident #3's crib. He may have put a toy in her crib. Resident #1 was removed and reprimanded. The Security Officer was called to monitor and to provide supervision. On 8/23/16 at 6:30 a.m., Resident #1 was found striking Resident #2 while Resident #2 was in bed. 4 consecutive strikes to Resident #2's head were reported. Resident #1 was removed from the room and the Security Officer was called to monitor and to provide supervision. The attached detailed timeline summary's Conclusion included the following: Ultimately this resident (Resident #1) has clearly expressed that he no longer wishes to be in this restrictive environment but wants to be able to live in a community setting or as close to one as possible. First choice of resident (Resident #1) is to be home with his parents. This information has been clearly shared with the family and with the state. It is our understanding that despite all interventions put into place, that these behaviors which put other residents at risk, and clearly demonstrate that this child's social needs and rights are not being met will continue to occur until these needs are met. Although (the facility) will continue to provide all care possible, the pediatric SCNF (Special Care Nursing Facility) setting does not allow for us to insure the safety of other residents from a resident with the will, ability and desire to act out his frustrations on being forced to stay in an inappropriate restrictive environment. The Progress Note (PN) dated 8/23/16, indicated that a patient care meeting was held to discuss the recent difficult behaviors exhibited by Resident #1 that escalate prior to a home visit and continue 1-2 days after he returned to the facility after the home visits. Last night (which was unusual, as (Resident #1) is not usually awake during the night.) Resident #1 left his room on three occasions, once knocking items off the counter and the other two occasions he entered other residents' rooms. The last time Resident #1 struck another resident, Resident #1 was restrained by the Security Officer until he calmed down, and staff assisted Resident #1 with getting ready for the day. Resident #1 attended school. The Behavioral Therapist has been working with Resident #1 and will continue, extra 1:1 time will be provided for (Resident #1) in the early mornings. Concern that home visits may becoming too much for Resident #1 to handle. This will be discussed further as analysis of the events continues. The Summary Comments Activities of Daily Living dated 8/23/16, indicated that Resident #1's family was made aware of Resident #1's increased aggressive behaviors exhibited the night before and this morning. Resident #1's family was made aware that increased 1:1 time was implemented and would begin at 5:00 a.m. Resident #1's family was also made aware that the Behaviorist would be monitoring the resident through out the night and would be working with the night shift staff on ways that they work with Resident #1; when he exhibited erratic behavior. The PN dated 8/23/16, indicated that Resident #2 had been slapped by another resident while still asleep. Resident #2 was reported to have been slapped on the head. According to the PN, Resident #2 did not wake up during or after the incident, and remained asleep. Resident #2 went to school on 8/23/16, and there were no reports of any negative outcomes by his 1:1 nurse or school teacher. The undated employee statement documented by the Security Officer indicated that on 8/22/16 between 11:00 p.m. and 11:15 p.m., Resident #1 came out of his room very agitated. Resident #1 kept saying that he wanted to call his mother. Resident #1 banged on the doors and was trying to leave the facility. Resident #1 threw things around in anger. Resident #1 finally calmed down and was assisted to bed with his feeding around 1:00 a.m. On 8/23/16 between 5:00 a.m. and 5:15 a.m., Resident #1 woke up in the same mood and continued in his agitated state. Resident #1 banged on the doors and threw everything off the nurses station. The Security Officer indicated in the statement that he stayed with Resident #1 until his assigned 1:1 arrived. An employee statement dated 8/23/16 documented by Registered Nurse (RN #1) indicated that RN #2 informed RN #1 that Resident #1 was awake and very agitated. Resident #1 tried to punch RN #2 and RN #2 was able to get out of harm's way. RN #1 documented that RN #1 approached the nursing station and observed Resident #1 banging on the nurse's station desk, then began throwing books, chairs, and any item within reach. Resident #1 then walked down the hallway toward the exit by the central bath and attempted to leave the facility. Resident #1 constantly signed, Call mom, angry. The Security Officer was notified via walkie talkie that the nurses needed assistance. Resident #1 was redirected back to the nurse's station but then went down the hallway to the facility's entrance and again tried to open the exit door. Resident #1 was redirected away from the door then grabbed the walkie talkie and tried to throw the walkie talkie at RN #2. RN #1 then placed Resident #1 in a basket hold. Resident #1 tried to scratch RN #1 during that time. When Resident #1 seemed calm, he was released from the basket hold. Resident #1 then headed toward the annex. Nursing staff and the Security Officer were with Resident #1. Resident #1 then punched the glass windows. The Security Officer then placed the resident in a basket hold. Resident #1 let out a long crying like sound and signed, Call mom angry. Resident #1 was placed in a light basket hold on the floor for approximately 20 minutes before he was calmed. Resident #1 was then released from the basket hold. Just after midnight he went to his bed and signed he wanted his GT (gastrostomy tube) feeding. Resident #1 slept until 5:40 a.m. Resident #1 was observed walking past room [ROOM NUMBER] as RN #1 and RN #2 were attending to an unsampled resident. A loud noise was heard and RN #2 observed Resident #1 violently shaking Resident #3's crib. RN #2 immediately directed Resident #2 away from the unsampled resident. Resident #1 then knocked over the formula that was stored in plastic containers on RN #2's medication cart. The formula containers opened and spilled all over the floor. The Security Officer was called again for assistance. The Security Officer sat next to Resident #1 by the computer. Resident #1 calmed down. Security had to leave the nursing unit to go to the outpatient area as part of his daily routine. Resident #1 was still engaged at the computer when the Security Officer left. The Certified Nurse Assistants (CNAs) were performing morning (a.m.) care and the nurses were administering medications. The oncoming CNAs were informed to be observant of Resident #1's behavior. The resident's doors were closed. At approximately 6:10 a.m., CNA #1 informed RN #2 that while performing a.m. care on an unsampled resident, CNA #1 heard footsteps in the room. CNA #1 looked past the curtain and observed Resident #1 hitting Resident #2 on the head 4 times. Resident #2 did not have any visual injuries and remained asleep. During these events multiple attempts to redirect (Resident #1) had failed. He was in an acute agitated stated and was extremely violent. Security was called again and stayed with (Resident #1) until his assigned 1:1 arrived. An employee statement dated 8/22/16-7:30 p.m.-7:30 a.m. documented by RN #2 indicated that around 5:45 a.m., RN #1 and RN #2 were tending to an unsampled resident. While in the unsampled resident's room, RN #2 heard noises coming from another resident's room and observed Resident #1 shaking Resident #3's crib. RN #1 and RN #2 immediately removed Resident #1 from Resident #3's room and told Resident #1 that he could not go into other residents' rooms. RN #1 and RN #2 then called the Security Officer and informed staff to keep a diligent eye out for Resident #1. At 6:00 a.m., CNA #1 informed RN #2 that while doing a.m. care on an unsampled resident, CNA #1 heard footsteps coming into the room. CNA #1 opened the curtain and observed Resident #1 strike Resident #2 four times on the head. CNA #1 removed Resident #1 from the room and notified RN #1 and RN #2. RN #1 and RN #2 assessed Resident #2; there were no injuries. RN #1 and RN #2 called the Security Officer again. An employee statement dated 8/23/16, indicated that CNA #2 also observed Resident #1 hit Resident #2 on his head. An interview was conducted by the surveyor on 10/3/16 at 2:52 p.m., with RN #1. RN #1 stated that at approximately 11:15 p.m., Resident #1 came to the nurses' station and started to throw things. RN #1 further stated that she called the Security Officer via the walkie talkie. RN #1 also stated that she was taught how to de-escalate the resident by placing the resident in a safety hold. RN #1 explained that Resident #1 slept until 5:40 a.m. RN #1 further explained that while RN #1 and RN #2 were providing care for an unsampled resident, RN #2 observed Resident #1 shaking Resident #3's crib. RN #1 explained that RN #2 stated that she saw a toy in Resident #3's crib that she did not recognize and thought maybe Resident #1 was trying to get the toy. RN #1 explained that RN #2 was able to redirect Resident #1 out of Resident #3's room. RN #1 also explained that the Security Officer sat with Resident #1 in the front of the nurses' station until Resident #1 calmed down. RN #1 stated that she believed that the Security Officer left to do rounds at approximately 5:55 a.m. RN #1 further stated that CNA #1 was providing care to an unsampled resident and observed Resident #1 punch Resident #2. RN #1 also stated when Resident #1 was asleep rounds were done every hour to an hour and a half. RN #1 explained when Resident #1 was awake, staff would keep a closer eye on the resident. RN #1 further explained that all staff had access to the care plans and were aware of the book that was located in Resident #1's room. Telephone interviews were conducted by the surveyor on 10/21/16 at 1:47 p.m. & 3:50 p.m., with the Security Officer. The Security Officer stated that he received a call between 11:15 p.m. and 11:30 p.m., stating that the nursing staff needed assistance with Resident #1 because the resident was still awake. The staff turned off his television. Resident #1 came out of his room and started banging on the trash cans and shoving the wheelchairs. Resident #1 swung at the nurse. The Security Officer further stated he told Resident #1 to calm down. Resident #1 was flinging items from the nurses' station. The Security Officer explained that he was trained to hug Resident #1 which calmed Resident #1 down. The Security Officer further explained that Resident #1 went into his room then came back out and tried to leave out of the exit door. Resident #1 started banging on the glass. The Security Officer stated that he and one of the nurses hugged Resident #1. The Security Officer further stated that one of the nurses checked to see if the resident had any medication ordered that would help him calm down. The Security Officer explained that it took 2-3 hours for Resident #1 to calm down. The Security Officer further explained that he sat outside of Resident #1's room until he fell asleep which was approximately 1-1.5 hour. The Security Officer stated that Resident #1 got up at approximately 5:30 a.m.-6:00 a.m. and started acting out again. Resident #1 knocked the tube feeding formula all over the floor and banged on the computer. Resident #1 typed on the computer that he wanted to go home. The Security Officer further stated that the nurses called him on the radio after Resident #1 shook Resident #3's crib. The Security Officer explained that the nurse asked him to keep an eye on Resident #1 until the CNAs or his 1:1 arrived on the unit. The Security Officer further explained by the time he arrived on the unit, Resident #1 had already slapped Resident #2. The Security Officer stated that when he arrived on the unit, Resident #1 was banging on the counter and the nurse was trying to get the resident to calm down. The Security Officer further stated that he did his last rounds between 6:00 a.m. and 6:30 a.m. A telephone interview was conducted by the surveyor on 10/21/16 at 2:14 p.m., with RN #2. The surveyor conducted a post-survey telephone interview on 11/1/16 at 3:34 p.m., with RN #2. RN #2 stated that around midnight, Resident #1 woke up very agitated and she tried to redirect him into his room. Resident #1 tried to hit RN #2 and was trying to pick up anything from the nurse's station to throw. RN #2 further stated that she called the Security Officer and RN #1 placed Resident #1 in a basket hold until the Security Officer arrived. RN #2 explained that Resident #1 calmed down and the Security Officer stayed with Resident #1. RN #2 further explained that while Resident #1 was with the Security Officer, he started hitting the wall and hitting himself in the head. The Security Officer placed Resident #1 in a basket hold until he calmed down, then Resident #1 went into his room. RN #2 stated that at approximately 4:30 a.m.-5:00 a.m., while providing care to an unsampled resident, she heard something and in the corner of her eyes, she observed Resident #1 shaking Resident #3's crib. RN #2 further stated that she saw a toy in Resident #3's crib that was not there before and was not sure if Resident #1 put it there and was trying to retrieve it. RN #2 stated that she redirected Resident #1 out of the room and called the Security Officer. RN #2 explained that the Security Officer sat with Resident #1 at the computer for approximately 45 minutes. RN #2 further explained that the Security Officer walked away to go unlock the doors. RN #2 stated that CNA #1 reported that she observed Resident #1 punch Resident #2 in the head 4 times. RN #2 further stated that the Security Officer was called again and stayed with the resident until the assigned 1:1 arrived. RN #2 explained that the nurses always had access to the behavior care plans. RN #2 further explained that the night shift staff were inserviced on how to handle Resident #1 if the situation occurred again. An interview was conducted by the surveyor on 10/21/16 at 2:30 p.m., with CNA #1. CNA #1 stated that while bathing an unsampled resident; she heard foot steps. CNA #1 further stated that she observed Resident #1 hit Resident #2 on his head 3 times. CNA #1 explained that Resident #1 in a knocking on the door manner hit Resident #2. CNA #1 further explained that she escorted Resident #1 to the hallway until the nurse came and called the Security Officer. Interviews were conducted by the surveyor on 10/21/16 at 12:15 p.m., 1:15 p.m., 2:57 p.m., & 5:02 p.m., with the Board Certified Behavior Analyst (BCBA). The BCBA stated that she met with Resident #1 two to three times per week. The BCBA further stated that all of the staff were trained on Resident #1's behavior care plan. The BCBA explained that she also taught the staff crisis intervention. The BCBA further explained that after the incident with Resident #1, Resident #2, and Resident #3, the assigned 1:1 for Resident #1 would begin at 5:00 a.m. The BCBA stated that she also taught the staff the primary restraint technique and the program was called handle with care. The BCBA also stated that safe techniques were used when a resident was a harm to himself or others to help the resident calm down. The BCBA further stated that only the security department and department heads were trained on handle with care; and was only used as a last resort. The BCBA explained that she met with the Security Officer after the incident but could not recall if she told him that he should have stayed with Resident #1 after the first incident with Resident #3 and did not have any documentation indicating such. The surveyor conducted interviews on 10/3/16 at 11:10 a.m., 2:15 p.m. and on 10/21/16 at 3:00 p.m., with the Nurse Manager (NM). The NM stated that Resident #1 was ambulatory, walked into Resident #2's room while Resident #2 was in the bed and hit Resident #2 on his face. The NM also stated that CNA #1 immediately took Resident #1 out of the room. The NM further stated that all staff were trained on how to protect themselves and the other children. The NM explained that all of the staff were aware of Resident #1's individualized care plan and that all shifts had access to the individualized care plan. The NM further explained that directions on how to handle Resident #1 was kept in a book. The NM also explained that after the incident, 1:1 hours were added to the mornings because previously, the 1:1 was with resident in the evening. The NM stated after the incident, stop signs were put on the the other residents' doors to prevent Resident #1 from entering their rooms. The NM also stated that all staff were trained in self defense and when the BCBA started working at the facility; she specifically did training for Resident #1. The NM further stated that Resident #1 had never acted out at night; until this incident. The NM explained that the basket hold was a therapeutic protective hold in which the staff member would stand behind the resident's back, the hands were placed behind the resident's back. The NM further explained that the staff member would place their arms around the resident then ease the resident to the floor. The NM also explained that the basket hold was used as a last resort. The NM stated that it was unclear what Resident #1 was doing when he shook Resident #3's crib. The NM further stated that Resident #1 was monitored every 30-40 minutes when he was not with his assigned 1:1. The NM also stated that staff followed Resident #1 then notified security after Resident #1 shook Resident #3's crib. The NM explained that the Security Officer stayed with Resident #1 until he went to bed. I guess they left and he got back out. The NM also explained that Resident #1's care plan and behavioral care plans were updated; and any updates were communicated to the staff. An interview was conducted by the surveyor on 10/21/16 at 4:23 p.m., with the Administrator. The Administrator stated that the Security Officer should have signed off Resident #1 to another physical employee after the incident with Resident #3. CNA #2 was not available for interview. The facility policy titled, Child Abuse, Protection From included but was not limited to: All patients have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion neglect and misappropriation of property. The PNC Immediate Jeopardy for 8/23/16, was corrected on 10/21/16, when the facility implemented the following: 1. Resident #2 and Resident #3 were assessed for injury and no injury was found. 2. All residents have the potential to be affected by the behavior of Resident #1. 3. Immediate team assessment and risk reduction plan- a. Adjustment of schedules immediately to insure supervision of resident 24 hours/day until bed alarm was delivered and implemented. b. Education for the security team that resident can not be left without direct supervision (Content-hand off, documentation of handoff and time, and resident's status at the time of handoff). c. Behavioral plan-Resident #1 updated and communicated in daily meetings-twice daily at 7:30 a.m. and 3:00 p.m. Education of all staff with both electronic sign off and in person meetings to acknowledge understanding of 24 hour supervision, observation of team for understanding and compliance. 4. Actions to insure deficient practice is being corrected: a. Administrator and Nurse Manager will provide report of events and actions to Long Term Care Quality Assurance quarterly meetings and monthly Safety Committee. Events reported are tracked and reviewed by the Violence Prevention Committee 10 times per year with the Administrator or designee (Nurse Manager) participation. b. Ongoing review of Resident #1 behaviors and plan during quarterly Patient Care Meeting with updates documented. NJAC 8:39-4.1(a)5

Based on observation in the facility, it was determined that the facility failed to ensure the appropriate handling and storage of the canister scoopers for Powdered supplements and bringing medication carts in and out of resident rooms. These deficient practices were found in 2 of 2 medication carts as evidenced by: On 12/20/13 at 10:29 a.m. the surveyor inspected the 2 medication carts located in the facility. Cart #1 contained Resource [MEDICATION NAME] Powder 8 oz canister, [MEDICATION NAME] Powder 8 oz. canister, [MEDICATION NAME] Powder 12.3 oz. canister, Duocal Powder 14 oz. canister and a Nutrisource Powder 7.2 oz. canister. All had the measuring scoop contained within the canisters. Cart #2 contained two [MEDICATION NAME] Powder 8 oz. canisters and a Duocal Powder 14 oz. canister with scoopers found within the canister. Multi-use scoopers should not be stored within the powder canister as to prevent hand contamination of the powder by the handled scooper. On 12/20/13 from 9:19 a.m. to 1:25 p.m. during the medication pass the surveyor observed 2 Registered Nurses (RN) administer 25 medications to 12 residents. During the medication passage both RNs entered each resident's room with the medication cart possibly transferring contaminations from room to room. Medication carts should be kept outside of resident's rooms as to prevent cross contamination between resident's rooms. NJAC 8:39 - 19.1(b)

Based on observation, interview and record review, it was determined that the facility failed: to monitor for expired medications and to provide a double locked storage area for refrigerated narcotics. This deficient practice was evidenced as follows: On 12/26/13 at 10:29 a.m. the surveyor, in the presence of a unit Registered Nurse (RN), inspected the refrigerator located within the medication room. The surveyor observed an opened multi dose vial of Tuberculin Purified Protein Derivative (PPD) with a documented opening date of 10/10/13. As per the Centers for Disease Control and Prevention (CDC) Standard Precautions, once opened or accessed the PPD vial should be dated and discarded within 28 days. This vial should have been discarded after 11/7/13. The surveyor also observed an opened 5ml multi dose vial of Polio Virus Vaccine Inactivated with a documented opening date of 3/5/13. As per CDC Standard Precautions, once opened or accessed the vial should be dated and discarded within 28 days. The vial should have been discarded after 3/31/13. On 12/26/13 at 12 p.m., the facility Administrator supplied the surveyor the Medication Regimen Review dated 12/11/13. The report supplied by the facility Consultant Pharmacist stated " Remove Tubersol vial opened 10/10/13---expires 30 days after opening." On 12/26/13 at 10:32 a.m. the surveyor, in the presence of a unit Registered Nurse (RN), inspected the removable, unlocked narcotic lock box located in the medication room's unlocked refrigerator. Three bottles of control substance liquid Lorazepam (Ativan) 2 milligrams per milliliter and a 1ml vial of injectable Lorazepam were stored in the unlocked narcotic box. Security for the storage of refrigerated controlled substances included a separately locked, permanently affixed compartment within a double locked area. The facility administrator informed the surveyor that the nurses could not find the key for the narcotic lock box. N.J.A.C. 8:39-29.4(g)

Based on observation, interview and record review it was determined that the facility failed to provide accurate administration for Schedule 4 Controlled Substance dispensed for a specific individual and administered to another resident. This deficient practice was identified in 5 of 7 residents reviewed who received controlled drugs, Resident #2, #9, #11, #12 and #13 as evidenced by the following: On 12/26/13 at 1:25 p.m. during medication passage the surveyor observed the Registered Nurse (RN) administering Valium to Resident #13. The Valium is concentrated at 1mg per 1 ml. The nurse administered 5 mg of Valium to Resident #13 from a bottle of Valium that was prescribed for Resident #11. The RN told the surveyor "this is how we do it." On 12/26/13 at 2:08 p.m. the surveyor interviewed another RN who stated "If we run out we borrow". On 12/26/13 at 2:15 p.m. the surveyor reviewed the Valium 5mg / 5ml Liquid Controlled Substance Disposition Record for Residents # 2, #9, #11 and #12. Resident #2's Valium Disposition Record documented 3 entries, 12/25/13 for 7 ml at 6:00 a.m., 2 ml at 12:00 p.m. and 7 ml at 6:00 p.m. as being borrowed for another resident. Resident #9's Valium Disposition Record documented 1 entry dated 12/25/13 that 7 mls was "borrowed" for another resident. Resident #11's Valium Disposition Record documented 2 entries dated 12/25/13 for 3 ml at 8:00 a.m. and 12/26/13 for 3 ml at 12:07 as " borrowed " for another resident. Resident #12's Valium Disposition Record documented that on 12/26/13 2 doses, one for 7 ml and the second for 4 ml had been "borrowed" for another resident. NJAC 8:39-19.2(4)

Based on observation, interview and record review, it was determined that the facility failed to ensure that all professional nursing staff performed their duties in accordance with accepted standards of clinical practices. This breach in professional standards affected 1 of 3 residents (Resident #11) reviewed during the medication pass and was observed with 1 of 3 nurses also observed during the medication pass on 11/22/11. This deficient practice was evidenced by the following: During the medication pass that was conducted on 11/22/11 at 8:45 a.m., the surveyor observed a Registered Nurse (RN) administer 250 cubic centimeters (cc) of [MEDICATION NAME] HN, via gastrostomy tube, to Resident #11. The RN administered the 250 cc of the [MEDICATION NAME] HN from 8:45 a.m. through 8:48 a.m. According to the electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s order to receive 240 cc of [MEDICATION NAME] HN over a time span of 30 minutes, via gastrostomy tube, at 8 a.m., 11 a.m. and 2 p.m. When interviewed at 8:48 a.m., the RN stated that Resident #11 would be late for school if she administered the [MEDICATION NAME] HN over 30 minutes. NJAC 8:39-27.1

Based on observation, interview and review of data provided by the facility, it was determined that the facility failed to provide adequate and efficient housekeeping on the nursing unit and the recreation therapy room that was utilized by the pediatric residents of the Long Term Care unit. This deficient practice was evidenced by the following: The following was observed, by the surveyor beginning at 1:00 p.m. on 11/21/11: 1. The storage room next to resident room 106 had a buildup of dust and dirt in the corners and the floor/wall junctures behind the entrance door. This room was used to store resident equipment, such as stand-up positioners and portable dental equipment. 2. The wall by the sink and behind the trashcan in the ante-room shared by resident rooms 107 and 108 was soiled with spillage. There was a buildup of dust and debris at the floor/wall junctures behind the doors of the 2 resident rooms. The laundry cart that was stored in this room was also soiled. 3. The floor/wall juncture around the perimeter of resident room 107 had a buildup of dust and debris especially in the area under the light switch. 4. Resident room 108 had a buildup of dust and debris in the corner of the floor under the light switches. 5. The footboard to the bed in resident room 108 was soiled with drippage. In addition, 1 of the 4 chest of drawers in the room was missing a drawer. 6. There were cobwebs in the recessed base of the closets located in resident room 104. 7. The closet, located next to the sink in resident room 103, was soiled with drippage. 8. The floor/wall juncture located behind the entrance doors to resident rooms 101 and 100 had a buildup of dust and debris. 9. The wall next to the sink in resident room 102 was heavily soiled with drippage under the wall mounted soap dispenser. 10. The floor/wall juncture throughout this large room was soiled with a buildup of dust, dirt and debris especially under "cabinet 9." The threshold to the door leading the outside of the building from this room was heavily soiled with ground-in dirt. The wall next to the microwave was heavily soiled with drippage. 11. The nutrition room floor was soiled with spillage and a buildup of dust, dirt and debris especially at the floor/wall junctures. The corner at the cove base located behind the entrance door to this room and behind the large trashcan had a heavy buildup of dust, dirt and debris. Except for the large storage room located next to resident room 106, the same observations were made of the above listed areas by the surveyor, the Administrator and the Housekeeping Director on 11/22/11 beginning at 9:45 a.m. According to data provided by the Housekeeping Director on 11/22/11 at 10:45 a.m., all walls and vertical surfaces, especially by trashcans and light switches, should be cleaned daily. In addition, the entire floor of the rooms should be dust mopped daily especially at the corners and along the baseboards. NJAC 8:39-31.4(a)