Every finding on record at Complete Care at Park Place LLC

Based on observation, interviews, and facility document review, the facility failed to ensure personal protective equipment (PPE) was worn by laundry staff in one of one laundry rooms while sorting soiled resident clothing and bed linens. This had the potential to infect the staff and/or residents with pathogens which could potentially lead to the development of infectious diseases.Findings include:During an observation conducted with the Infection Preventionist (IP) on 03/13/26 at 9:42 AM, upon entrance to the laundry room, the Laundry Aide was observed reaching into a soiled container of linens and loading them into the washing machine. The Laundry Aide wore disposable gloves but did not wear a protective gown. During the observation, the Laundry Aide stated that he/she had forgotten to don (put on) a protective gown prior to handling the soiled items. At 9:44 AM, The Director of Environmental Services (DES) entered the area and confirmed the Laundry Aide was required to don a protective gown since this was a potential infection control issue. The IP stated that the Laundry Aide should have been wearing a gown, as the staff member was handling soiled linens and resident clothing, which constituted an infection control concern.During an interview on 03/13/26 at 10:04 AM, the Director of Nursing (DON) stated it was his/her expectation that laundry staff don gowns and gloves prior to handling soiled items since this could spread infection for the workers and others.Review of an undated document provided by the facility titled Sorting Soiled Linens, indicated, . The laundry room must have a process in place to effectively sort soiled linen without cross contaminating clean linen . This requires employees to use proper PPE . NJAC 8:39-19.4

Based on observation, interview, and document review, the facility failed to maintain a safe, clean, comfortable, and homelike environment on the memory care unit. Specifically, the floor in the dining/activity area was observed to be sticky. Additionally, a large table surface was visibly dirty. The sticky floor posed a potential risk for residents who ambulate, as it could contribute to loss of balance of falls. The unclean condition of the table had the potential to attract pests. Findings include:During an observation conducted on 03/10/26 at 10:35 AM of the memory care unit's main dining/activity room, there were multiple staff and residents in the area participating in activities. The floor was observed to be dull and sticky. There was a rectangular table that faced the back wall and cabinets. The table's surface was visibly smudged, contained fingerprints, and had large areas of dry, raised substance. The observation ended at 12:10 PM. During an observation conducted on 03/10/26 at 1:52 PM, the memory care's dining/activity room had a small group of residents who were participating in an activity with staff in the area. The floor was sticky. The rectangular table that faced the back wall and cabinets was soiled with fingerprints, smudges, and a thick, dry raised substance. The observation ended at 3:58 PM. During an observation conducted on 03/11/26 at 8:36 AM, the memory care's main dining/activity room had a few residents waiting for breakfast. The floor was still sticky. The rectangular table still had fingerprints, smudges and a thick dried, raised substance on it. No residents were served their breakfast meal on this table. The observation ended shortly after observing the breakfast meal being served and eaten by the residents. During an observation conducted on 03/11/26 at 12:00 PM, the memory care's dining/activity area had a few residents waiting for the lunch meal. The floor continued to be sticky. There were a few residents sitting next to the rectangular table. In addition, there were three unknown residents and visitors sitting at this table. The Activity Aide (AA) 1 stated that he/she noticed the soiled rectangular table and would alert a staff member to clean it off. AA1 stated that housekeeping typically cleaned the area. On 03/11/26 at 12:16 PM, the floor technician arrived and donned (put on) gloves, sprayed the table and was able to effectively clean off the fingerprints, smudges, and the dried substance. The floor technician verified the condition of the soiled table. One of the two visitors who wanted to remain anonymous stated that the sticky floors were from using too many chemicals and stated he/she used to work in a nursing home. The second visitor began to stand up and attempted to walk away from the rectangular table, and his/her shoes stuck to the floor. On 03/11/26 at 12:45 PM, the Administrator entered the unit and walked through the dining/activity room. The Administrator stated that his/her shoes were stuck to the floor. During an interview on 03/11/26 at 12:58 PM, the Housekeeper stated he/she cleaned the memory care's dining/activity area. The Account Manager, from another facility, stated that the cleaner that the facility used had a neutralizer which was to prevent the floor from being sticky. The Account Manager confirmed that the dining/activity floor was sticky. During an interview conducted on 03/11/26 at 2:07 PM, the Director of Environmental Services (DES) stated that the Housekeeper arrives at 7:00 AM each morning and swept and then washed the dining/activity floor. During the interview, the facility provided a document titled Garden or Terrace for the 7:00 AM to 3:00 PM shift, which failed to contain evidence of the cleaning schedule for the memory unit's dining/activity area. During an interview on 03/12/26 at 12:03 PM, the Regional District Manager for the facility's housekeeping company stated that they were able to identify the cause of the sticky dining/activity floor. The Regional District Manager stated that the chemical used to wash the floor needed re-calibration. Review of a document provided by the facility titled Ecolab dated 03/12/26, indicated that the floor chemical dispenser was out of alignment and required replacement and calibration. The document confirmed that the floor was sticky. NJAC 8:39-4.1(a)(11)NJAC 8:39-31.4(a)(f)

Based on record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that a comprehensive Minimum Data Set (MDS) assessment was completed accurately to reflect post-traumatic stress disorder (PTSD) for one of four residents (R87) reviewed for mood/behavior related to PTSD in the sample of 25 residents. This failure had the potential to affect the care planning and provision of needed services.Findings include:Review of R87's Face Sheet located in resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included PTSD. Review of R87's Hospital Notes dated 01/28/26 located in the EMR under the Misc tab revealed a diagnosis of PTSD effective 11/2024. Review of R87's admission MDS with an Assessment Reference Date (ARD) of 01/28/26 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Further review revealed no active diagnosis of PTSD indicated. Review of R87's Diagnosis tab of the EMR dated 02/05/26 revealed a diagnosis of PTSD. During an interview on 03/13/26 at 9:47 AM, the Minimum Data Set Coordinator (MDSC) stated the PTSD diagnosis should have come across on the diagnosis list, but the diagnosis was not entered into the EMR's diagnosis tab until 02/05/26, and somehow it was missed. It should have been indicated on the admission MDS. During an interview on 03/13/26 at 10:05 AM, the Director of Nursing (DON) stated that he/she expected MDS assessments to be completed accurately. Review of the Resident Assessment Instrument (RAI) User's Manual, dated 10/01/25 and located at https://www.cms.gov/files/document/final-mds-3-0-rai-manual-v1-20-1-october-2025.pdf revealed, The following indicators may assist assessors in determining whether a diagnosis should be coded as active in the MDS. There may be specific documentation in the medical record by a physician, nurse practitioner, physician assistant, or clinical nurse specialist of active diagnosis . Specific documentation may be found in . hospital discharge summary . NJAC 8:39-33.2(d)

Based on record review, interview, and policy review, the facility failed to ensure the baseline care plan included information necessary to meet the care needs for one of two sampled residents (Resident (R) 91) reviewed for dialysis.Specifically, the baseline care plan did not address peritoneal dialysis (PD). This failure had the potential to result in staff lacking the necessary guidance to provide effective care and meet the resident's needs. Findings include:Review of R91's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed R91 was admitted to the facility on [DATE] with diagnoses that includes end stage renal disease (ESRD). Review of R91's Physician Orders, located in the EMR under the Orders tab, reflected an order, dated 02/27/26, for, Peritoneal dialysis: Exchange frequency: Q [every] 4 Hours. Exchange volume: 2L [liters] Dialysate: 2.5% Dianeal [sterile solution used for dialysis]. Instill PD Fluid over: 20mins [minutes]. PD fluids drain time: 20Mins. Continue with . Home prescription with a cycler [portable machine used for dialysis] . Patient uses a combination of 2.5% and 1.5% bags. (usually 2 green and 1 yellow bag). Every evening shift for PD. The Baseline Care Plan, located in the EMR under the Assessments tab, dated 02/27/26, failed to include the presence of peritoneal dialysis and interventions to implement for care.During an interview on 03/12/26 at 1:45 PM, Licensed Practical Nurse (LPN) 3 stated, The nurse responsible for the admission does the baseline care plan, or sometimes the unit manager. I'll be honest, I don't know. I have to look it up since I don't usually work the times we get the admissions.During an interview on 3/12/26 at 1:50 PM, LPN4 stated, I believe the supervisor does [the baseline care plans], but it may fall onto the unit manager. I'm not real sure since they are kind of new. Yes, I believe peritoneal dialysis should be included on it [the baseline care plan].During an interview on 03/12/26 at 4:48 PM, the Director of Nursing (DON) stated, The supervisor or nurse would write it, [the baseline care plan] and we would look at it the next morning. The staff on the 7AM to 3PM shift don't get many admissions. Just uncertain as to why it was missed.Review of the facility's policy titled, Care Plans- Baseline, updated on 10/2019, revealed, To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the Resident's immediate care needs . NJAC 8:39-11.2

Based on record review, interview, review of Resident Assessment Instrument (RAI) User's Manual, and policy review, the facility failed to develop person-centered, comprehensive care plans with measurable goals and interventions for two residents (Resident (R) 13 and R87) reviewed for care plans out of a sample of 25 residents. The failure placed R13 at risk for skin breakdown due to incomplete and/or inconsistent care to prevent pressure ulcers and placed R87 at risk for compromised emotional stability and impaired daily functioning related to a diagnosis of Post Traumatic Stress Disorder (PTSD).Findings include: 1. Review of R13's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident on 09/01/23. Review of R13's EMR titled annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/25, located under the MDS tab indicated that the staff could not determine a Brief Interview for Mental Status (BIMS) score for the resident. The resident was identified to be at risk for the development of pressure ulcers. Review of the Care Area Assessment (CAA) indicated that the resident triggered for pressure ulcers and directed the staff to develop a care plan. Review of R13's EMR titled Care Plan located under the Care Plan tab failed to contain evidence that the facility developed a care plan for pressure ulcers. During an interview conducted on 03/12/26 at 11:21 AM, the MDS Coordinator (MDSC) stated that if an area triggers under the CAA, and directs staff to develop a care plan, then staff were to develop a care plan from the area that was triggered. The MDSC confirmed that there was no care plan for R13 being at risk for the development of pressure ulcers. During an interview conducted on 03/12/26 at 4:47 PM, the Director of Nursing (DON) stated if the CAA triggered a care area and directed staff to develop a care plan, he/she would expect that this would be done. The DON stated it was important to develop an appropriate care plan since this was a guide for a resident's care. Review of the Resident Assessment Instrument (RAI) User's Manual, dated 10/25, located at www.cms.gov/files/document/final-mds-3-0-rai-manual-v1-20-1-october-2025.pdf,indicated . The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA (Care Area Assessment) process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers . After completing the MDS and CAA portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems. Subsequently, the IDT [Interdisciplinary Team] must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths, problems, and needs . 2. Review of R87's admission Record located in resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included PTSD. Review of R87's admission MDS with an ARD of 01/28/26 and located in the resident's EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R87's Care Plan dated 01/28/26 and located in the residents' EMR under the Care Plan tab revealed the resident was at risk for PTSD; however, there were no interventions in place for staff to be aware of potential stressors or triggers. During an interview on 03/12/26 at 1:59 PM, the Social Services Director (SSD) stated when a resident is admitted with a diagnosis of PTSD that it was discussed during the clinical meetings and morning support. He/she said that that specific diagnosis stays in the back of his/her mind as someone with trauma, but sometimes the residents did not tell him/her what their trauma was. She said R87 should have been care planned for PTSD, and he/she was unsure why it was missed. During an interview on 03/13/26 at 10:05 AM, the DON stated that R87 would not discuss what his/her trauma was or potential triggers or stressors. The DON stated there was no documentation in the resident's medical record that staff had attempted to discuss R87's PTSD with him/her, and there should have been. During an interview on 03/13/26 at 11:10 AM, R87 stated he/she had no issues with discussing his/her past trauma and that he/she saw psych providers regularly. R87 stated he/she had spoken with the SSD, but no staff had asked him/her about potential triggers or stressors. Review of the facility's policy titled, Comprehensive Care Plans, dated 06/01/25, revealed, . 'Trauma-informed care' is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. NJAC 8:39-11.2 (e) thru (i) NJAC 8:39-27.1(a)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents received services to maintain or improve their activities of daily living (ADLs) for one of one resident (Resident (R) 19) reviewed for ADLs out of a sample size of 25 residents.Specifically, R19 was not properly assessed by the facility's interdisciplinary team prior to the staff altering the method of meal consumption by placing pureed food and thickened liquids into a plastic cup for the resident to consume.This had the potential for the resident to experience a decline in functioning. Findings include:1. Review of R19's electronic medical record (EMR) titled admission Record located under the Profile tab indicated that the facility admitted the resident on 12/13/24. Review of R19's EMR titled Care Plan located under the Care Plan tab dated 05/27/25, indicated that the resident required verbal cues during mealtimes provided by one staff member. There was no direction to provide the resident with a plastic cup to consume his/her meals. Review of R19's EMR titled physician Orders located under the Orders tab dated 07/29/25, indicated that the resident was to be provided with a pureed meal with nectar thick liquids. There were no other written orders that directed staff to use a plastic cup to allow the resident to consume his/her meals. Review of R19's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/26, located under the MDS tab indicated that the staff could not determine the resident's Brief Interview for Mental Status (BIMS) score. The resident had no impairment of bilateral upper body extremity function. R19 required supervision or touch assistance with eating. Review of R19's EMR titled dietary Progress Notes dated 01/06/26, located under the Prog (Progress) Notes tab indicated that the resident was losing weight, and this was to be expected since the resident received hospice services. There was no mention that the resident required his/her meals to be taken by drinking it out of a plastic cup. During an observation conducted on 03/10/26 at 12:30 PM, R19 was pulled up to a table. Certified Nurse Aide (CNA) 3, a hospice staff member assigned to the resident, had the resident's tray in front of R19. CNA3 placed the resident's pureed food in a plastic cup and then poured thickened liquids into the cup and stirred the contents. The resident picked up the cup and drank it. An interview took place at 12:47 PM, and CNA3 stated that the resident consumed his/her meals better with the food being placed in a cup instead of him/her assisting the resident with the meal. The meal ticket was provided during this interview. The meal ticket failed to direct the staff to pour the resident's pureed meal into a cup.During an observation conducted on 03/11/26 at 9:29 AM, CNA3 was present in R19's room and assisted the roommate of R19 with his/her meal during the interview. R19's tray was not sitting in front of him/her. R19's breakfast meal was 100 percent consumed. CNA3 confirmed that he/she poured R19's pureed breakfast meal into the plastic cup for the resident to be able to feed himself/herself. During an interview on 03/11/26 at 3:14 PM, the Regional Registered Dietician (RD) 2 stated he/she reviewed R19's clinical records and there was no note that would indicate that the resident was assessed to have his/her meal poured in a plastic cup. During an interview conducted on 03/12/26 at 11:15 AM, the Director of Rehabilitation (DOR) and the Speech Therapist (ST) stated that there was no prior assessment in place for R19 for the resident to use a plastic cup to ingest his/her meals. During an interview conducted on 03/12/26 at 4:47 PM, the Director of Nursing (DON) stated it was his/her expectation that for a resident to drink his/her meals from a cup, an assessment should be in place to identify the benefit, and it should then be care planned. Review of a facility policy titled, Activities of Daily Living (ADLs), dated 06/01/25, indicated, . The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable . NJAC 8:39-27.1(a)

Based on observations, record review, and interviews, the facility failed to administer oxygen in accordance with physician orders, document oxygen use, and change oxygen tubing for one of two residents (Resident (R) 87) reviewed for oxygen therapy out of a total of 25 sampled residents. This failure had the potential to place the resident at risk for adverse outcomes related to improper oxygen administration, including hyperoxia, a condition in which cells, tissues, and organs are exposed to an excessive level of oxygen. Findings include:Review of R87's Face Sheet located in resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE], with diagnoses which included unspecified asthma.Review of R87's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/28/26 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R87's Care Plan dated 01/28/26 and located in the resident's EMR under the Care Plan tab revealed there were no interventions in place for oxygen use.Review of R87's Physician Orders located under the Resident tab in the EMR indicated an order dated 01/29/26, for Oxygen: Administer oxygen (O2) via nasal cannula as needed for SOB [shortness of breath]/low O2 at: 2 [two] liters/minute [liters per minute] . There was no order to change the oxygen tubing.Review of the Medication Administration Record (MAR) dated March 2026 and located under the Orders tab revealed no documentation that oxygen was administered to R87.During observations on 03/11/26 at 12:35 PM and 03/12/26 at 10:46 AM, R87 was lying in bed with the oxygen concentrator approximately two feet from the left side of the bed administering oxygen at three liters per minute via nasal cannula. Further review revealed the tubing was undated. During an interview and observation on 03/12/26 at 10:46 AM, Licensed Practical Nurse (LPN) 3 confirmed R87's oxygen concentrator setting and stated, It is on three liters right now. LPN3 stated that he/she did not document on the MAR that R87 was using oxygen. LPN3 also confirmed the tubing was undated and stated he/she was not sure if the tubing had been changed; the night shift was responsible for that. During an interview on 03/13/26 at 10:05 AM, the Director of Nursing (DON) stated he/she expected the oxygen flow to be set at the correct amount or a revised order to be obtained for three liters per minute. The DON also stated staff should indicate as needed (PRN) oxygen use on the MAR, and the tubing should be changed and dated. No policy was provided. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure that, prior to the installation of bed rails, alternative measures were attempted, discussions regarding the risks versus benefits were documented, and signed informed consent was obtained for one of four residents (Resident (R) 108) reviewed for bed rails out of 25 sampled residents. The failure to complete these required steps before bed rail installation increased the potential risk for resident entrapment or for bed rails to be used as restraints. Findings include: Review of R108's admission Record in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE], with diagnoses of repeated falls and muscle weakness.Review of R108's Side Rail Assessment Screening located under Assessments tab in the EMR, dated 03/04/26, revealed no indication if bed/side rails would be used or not used. Further review revealed no documentation of risk versus benefits or signed informed consent. Review of R108's Care Plan located under the Care Plan tab of the EMR, dated 03/05/26, revealed no care plan for bed/side rail use. Review of R108's Physician Orders located under the Orders tab in the EMR, dated 03/10/26, revealed no order for bed/side rail use.Review of R108's 5-day Minimum Data Set (MDS) assessment under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/11/26 revealed a Brief Interview for Mental Status (BIMS), score of 15 out of 15 indicating intact cognition. Observations on 03/10/26 at 1:44 PM and on 03/11/26 at 3:10 PM, revealed R108 in bed with a side rail up on the right side. During an interview on 03/11/26 at 3:10 PM, Licensed Practical Nurse (LPN) 4 revealed residents use bed/side rails for repositioning and to turn side to side. LPN4 was unable to answer whether the facility explored alternatives prior to bed/side rail use and stated that all the bed/side rails were already on the beds. He/she was also unsure if the resident signed a consent form for bed/side rail use and stated he/she would need to talk to the unit manager about the care plan. LPN4 said the unit managers should be aware of bed rail use since the bed rails were already on the beds, so he/she did not need to tell anyone that a resident had bed rails. LPN4 completed the risk of entrapment for R108 and was unsure why he/she did not complete R108's bed rail assessment. LPN4 said the bed rail assessment should indicate whether the resident would use bed rails. LPN4 also verified that R108's bed rail consent was not completed or signed by the resident. During an interview on 03/13/26 at 10:05 AM, the Director of Nursing (DON) stated that staff should discuss the risks and benefits of bed/side rail use with the residents, and they should complete the informed consent form. The DON was unaware that alternatives were supposed be explored prior to bed/side rail use. Review of the facility's policy titled, Proper Use of Bed Rails, revised 10/07/25, revealed, it is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. NJAC 8:39-27.1(a)

Based on interviews, record review, and hospice agreement review, the facility failed to obtain documentation of recertification of hospice services for one of one resident (Resident (R) 14) reviewed for hospice services out of a total sample of 25 residents. This had the potential to result in a lack of coordination of care and services. Findings include:Review of R14's electronic medical record (EMR) titled admission Record located under the Profile tab indicated that the facility admitted the resident on 02/22/17.Review of R14's EMR titled physician Orders located under the Orders tab dated 12/16/24, indicated the resident was ordered hospice services.Review of R14's EMR titled annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/25, located under the MDS tab indicated that the staff could not determine the resident's Brief Interview for Mental Status (BIMS) score. The assessment indicated that the resident was dependent on staff for all activities of daily living and had a diagnosis of having six months or less to live. Review of R14's EMR Misc (Miscellaneous) tab failed to show that the facility maintained the hospice recertification in the clinical record at the time of the survey. Review of R14's hospice book, a communication book between hospice visits and the facility, failed to contain evidence that the hospice provided the facility with copies of the hospice recertification. During an interview conducted on 03/11/26 at 9:14 AM, the Director of Nursing (DON) stated he/she would need to reach out to the Social Services Director (SSD) to locate the hospice recertification documents for R14. During an interview conducted on 03/11/26 at 10:44 AM, the SSD confirmed that R14's hospice book did not contain the recertification documents for the resident. The SSD stated that the interdisciplinary team met monthly with hospice to discuss the resident's care. The SSD stated the meetings were when hospice would notify the facility if a resident was recertified for hospice services or not. During an interview conducted on 03/11/26 at 10:59 AM, the Director of Clinical Services for hospice stated that he/she has only provided verbal notification of recertification of a resident for hospice services and had never provided the recertification documents to the facility. The Director of Clinical Services stated that hospice staff does meet with the facility once a month and verbally reports to the facility whether a resident has been recertified or not for hospice services. During an interview conducted on 03/11/26 at 11:13 AM, The DON brought in R14's recertification documents for the past year and confirmed that they were received on this date. The documents were not available in R14's clinical record prior to request. Review of a document provided by the facility titled, Nursing Facility Hospice, General Inpatient and Respite Care Services Agreement, dated 04/21/21, indicated that hospice would provide the facility with . a copy of the physician certification and recertification of the terminal illness specific to each Hospice patient . NJAC 8:39-5.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow a physician's order for a resident who required a continuous positive airway pressure (C-PAP) machine at night. This deficient practice was identified for one (1) of two (2) residents reviewed for Respiratory Care (Resident #33), and was evidenced by the following: During the initial tour of the facility on 8/22/24 at 09:35 AM, the surveyor observed an oxygen concentrator near Resident #33's bed. At that time, the surveyor did not observe a C-PAP machine (delivers oxygen via a mask while asleep) in the resident's room. According to the Admission Record, Resident #33 was admitted to the facility with diagnoses which included but not limited to: Obstructive Sleep Apnea (occurs when airway is blocked during sleep), and Chronic Respiratory failure (low oxygen levels). A review of the Order Details revealed a physician's order (PO) dated 5/25/23 at 5:06 AM, Please assist pt [patient] in wearing C-PAP at HS [at night] please have respiratory come to ensure proper set-up. A review of the comprehensive Care Plan revealed a focus area of altered respiratory status/difficulty breathing r/t [related to] sleep apnea initiated on 11/22/22. The interventions included, Auto C-pap 10-20 cm [centimeter] H2O [water] (setting on C-PAP machine), also initiated on 11/22/22. During an interview with the surveyor on 08/23/24 at 12:38 PM, Resident #33 stated that he/she wore a C-PAP machine at home. When asked did he/she wear the C-PAP machine while at the facility? The resident stated, maybe I should use it here. During an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) stated that Resident #33 previously had a C-PAP machine and PO prior to being discharged to the hospital. At that time, the RN/UM reviewed the resident's electronic medical record (EMR) and confirmed the above order and stated that if the resident had an order for a C-PAP machine, then he/she should have it. During an interview with the surveyor on 8/27/24 at 12:15 PM, the Director of Nursing (DON) stated that based on the PO referenced above, a respiratory consult should have been completed and the agency that provided respiratory services should have been contacted. The DON reviewed the EMR and confirmed that a respiratory consult was not completed. During an interview with the surveyor on 8/28/24 at 10:07 AM, the physician stated that Resident #33 required a BiPAP (a machine that delivers air through a mask on your face) or C-PAP machine and based on the PO referenced above, usually a respiratory therapist would come to the facility to set up the C-PAP machine. A review of the facility's PAP Equipment policy, dated reviewed 1/1/2023, included 2. Verify Medical Doctor order. 3. Gather necessary equipment. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, the facility failed to order a dental consult in a timely manner for one resident in a total sample of 12 (Resident (R)11) who was reviewed for dental. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings include: Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R11 was admitted to the facility on [DATE] with diagnoses that included spina bifida [a congenital defect of the spinal cord,] lower leg paralysis, and a stroke. Review of the admission Minimum Data Set (MDS) located the MDS tab of the EMR with an Assessment Reference Date (ARD) of 04/13/23, revealed, R11 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated R11 was cognitively intact for daily decision-making and had no dental issues. A Physician Note, located in the Progress Notes tab of the EMR, dated 05/25/23 at 1:17 PM revealed, .Seen at bedside .tooth infection-dental eval .case rev [reviewed] with RN at time of visit . Review of the Progress Notes from 05/25/23 to 06/05/23 revealed no referral to the dentist had occurred. Review of the Physician Orders, from 05/25/23 to 06/05/23 and located in the Orders tab revealed no physician order for a dental referral for tooth infection. During an observation and interview on 06/05/23 at 8:52 AM, R11 was sitting up in bed, with her breakfast tray in front of her. R11 was asked if she had been provided with a dentist appointment due to her tooth pain. She stated, No, they have not informed me of any dental appointment. During an interview on 06/05/23 at 11:30 AM, the Unit Clerk was asked if an appointment had been scheduled R11. She stated, I haven't scheduled her yet. This is the first time I am hearing about it. During an interview on 06/05/23 at 11:43 AM, Registered Nurse Supervisor (RNS) 2 was asked if R11 had been provided an appointment with the dentist. He stated that R11 had refused to see the dentist on 05/15/23 (prior to progress note of 05/25/23) however, she was put on a list to be seen on 07/03/23. During an interview on 06/05/23 at 2:39 PM, the Director of Nursing (DON) was asked what her expectation was for a resident who was having tooth pain. She stated that staff should attempt to call the dentist and schedule an appointment. NJAC 8:39-15.1 (a) (b)

Based on observations, record reviews, interviews, and policy review, the facility failed to ensure that one of one resident (Resident (R) 23) reviewed for tracheostomy (trach) care out of a total sample of 20 residents was provided necessary suctioning of the airway, had the necessary supplies at the bedside in the event of a life-threatening emergency, and failed to train staff on appropriate emergency tracheostomy care in the event that a resident's airway was compromised, which placed residents with a tracheostomy at increased likelihood of serious harm or death and resulted in harm to R23 who was admitted to the hospital with diagnoses of pneumonia due to an infectious organism, AMS (altered mental status), SOB (shortness of breath), rigors (fever causing severe chills and shaking), respiratory distress, increasingly thick trach secretions, and sepsis (injury to tissues and organs due to infection). On 11/29/22 at 10:30 PM, the Administrator in Training (AIT), the Regional Clinical Supervisor, and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) at F695-J: Respiratory/Tracheostomy Care and Suctioning. The Immediate Jeopardy began on 11/29/22 when the survey team identified the concerns related to the facility staff not providing suctioning of R23's tracheostomy (surgical opening into the windpipe for breathing) and no emergency tracheostomy supplies and/or staff training in the event of dislodgement of the trach from the airway for R23. The facility provided an acceptable removal plan on 12/01/22 at 6:30 PM. The removal plan included physician order revisions, placing tracheostomy supplies at the bedside in the resident's room, placing extra tracheostomy supplies in the medication room, in-servicing nursing staff on the location of tracheostomy supplies and tracheostomy care, care plan revisions, policy development of emergency management of trach, and re-education of all clinical staff. Following interviews with facility staff, observation of tracheostomy supplies, clinical record review of revised care plans and physician orders, and review of staff in-services for emergent trach care, the survey team verified implementation of the Removal Plan and removed the IJ on 12/02/22 at 8:30 PM. During the exit conference, the Associate Regional Director and the Regional Clinical Supervisor were notified that the IJ was removed but the deficient practice existed at F695-G (isolated harm). Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) Respiratory/Tracheostomy Care and Suctioning (F695 S/S: J). Findings include: Review of R23's undated ADMISSION RECORD, located in the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE] with multiple diagnosis to include malignant neoplasm of larynx (cancer of the voicebox), tracheostomy status, and dysphagia (difficulty swallowing). Review of R23's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/22 and located EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R23 was cognitively intact, had a tracheostomy, and required suctioning while not a resident but no suctioning required while a resident at the facility. Suctioning removes thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing. Review of R23's comprehensive Care Plan, under the Care Plan tab located in the EMR and revised on 08/23/22, revealed .has a tracheostomy r/t [related to] impaired breathing mechanics . Further review of the care plan revealed no information for suctioning, for emergency management of tracheostomy, no style, size, or cuff or uncuffed tracheostomy information, and no intervention related to tracheostomy care including suctioning, cleaning, or ensuring, oxygenation. Review of R23's Physician's Orders, under the Orders tab located in the EMR revealed the following: .Trach suctioning as needed . dated 08/23/22 and in conflict with the physician's order for no suctioning dated 09/02/22. .Tracheostomy care WITH NO SUCTIONING. ALLOW PATIENT TO COUGH OUT PHLEGM . dated 09/02/22 without specific definition of tracheostomy care such as cleaning the skin around the stoma and assessing for complications. Normal functions of the upper airway include warming, filtering, and humidifying inspired air]. .change disposable inner cannula [secretions can adhere to the internal lumen of a tracheostomy tube and severely reduce the inner lumen diameter over time. This potentially can increase the work of breathing and/or obstruct the patient's airway] every shift every day . dated 11/14/22 and without specific information about the inner cannula [it should be noted that there can be significant differences between the different manufacturer's tubes]. O2 [oxygen] concentrator set to 2 liters/min [minute] PRN [as needed] to maintain SPO2>92% [oxygen levels] . dated 09/02/22 and without route (nasal, face mask or trach) of oxygen administration. .# [number] 6 Shiley [brand of tracheostomy] and Ambu bag [bag used as a method of artificial ventilation] at bedside check every shift . dated 08/23/22 and without information if the Shiley was to be cuffed or uncuffed. Uncuffed tubes allow airway clearance but provide no protection from aspiration (foreign objects such as fluids or foods entering the lungs). Cuffed tracheostomy tubes allow secretion clearance and offer some protection from aspiration, and positive-pressure ventilation can be more effectively applied when the cuff is inflated. Further review of the physician orders revealed no order for an emergency tracheostomy kit at the bedside. Review of R23's Treatment Administration Record (TAR), located in the EMR and dated for 11/22, revealed: .Trach suctioning as needed Pre/Post Treatment . dated 08/23/22, with no staff's initials documented indicating the procedure was not performed from 11/01/22 through 11/30/22. .Tracheostomy care WITH NO SUCTIONING. ALLOW PATIENT TO COUGH OUT PHLEGM . dated 09/02/22, and with no specific direction for cleaning the skin around the stoma and assessing for complications. Review of this TAR revealed staff initials documented for 11/01/22 through 11/29/22 indicating care was provided with no suctioning. .change disposable inner cannula every day shift . ordered on 08/23/22 and discontinued and restarted on 11/14/22 without specific information of size of inner cannula. Review of the November 2022 TAR revealed staff initials from 11/01/22 through 11/29/22 indicating the cannula was changed every day shift. .#6 Shiley and Ambu bag at bedside check every shift . ordered 08/23/22 without specific order for cuffed or uncuffed Shiley. Review of this TAR revealed staff's initials indicating the ambu bag was at the bedside from 11/01/22 through 11/29/22. .Change disposable inner cannula every 12 hours as needed . dated 11/14/22 without information of size of inner cannula with no staff's initials for 11/14/22 through 11/29/22 indicating the order was not performed. .O2 concentrator set to 2 liters/min PRN to maintain SPO@>92% as needed . without route (nasal, face mask or trach mask) . Further review of this TAR revealed no staff's initials indicating the treatment was not provided from 11/01/22 through 11/30/22. .Change trach ties after bath/shower and as needed . dated 08/23/2022 with no staff's initials documented indicating the procedure was not performed from 11/01/22 through 11/30/22. Trach ties are bands that go around the neck to keep the trach tube in place. During an interview on 11/29/22 at 5:32 PM, Licensed Practical Nurse (LPN) 1 stated R23 did not have a physician's order to suction his trach. During an interview on 11/29/22 at 6:37 PM, Certified Nursing Assistant (CNA) 2, who indicated she provided care for R23, stated the facility did not provide her with emergency management care training in the event the trach became dislodged. During an observation on 11/29/22 at 6:39 PM, R23 was observed in his room sitting on his bed awake and alert. R23 had a trach with a large amount of white sputum at the trach site. R23 did not have a trach emergency medical kit or an ambu bag visible at his bedside. R23 had a suction machine on his bedside table but there was no suction tubing connected to the suction machine. During an observation and interview on 11/29/22 at 6:47 PM, LPN1, assigned to R23, confirmed that there was no emergency kit, no ambu bag, and no extra trach at R23's bedside. LPNl stated if the trach became dislodged, she would let the manager know as she (LPN1) had no trach emergency management training. LPNl stated she would not know what to do if there was no manager on duty. LPN1 stated she had not performed suction for R23's trach. During observation and interview on 11/29/22 at 7:0 PM, LPN2 confirmed there was no emergency kit at the bedside. LPN2 stated she worked at the facility for one year and had not been provided emergency management training in the event the trach became dislodged. LPN2 stated she had not performed suction for R23's trach. During an observation and interview on 11/29/22 at 7:13 PM, the DON confirmed R23 did not have an emergency trach kit at his bedside or an ambu bag. The DON, who as part of the leadership team was responsible for providing staff training, stated trach emergency management was not provided by the facility for the staff. During an interview on 11/29/22 at 7:22 PM, the DON verified there was no emergency trach kit in the supply room. The DON stated R23 moved to another room recently and staff did not follow the order and placed an ambu bag at his bedside. During an interview on 11/29/22 at 7:25 PM, the Unit Manager (UM-Registered Nurse)1 stated she had been at the facility for [AGE] years. UM1 confirmed the facility had not provided her with tracheostomy emergency management training and confirmed the physician's orders were conflicting concerning suctioning. During an interview on 11/29/22 at 7:28 PM, the Assistant Director of Nursing (ADON) confirmed he was employed at the facility for a year and the facility had not provided him with tracheostomy emergency management training. During an interview on 11/29/22 at 8:13 PM, the Medical Director confirmed he expected the facility's staff to be provided training with tracheostomy emergency management training. An interview attempt was made on 11/29/22 at 8:47 PM with the facility's Administrator and was unsuccessful. During an observation and interview on 11/29/22 at 10:41 PM of R23's room with the ADON, the DON, and UM1 revealed R23 did not have emergency trach supplies at his bedside. UM1 confirmed the facility crash cart did not contain any tracheostomy supplies. UM1 stated the facility may have a size smaller of tracheostomy in the outside storage shed. UM1 confirmed R23 did not have a physician's order with specifications regarding if the tracheostomy was cuffed or uncuffed. UM1 confirmed R23's physician's order should contain whether his tracheostomy was cuffed or uncuffed to ensure the correct replacement tracheostomy was at his bedside. Review of R23's Progress Note, under the Progress Notes tab located in the EMR revealed the following: 11/30/22 .Called into room to assess resident. Resident not able to answer questions, making groaning noises. SpO2 69% [out of 100%] on room air. Non-rebreather [mask] applied. Resident with twitching movements. MD called and order given to sent (sic) to ER [emergency room ] via 911. 911 called .resident was pick [sic] up at 2:20pm taking to ER . During an interview on 12/01/22 at 1:16 PM, UM1 confirmed R23 was sent to the emergency room for hypoxia and altered mental status on 11/30/22 at 2:20 PM. UM1 confirmed Respiratory Therapist (RT)2 was providing ventilation by ambu bag to R23's trach and did not provide trach suctioning while awaiting the ambulance to arrive. UM1 confirmed R23 had audible rhonchi (coarse rattling lung sounds usually caused by secretions in the airways), with low oxygen saturation, twitching behavior, and a foul odor from his tracheostomy site. UM1 also confirmed that respiratory therapy did not provide suctioning to R23 during routine care. Review of an untitled hospital document, provided by R23's family and dated 11/30/22, revealed XR [x-ray of] CHEST .Hypo aeration [can be caused by blockages in the air passages] of the lungs, compatible with decreased inspirations .Asymmetric left basilar bandlike opacity appearance favors basilar atelectasis [Bibasilar atelectasis is a condition that happens when you have a partial collapse of your lungs. This type of collapse is caused when the small air sacs in your lungs deflate.], with minimal right basilar atelectasis .Problem List .Pneumonia due to infectious organism .AMS [altered mental status] SOB [shortness of breath] rigors [fever causing severe chills and shaking], respiratory distress, and increasingly thick trach secretions .trachea-pneumonitis [pneumonitis is a general term for lung inflammation. It can cause difficulty breathing and is often accompanied by a cough.] .Found to have GAS [Group A Strep bacteria] bacteremia [Invasive GAS infections are defined as bacteremia, pneumonia, osteomyelitis, septic arthritis, or any other infection associated with the isolation of GAS from a normally sterile body site] , likely pathogen of PNA [inflammation of the lungs, usually due to infection with bacteria, viruses, or other pathogens.] .Pt [patient] will need frequent suctioning .Tracheal suction with 100 cc of brown/yellowish output .Sepsis likely 2/2 [secondary to] GAS bacteremia .Pt observed to upper airway congestion, and copious [abundant] secretions coming through his trach. His cough is [NAME], but no secretions are expectorated from his mouth. Trach was cleaned and suctioned . During an interview on 12/01/22 at 2:31 PM, the Doctor of Osteopathic Medicine-Pulmonologist (DOP) confirmed it was standard of practice for a resident with a trach to have a physician's order for brand, style, size, and cuff or uncuffed trach.The DOP confirmed if the facility did not provide a resident with trach suctioning it could cause a mucous plus in the resident's airway which causes pneumonia and the resident's lungs to collapse During an interview on 12/01/22 at 6:29 PM with R23's Family Member (FM)1 with the team of surveyors present in the conference room at the facility, FM1 confirmed he was informed by the hospital staff R23 may not survive. FM1 confirmed R23 had a bad lung infection due to suctioning not being provided by the facility. FM1 confirmed R23 was diagnosed with pneumonia and sepsis by the hospital staff on 11/30/22. During an interview on 12/02/22 5:33 PM, the Medical Director confirmed he was responsible for writing physician orders and ensuring the physician's orders were correct. The Medical Director stated he may have overlooked incomplete or conflicting physician orders. The Medical Director confirmed R23's physician's orders contained conflicting orders to provide suction and to not suction R23's trach. The Medical Director stated he expected the nursing staff to know when to suction the resident with a trach (even with conflicting physician's orders). The Medical Director confirmed it was important that R23's physician's orders contained specifics regarding his trach to include brand, size, type of his inner cannula and trach. The Medical Director confirmed R23's oxygen administration physician's orders should include the route of administration of the oxygen. The Medical Director stated he did not have clinical experience with replacing resident's trach. The Medical Director stated if R23's trach became dislodged, he would call 911 and attempt to locate a trach replacement and attempt to replace R23's because it would be considered a life-or-death situation. The Medical Director confirmed not providing a resident with a trach with suctioning could potentially cause formation of mucous plug, respiratory distress, pneumonia, lung collapse, and most importantly death. Review of facility-provided policy titled, Tracheostomy Care revealed .This policy is to instruct on how to effectively clean a patient's tracheostomy and surrounding area to reduce the risk of infection and maintain a patent airway .Each resident has a specific trach tube, as ordered by a Physician .Each trach resident should have a spare back up trach at the bedside .Tracheostomy tubes have different sizes and styles .Cuffed and un-cuffed .Fenestrated and non-fenestrated .Disposable inner cannulas and non-disposable inner cannula .Different sizes .Different brands .Trach tubes and stoma sites require regular cleaning .If there is redness, bleeding or drainage from stoma, it should be reported to the resident's nurse .Whenever the tube is manipulated, respiratory, cardiovascular and skin parameters should be assessed .Suctioning is necessary to insure patent airway .Procedure for Changing Disposable Inner Cannula .equipment .Sterile disposable inner cannula .Sterile suction catheter .Sterile container .Sterile gloves .Sterile gloves .Trach Ties .Drain sponge .Sterile cotton applicators .Have a manual resuscitator available in case of respiratory distress .It is recommended infection control practice that trach care be performed on each shift . NJAC 8:39-27.1(a)

Based on record review, interviews, and policy review, the facility failed to ensure the physician clarified orders for suctioning and emergency tracheostomy care for one of one resident (Resident (R) 23) with a tracheostomy (a surgical opening into the windpipe for breathing) out of a total sample of 20 residents. These failures resulted in harm to R23 who was admitted to the hospital with diagnoses of pneumonia due to an infectious organism, AMS (altered mental status), SOB (shortness of breath), rigors (fever causing severe chills and shaking), respiratory distress, increasingly thick trach secretions, and sepsis (injury to tissues and organs due to infection). Findings include: Review of R23's undated ADMISSION RECORD, located in the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with multiple diagnosis to include malignant neoplasm of larynx (cancer of the voice box), tracheostomy status, and dysphagia (difficulty swallowing). Review of R23's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/22 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R23 was cognitively intact, had a tracheostomy, and required suctioning prior to admission to the facility but not while a resident. Suctioning removes thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing. Review of R23's Physician's Orders, under the Orders tab located in the EMR revealed the following: .Trach suctioning as needed . dated 08/23/22 and in conflict with the physician's order for no suctioning dated 09/02/22. .Tracheostomy care WITH NO SUCTIONING. ALLOW PATIENT TO COUGH OUT PHLEGM . dated 09/02/22 without specific definition of tracheostomy care such as cleaning the skin around the stoma and assessing for complications. Normal functions of the upper airway include warming, filtering, and humidifying inspired air]. .change disposable inner cannula [secretions can adhere to the internal lumen of a tracheostomy tube and severely reduce the inner lumen diameter over time. This potentially can increase the work of breathing and/or obstruct the patient's airway] every shift every day . dated 11/14/22 and without specific information about the inner cannula [it should be noted that there can be significant differences between the different manufacturer's tubes]. O2 [oxygen] concentrator set to 2 liters/min [minute] PRN [as needed] to maintain SPO2>92% [oxygen levels] . dated 09/02/22 and without route (nasal, face mask or trach) of oxygen administration. .# [number] 6 Shiley [brand of tracheostomy] and Ambu bag [bag used as a method of artificial ventilation] at bedside check every shift . dated 08/23/22 and without information if the Shiley was to be cuffed or uncuffed. Uncuffed tubes allow airway clearance but provide no protection from aspiration (foreign objects such as fluids or foods entering the lungs). Cuffed tracheostomy tubes allow secretion clearance and offer some protection from aspiration, and positive-pressure ventilation can be more effectively applied when the cuff is inflated. Further review of the physician orders revealed no order for an emergency tracheostomy kit at the bedside. Review of R23's Treatment Administration Record (TAR), located in the EMR and dated for 11/22, revealed: .Trach suctioning as needed Pre/Post Treatment . dated 08/23/22, with no staff's initials documented indicating the procedure was not performed from 11/01/22 through 11/30/22. .Tracheostomy care WITH NO SUCTIONING. ALLOW PATIENT TO COUGH OUT PHLEGM . dated 09/02/22, and with no specific direction for cleaning the skin around the stoma and assessing for complications. Review of this TAR revealed staff initials documented for 11/01/22 through 11/29/22 indicating care was provided with no suctioning. .change disposable inner cannula every day shift . ordered on 08/23/22 and discontinued and restarted on 11/14/22 without specific information of size of inner cannula. Review of the November 2022 TAR revealed staff initials from 11/01/22 through 11/29/22 indicating the cannula was changed every day shift. .#6 Shiley and Ambu bag at bedside check every shift . ordered 08/23/22 without specific order for cuffed or uncuffed Shiley. Review of this TAR revealed staff's initials indicating the ambu bag was at the bedside from 11/01/22 through 11/29/22. .Change disposable inner cannula every 12 hours as needed . dated 11/14/22 without information of size of inner cannula with no staff's initials for 11/14/22 through 11/29/22 indicating the order was not performed. .O2 concentrator set to 2 liters/min PRN to maintain SPO@>92% as needed . without route (nasal, face mask or trach mask) . Further review of this TAR revealed no staff's initials indicating the treatment was not provided from 11/01/22 through 11/30/22. .Change trach ties after bath/shower and as needed . dated 08/23/2022 with no staff's initials documented indicating the procedure was not performed from 11/01/22 through 11/30/22. Trach ties are bands that go around the neck to keep the trach tube in place. Review of R23's Progress Note, under the Progress Notes tab located in the EMR, revealed the following: 11/30/22 . Called into room to assess resident. Resident not able to answer questions, making groaning noises. SpO2 69% [out of 100%] on room air. Non-rebreather [oxygen mask] applied. Resident with twitching movements. MD called and order given to sent (sic) to ER [emergency room ] via 911. 911 called . During an interview on 12/01/22 at 1:16 PM, Unit Manager (UM) 1, confirmed R23 was sent to the emergency room for hypoxia [low blood oxygen levels] and altered mental status on 11/30/22. UM1 confirmed Respiratory Therapist (RT) 2 was providing ventilation by ambu bag to R23's trach and did not provide trach suctioning while awaiting the ambulance to arrive. UM confirmed R23 had audible rhonchi (lung sounds due to the airflow being blocked), with low oxygen saturation and twitching behavior and a foul odor from the trach. Review of R23's untitled hospital document, dated 11/30/22 and provided by the family, revealed XR [x-ray of] CHEST .Hypo aeration [can be caused by blockages in the air passages] of the lungs, compatible with decreased inspirations .Asymmetric left basilar bandlike opacity appearance favors basilar atelectasis [Bibasilar atelectasis is a condition that happens when you have a partial collapse of your lungs. This type of collapse is caused when the small air sacs in your lungs deflate. These small air sacs are called alveoli.], with minimal right basilar atelectasis .Problem List .Pneumonia due to infectious organism .AMS [altered mental status] SOB [shortness of breath] rigors [severe shaking chills caused by fever], respiratory distress and increasingly thick trach secretions .trachea-pneumonitis [Pneumonitis is a general term for lung inflammation. It can cause difficulty breathing and is often accompanied by a cough.] .Found to have GAS [Group A Strep] bacteremia [Invasive GAS infections are defined as bacteremia, pneumonia, osteomyelitis, septic arthritis, or any other infection associated with the isolation of GAS from a normally sterile body site] , likely pathogen of PNA [Inflammation of the lungs, usually due to infection with bacteria, viruses, or other pathogens.] .Pt [patient] will need frequent suctioning .Tracheal suction with 100 cc of brown/yellowish output .Sepsis likely 2/2 [secondary to] GAS bacteremia .Pt observed to upper airway congestion, and copious [abundant] secretions coming through his trach. His cough is [NAME] [sic], but no secretions are expectorated from his mouth. Trach was cleaned and suctioned . During an interview on 12/01/22 at 6:29 PM, R23's Family Member (FM)1, with the team of surveyors present in the conference room at the facility, confirmed he was informed by the local hospital staff that R23 may not survive. FM1 confirmed the hospital staff informed him R23 had a bad lung infection due to suctioning not being provided by the facility. FM1 confirmed R23 was diagnosed with pneumonia and sepsis by the hospital staff on 11/30/22. During an interview on 12/02/22 05:33 PM, the Medical Director confirmed he was responsible for ensuring R23's physician's orders were correct and that he signed R23's physician's orders. The Medical Director confirmed R23's physician's orders should not be conflicting in particular whether or not to provide suctioning. The Medical Director stated he expected the nursing staff to know when to suction the resident with a trach (with conflicting physician's orders). The Medical Director confirmed it was important that R23's physician's orders contained specifics regarding his trach to include brand, size, type of his inner cannula and trach. The Medical Director confirmed R23's oxygen administration physician's orders should include the route of administration of the oxygen. The Medical Director confirmed not providing suctioning of a trach could result in the formation of a mucous plug, respiratory distress, pneumonia, lung collapse, and most importantly death. Cross Reference: F695-J Respiratory/Tracheostomy Care & Suctioning. Review of facility-provided policy titled Physician Services, 03/22, revealed .The medical care of each resident is under the supervision of a Licensed Physician .prescribe an appropriate medical regimen .Physician orders .shall be maintained . NJAC 8:39-27.1(a)

Based on interviews, record review, and policy review, the facility failed to ensure the clinical staff were trained to provide emergency treatment for one of one resident (Resident (R) 23) with a tracheostomy (surgical incision into the windpipe for breathing) out of a total sample of 20 residents. This failure increased R23's risk of not receiving appropriate tracheostomy care during an emergency situation. Findings include: Review of R23's undated ADMISSION RECORD, located in the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with multiple diagnosis to include malignant neoplasm of larynx (cancer of the voice box), tracheostomy status, and dysphagia (difficulty swallowing). Review of R23's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/22 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R23 was cognitively intact, had a tracheostomy, and required suctioning prior to being a resident but not while a resident in the facility. Suctioning removes thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing. During an interview on 11/29/22 at 6:32 PM, Certified Nursing Assistant (CNA) 1 confirmed she had been employed at the facility for two years. CNA1 confirmed the facility had not provided her tracheostomy care or emergency training. During an interview on 11/29/22 at 6:37 PM, CNA2 confirmed she provided care for R23 to include washing and changing him. CNA2 confirmed the facility had not provided her with trach emergency management or care training. During an interview and observation on 11/29/22 at 7:00 PM, Licensed Practice Nurse (LPN) 4 confirmed the facility had not provided her training on emergency trach management. During an observation and interview on 11/29/22 at 7:25 PM, the Unit Manager (UM) 1 confirmed the facility did not provide her with trach emergency management training in the past year. UM1 confirmed she had worked at the facility for [AGE] years. During an interview on 11/29/22 at 7:28 PM, the Assistant Director of Nursing (ADON) confirmed the facility had not provided him with emergency management of tracheostomy in the past year. During an interview on 11/29/22 at 7:55 PM, the Director of Nursing (DON), who as part of the leadership team was responsible for providing staff training, stated trach emergency management was not provided by the facility for the staff. The DON stated the facility did not have a policy for trach emergency kits or dislodgement of a resident's tracheostomy. During an interview on 11/29/22 at 8:47 PM, the Regional Clinical Supervisor stated the facility had 100 staff members and only 18 were trained in tracheostomy care and no training was provided on emergency management for tracheostomies. The Regional Clinical Supervisor also stated that the facility did not have a policy on emergency management training for tracheostomies. During an interview on 11/29/22 at 8:13 PM, the Medical Director confirmed he expected the facility staff to be trained to provide emergency management care for residents with tracheostomies. Attempted an interview on 11/29/22 at 8:47 PM with the facility's Administrator and was unsuccessful. Cross Reference: F695-J Respiratory/Tracheostomy Care & Suctioning. Review of facility-provided document titled, Facility Assessment Tool, dated 03/22, revealed .Special Treatments .Suctioning .Tracheostomy Care .staff .competencies .existing staff also receive this training annually . Review of facility-provided policy titled, Competency of Nursing Staff, undated, revealed .The staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents .factors are considered in the creation of the training program .Specialized skills or training needed based on the residents population .The facility assessment includes an evaluation of the staff competency that are necessary to provide the level and types of care specific to the residents population .resident-specific competency evaluations will be conducted .annually and as deemed necessary based on the facility assessment .will include .return demonstration .Demonstrated ability to use tools, devices, or equipment used to care for residents . NJAC 8:39-13.4(c)1

Based on observation, interviews, record reviews, and review of facility policy, the facility failed to ensure one of 20 sampled residents (Resident (R) 23) had a physician's order and was assessed and care planned for the self-administration of medications. This failure increased the risk of incomplete or inaccurate administration of medication for R23. Findings include: Review of the electronic medical record (EMR) revealed R23 was admitted to the facility on [DATE] with multiple diagnosis to include malignant neoplasm of larynx (cancer of the voice box), tracheostomy (surgical opening in the windpipe for breathing) status, and dysphagia (difficulty swallowing). Review of R23's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/22 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R23 was cognitively intact, had a tracheostomy, and required suctioning prior to admission but not while a resident at the facility. Suctioning removes thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing. Review of R23's Physician's Orders, for 11/22 and under the Orders tab in the EMR, revealed no order for self-administration of medication. Review of R23's Medication Administration Record (MAR), dated 11/22 and located under the Orders tab in the EMR, revealed no order for self-administration of medication. Review of R23's comprehensive Care Plan, located in the EMR, revealed no interventions for self-administration of medication. Observation on 11/29/22 at 6:39 PM revealed R23 in his room sitting on his bed, with a trach mask (for the delivery of oxygen) over his trach site connected to nebulizer machine (administers medication in the form of a mist inhaled into the lungs). R23 had a nebulizer treatment administered via trach mask oxygen tubing, without clinical staff present, indicating R23 was self-administering his medication. During an interview on 11/29/22 at 6:43 PM, Licensed Practical Nurse (LPN) 1 confirmed she did not remain with R23 for inhalation (nebulizer) of R23's albuterol medication administration. LPN1 confirmed she instilled the albuterol inhalation medication into the oxygen tubing reservoir and connected it to his trach and turned the nebulizer on and left R23's room. LPN1 confirmed R23 was not assessed by the facility for self-administer of his medications. LPN1 confirmed the facility expected the nursing staff to administer R23's medications. LPN stated she planned to return to R23's room and remove his trach oxygen mask nebulizer treatment after 15 minutes. During an interview and second observation on 11/29/22 at 6:47 PM, LPN1 removed the trach oxygen mask from R23's trach and turned off the nebulizer machine. LPN1 confirmed R23's oxygen tubing reservoir was filled with white sputum. LPN1 confirmed that the oxygen tubing reservoir should not contain sputum as the sputum could block the flow of oxygen into the trach. Review of facility provided policy, dated 10/01/18, titled Self-Administration of Medication, revealed .The decision for self-administration is made after the completion of a comprehensive assessment. The decision for self-administration is recommended to be completed and care planned within seven (7) days .Orders for self-administration must list specific medications the customer may self-administer . Review of facility provided policy, dated 10/22, titled .Nebulizer . revealed .To deliver specific medication/agents .to a patient via inspiration and targeted to the respiratory system .Observe the patient for any signs of hyperventilation or adverse reactions to medications. Treatment time is generally 10 minutes. Stay with patient the duration of the therapy . Suction, if necessary . NJAC 8:39-29.2(c)1,6

Based on observations, record reviews, staff interviews, and policy review, the facility failed to ensure care plan interventions for emergency tracheostomy (trach) care were developed for one of one resident (Resident (R 23) reviewed for tracheostomy (a surgical opening into the windpipe for breathing) care out of a total sample of 20 residents. This failure increased R23's risk for compromised airway/respiratory distress and/or respiratory infections. Findings include: Review of R23's undated ADMISSION RECORD, located in the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with multiple diagnosis to include malignant neoplasm of larynx (cancer of the voice box), tracheostomy status, and dysphagia (difficulty swallowing). Review of R23's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/22 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R23 was cognitively intact, had a tracheostomy, and required suctioning prior to admission but not while a resident at the facility. Suctioning removes thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing. Respiratory therapy was provided zero out of 7 days during the assessment period. Review of R23's comprehensive Care Plan, under the Care Plan tab in his EMR with a revision date of 08/23/22, revealed . has a tracheostomy r/t [related to] impaired breathing mechanics ., that included no information for emergency tracheostomy management, no tracheostomy information (style, size, or cuff or uncuffed), and no intervention related to tracheostomy care including suctioning, cleaning, or ensuring oxygenation. During an interview on 12/01/22 at 12:01 PM, the Unit Manager (UM) 2 confirmed R23's care plan interventions for emergency tracheostomy management should have been included on his care plan for directions for nursing to follow for his care. During an interview on 12/01/22 at 12:53 PM, the MDS Coordinator (MDSC) confirmed the nursing staff generated R23's baseline care plans. The MDSC confirmed the residents' care plans should reflect the resident's physician's orders. The MDSC verified R23 had a physician's order for an ambu bag [respiration device for manual ventilation needed during resuscitation] to remain at his bedside. The MDSC confirmed R23's care plan should include specific orders for an ambu bag at his bedside and emergency trach management. Review of facility-provided policy titled Care Plan, Comprehensive Person-Centered, revised 10/21, revealed . Resident population is long term and sub acute [sic] therefore care plans need to be updated, for sub acute [sic] on admission, after significant clinical changes, and as needed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical .is developed and implemented for each resident .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical .well-being .Incorporate identified problem areas .Reflect treatment goals .Aid in preventing or reducing decline in the resident's functional status .Reflect currently recognized standards of practice for problem areas and conditions . Cross Reference: F695-L Respiratory/Tracheostomy Care and Suctioning. NJAC 8:39-11.2(e)1 NJAC 8:39-27.1(a)

Based on interviews, record review, and policy review, the facility failed to provide a discharge assessment and discharge plan, for one of three residents (Resident (R) 39) reviewed for discharge out of a total sample of 20 residents. This failure increased the risk of delayed and/or incomplete discharge planning for residents wanting to be discharged from the facility. Findings include: Review of R39's undated ADMISSION RECORD, under the Profile tab in the electronic medical record (EMR), revealed R39 was admitted to the facility on [DATE] with multiple diagnosis to include major depression disorder and dementia without behavior disturbances. Review of R39's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/22 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R39 was cognitively intact. Review of R39's documents under the Miscellaneous tab located in the EMR revealed no information and/or documentation for an alternative decision maker for R39. Review of R39's Social Services Assessment, under the Assessments tab in the EMR and dated 03/09/22, revealed .to be discharged to the community .barrier was weakness .'Was referral made to Local State agency' .no-referral not needed .why .SAR [short term rehab]. Review of R39's Progress Notes, under the Progress Notes tab located in the EMR revealed the following: 06/09/22 .[R39] Says 'I want the door to open, and I want to walk through it, I've had it with this place, you're trying to get around me and I won't allow this to happen' . signed by Physician Assistant Certified (PA-C). 06/16/22 .[R39] says she is still eager to go home . signed by Physician Assistant Certified (PA-C). 11/11/22 .Call received from resident's daughter .resident's issues with staff, continued irritability and agitation .increasing Lexapro [antidepressant] .irritability and agitation .agreeable .discussed Psychology consult for resolution of issues .being in SNF .suggested [daughter] contact National Alliance on Mental Illness .to connect with support services for herself .increase Lexapro .daughter in agreement . signed by Advance Practice Nurse Certified (APN-C) Behavioral Health. 12/01/22 .Psychiatry Progress Note .admits she has not adjusted well to living in facility . Physician Assistant Certified (PA-C). 12/01/22 .SW [Social Worker] expressed that the goal is to begin adjusting to living with us and that we [the facility] would expect moving forward that she begins to express her preferences and needs to the IDT[ Interdisciplinary Team] .[R39] said .'It has been difficult overall' .Care Plans are updated to reflect discussed goals and adjustment interventions .A psych consult was placed for needs . signed by the Regional Social Services Director (RSSD). Review of the EMR Care Plan tab revealed the following Care Plan, initiated 12/01/22: [R39's name] has adjustment issues related to admission to nursing facility, recent changes in independence .I [R39] will maintain the ability to seek social contact and stimulation through the next review .I will show evidence of adjustment to nursing home by being more involved in facility life to increase quality of life .Encourage me to participate in conversations with staff and other residents daily . I need the opportunity to express my feelings about how things effect [sic] me, such as nursing home placement, loss of independence etc. Allow free nonjudgmental space to speak freely .Learn to recognize and help me to identify my stressors which may be early warning signs of problem behavior . will be involved in psychotherapy as need and ongoing based on the resident's preference. Further review of R39's comprehensive Care Plan, under the Care Plan tab located in the EMR, revealed no discharge care plan, goals, or interventions. During an interview on 11/30/22 at 12:35 PM, R39 stated she wanted to be discharged from the facility. R39 stated the facility did not provide her with assistance with discharge plans from the facility. R39 stated she wanted to be discharged to an assisted living facility. During an interview on 12/02/22 at 9:05 AM, the Social Services Director (SSD) confirmed that she routinely started discharge planning with residents at the facility on the day of their admission. The SSD stated the discharge planning was not included on R39's care plan and should be. The SSD confirmed she had not assisted R39 with any discharge care planning. The SSD confirmed R39 could make her own decisions regarding her care and plans. The SSD confirmed R39 had her own apartment prior to being admitted to the facility. The SSD stated R39 was sharp and articulate and care decisions should be discussed with R39 and not with R39's daughter. During an interview on 12/02/22 at 9:36 AM, the RSSD confirmed she had a conversation with R39 and developed a new adjustment care plan for R39 on 12/01/22 regarding adjusting to life at the facility. The RSSD confirmed R39's discharge plan should begin on admission and was not. The RSSD verified R39 did not have a medical power of attorney and could make her own decisions The RSSD stated the facility's social services department was responsible for assisting residents with the discharge process, setting up home care, ordering equipment, financial assistance, and assessing the possibility of returning to the community. The RSSD verified R39's social services assessment note included R39's plan was to be discharge home and the only barrier was weakness on 09/22. Review of the facility-provided policy titled, Discharge Summary and Plan, updated 01/19, revealed When a resident's discharge is anticipated .post-discharge plan will be developed .Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan .The post-discharge plan will be developed by the Care Planning/Interdisciplinary with the assistance of the resident .Where the individual plans to reside .Arrangements that have been made for follow-up care and services .A description of the resident's stated discharge goals .The degree of caregiver/support person availability .How those factors will be address . Team .Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge .If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination . NJAC 8:39-35.2(d)15

Based on observations, interviews, record review, and policy review, the facility failed to ensure two of two residents (Resident (R) 54 and R69) reviewed for limited Range of Motion (ROM) out of a total sample of 20 residents was provided treatment to maintain and/or increase ROM. This failure increased the risk of a decline in ROM for residents that require treatment. Findings include: 1. Review of R54's undated ADMISSION RECORD, under the Profile tab located in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with multiple diagnoses to include chronic inflammatory demyelination polyneuritis (nerve damage resulting in pain and tingling), neuromuscular dysfunction of bladder (loss of bladder control), and functioning quadriplegic (paralysis of arms and legs). Review of R54's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/22 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R54 was cognitively intact, had limited range of motion in upper and lower extremities and was provided physical therapy 0 out of 7 days and restorative therapy 0 out of 7 days of the assessment period. Review of R54's Physician's Orders, for 11/22 under Orders tab located on her EMR, revealed the following: .Occupational Therapy (OT)-Evaluation & treatment as recommended . dated 02/23/22. .Physical Therapy (PT)- Evaluation & treatment as recommended. No directions specified for order . dated 2/23/22. Further review of the physician's orders revealed no orders for treatment to maintain or improve the limited range of motion of R54's lower extremities or feet. Review of R54's comprehensive Care Plan, under the Care Plan tab located in the EMR and dated 09/14/21, revealed . has limited physical mobility . Monitor/document any s/sx [signs and symptoms] of immobility: worsening contractures [shortening of tendon or muscle resulting in a fixed joint deformity] forming Provide supportive care . Further review of the Care Plan revealed no person-centered problems list and/or interventions to direct the staff to provide treatment to maintain or improve R54's limited range of motion or prevent further contractures of her lower extremities. Observation and interview on 11/30/22 at 12:07 PM revealed R54 lying on her bed, in her room. R54 stated she had a diagnosis of foot drop [a condition in which you cannot raise the front part of one or both feet] in both feet. R54 stated the facility had not provided her with braces or splints or ROM exercises for her feet or lower extremities. During an interview on 12/01/22 at 11:29 AM, Rehabilitation Director (RD) confirmed the rehab department was responsible for providing residents with services for limited range of motion to maintain or increase range of motion of upper and lower extremities, such as: passive range of motion exercise, stretching exercises, strengthening exercises, positioning of the extremities, positioning, and evaluation for devices. The RD stated the department provided ankle foot orthotics (brace) for resident's ankles (for with foot drop) to avoid further contracture decline and prevent heel sores. The RD confirmed residents with contractures, their joints got very tight and increased their potential to develop wounds. The RD verified R54 had a diagnosis of foot drop with limited range of motion in her upper and lower extremities. The RD confirmed the facility's resident's (with foot drop and limited ROM) care plans should include interventions for person-centered specific directives for the facility's staff to maintain or improve resident's limited ROM and contractures and R54's care plan did not. The RD verified the facility was not providing R54 with foot splints or range of motion exercises. During an observation and interview on 12/01/22 at 11:58 AM with the RD revealed R54 in her room lying on her bed. RD removed R54's sheet and exposed R54's legs and feet (positioned on pillow). R54's bilateral feet were flexed with toes pointed downward without splint or brace. R54 was unable to move her feet or legs. The RD moved R54's legs and bent at knee and attempted to passively move R54's feet and ankles. The RD confirmed R54's ankles were fixed and contracted. The RD confirmed R54 had limited range of motion with both feet, ankles, knees, and right upper arm. The RD confirmed R54 would benefit from services from the rehabilitation department to maintain and prevent further decline with her limited range of motion with her feet and lower legs to include ROM exercises and foot braces. 20064 2. Review of the Medical Diagnoses, under the Medical Diagnoses tab in the EMR, indicated R69 had diagnoses of Cerebral Infarction (stroke) affecting his left upper and lower extremity, Parkinson's disease, and muscle weakness. Review of the quarterly MDS, found under the EMR MDS tab with an ARD of 09/15/22, revealed R69's was originally admitted to the facility on [DATE]. Further review of this MDS revealed R69's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of this MDS revealed R69 required extensive staff assistance with activities of daily living (ADLs) such as bed mobility, transfers, and dressing, had not walked during the assessment period, was incontinent of bowel and bladder, and had ROM limitations on one side of both his upper and lower extremities (shoulder, elbow, arms, hands, legs, feet). Review of the Care Plan, last revised 06/21/22 and located in the EMR under the Care Plan tab, revealed no ROM interventions for R69. Review of R69's Physician's Orders, for 11/22 and located under the EMR Orders tab, revealed the following orders: Occupational Therapy (OT)-Evaluation & treatment as recommended . dated 04/07/22. Physical Therapy (PT)-Evaluation & treatment as recommended . dated 04/07/22. Further review of the Orders revealed no orders to maintain or improve the limited ROM of R69's lower extremities or feet. Observation and interview on 12/2/2022 at 5:18 PM revealed R69 had a contracted left hand and left leg. R69 stated he does not receive any exercises from staff to his hand or leg but would like assistance in moving his hand and leg before they got [sic] any worse. R69 did not have any devices in place to prevent further decline in ROM. During an interview on 12/02/22 at 4:50 PM, UM1 (unit manager) stated R69's hand was not completely contracted .UM1 said she was not aware R69 needed ROM and did not believe staff provided ROM to R69. During an interview with (Certified Nursing Assistant) CNA2 on 12/02/22 at 4:55 PM, she said she had not done any ROM on the R69's hand. On 12/02/22 at 5:05 PM during an interview with the Regional Clinical Supervisor she stated her expectations were that residents requiring ROM received the care and services to prevent further decline in ROM. Review of the policy titled, Contracture Management Program, undated, revealed .Contracture management is essential to minimize decline of ROM, prevention of deformity, improve joint mobility and posture, protect skin integrity, minimize pain and maximize function and quality of life .Obtain an MD order for splint, wear schedule .Establish a schedule for use of all positioning devices .Establish a ROM program . Review of the policy titled, Functional Maintenance Program, undated, revealed To ensure all residents discharged from the rehab services who continue to require a lesser level of rehab care are afforded a Functional Maintenance Program to prevent decline of function . NJAC 8:39-27.1(a) NJAC 8:39-27.2(m)

Based on observations, interviews, record review, and policy review, the facility failed to ensure an indwelling catheter was anchored to prevent excessive tension on the catheter tubing for one of two residents (Resident (R) 54) reviewed for catheter care out of a total sample of 20 residents. This failure increased R54's risk of injury to the urinary tract. Findings include: Review of R54's undated ADMISSION RECORD, located in the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with multiple diagnosis to include chronic inflammatory demyelination polyneuritis (nerve damage resulting in pain and tingling), neuromuscular dysfunction of bladder (loss of bladder control), and functioning quadriplegic (paralysis of arms and legs). Review of R54's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/22 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R54 was cognitively intact and had an indwelling catheter. Review of R54's Physician's Orders, for 11/22 and under the Orders tab located in the EMR, revealed no order for a catheter guard to secure her catheter tubing. Review of R54's comprehensive Care Plan, initiated 09/16/21 and located under the Care Plan tab in the EMR, revealed .Catheter Strap- check placement of catheter strap every shift . Observation on 11/30/22 at 12:01 PM revealed R54 lying on her bed in her room awake. R54 had a urinary bag on the left lower bed frame. During an interview on 11/30/22 at 12:01 PM, R54 stated she had had an indwelling urinary catheter since 2019 because she could not fully empty her bladder. R54 confirmed she did not have a stat lock or leg strap on either of her upper legs to hold the catheter tubing in place. R54 stated her catheter accidentally came out with the bulb (inflated balloon used to keep the catheter in the bladder) intact a few months ago. R54 stated that it was painful when the catheter came out. During an observation and interview on 12/01/22 at 11:58 AM of R54 with the Rehabilitation Director (RD), she confirmed R54 did not have a stat lock or leg strap holding her indwelling catheter tubing in place. During an interview on 12/01/22 at 1:35 PM, License Practical Nurse (LPN) 3 confirmed the facility required the indwelling catheter's tubing to be secured to the upper leg with a secure guard to avoid the indwelling catheter tubing from pulling or coming out and injuring the resident. LPN3 confirmed if a resident's indwelling catheter tubing were accidentally pulled out with the balloon inflated, it could cause a resident a serious injury. LPN3 confirmed R54 had an indwelling catheter but she was not sure if R54 had a stat lock holding her indwelling tubing in place. During a second observation on 12/01/22 at 1:47 PM of R54 with LPN3 in her room, LPN3 verified R54 did not have a stat lock on her upper leg to hold her catheter tubing in place. During an interview on 12/01/22 3:55 PM, Unit Manager Registered Nurse (UM) 2 confirmed a secure guard was a device used by the facility to stabilize a resident's indwelling catheter tubing. UM2 confirmed R54 did not have a secure guard in place but should to ensure her catheter tubing did not get yanked out causing injury to R54. Review of facility-provided undated policy titled, .CATHETER CARE revealed .Ensure catheter is anchored using strap or other anchoring device . NJAC 8:39-19.4(a)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to utilize appropriate personal protective equipment (PPE) to prevent the potential spread of infection in accordance of Center for Disease Control and Prevention (CDC) guidelines and acceptable standards of practice. This deficient practice was identified for one staff member on 1 of 2 units reviewed for infection control practices and was evidenced by the following: On 02/04/21 at 9:30 AM, during the surveyors' entrance conference, the Administrator stated the entire facility was on patient-specific contact plus airborne precautions, and the required PPE to be worn on the units were N95/KN95 and face shields. She stated gowns needed to be worn inside the resident rooms. On 02/04/2021 at 9:55 AM, the surveyor observed signage on double doors before the Garden unit entrance. The doors were closed and had yellow signs that included a picture of a face shield and an N95 mask. During an interview with the surveyor on 02/04/2021 at 10:05 AM, the Licensed Practical Nurse (LPN) on the Garden Unit stated the required PPE to be worn on the unit was an N95 with a face shield. She said when going into the resident's room, the staff had to wear a gown. On 02/04/2021 at 10:40 AM, the surveyor observed a housekeeper enter the Garden Unit with her cart and stopped in front of a resident's room. The housekeeper was observed wearing a face shield with an N95 over a surgical mask and had a gown in her hands. As the surveyor approached the housekeeper, the housekeeper walked away from the surveyor and came back with the Environmental Supervisor. On 02/04/2021 at 10:45 AM, the surveyor interviewed the Environmental Supervisor due to the housekeeper's language barrier. The Environmental Supervisor stated she trained the housekeeper on the proper use of the N95 with the assistance of an employee who spoke the housekeeper's language. She noted the housekeeper was not wearing the masks correctly, and the N95 should not be worn over a surgical mask because there would not be a seal, and the mask would not be effective. During an interview with the surveyor on 02/04/2021 at 12:00 PM, the Staff Educator and Infection Preventionist stated the facility was on contact airborne precautions. The PPE worn in the hallway was supposed to be an N95 and face shield. She further noted that staff was educated on the PPE that should be worn in the facility and on the units. She stated the document labeled, Use of Goggles, Face shields and N95 Respirators On and Off Units were the guidelines used in the facility for PPE use. Additionally, she stated the proper way to wear an N95 was to wear it directly on the face to create a seal, and a surgical mask should not be worn underneath an N95. A review of a document dated November 9, 2020, titled Use of Goggles, Face Shields, and N95 Respirators on an off units indicated that when units were placed on Contact and Airborne Precautions, the staff must wear goggles or face shields with an N95 that will serve as the universal mask for the shift. Review of in-service dated 12/20/20, with the topic of Infection Control Prevention, included a brief description that face shields and N-95 were to be applied before entering the units, and gowns and gloves were to be applied and changed with each resident contact. The in-service revealed the housekeeper's attendance. Review of a document labeled Clinical Competency Validation: Putting on (Donning) Personal Protective Equipment (PPE)/ Taking Off (Doffing) PPE for the housekeeper revealed the housekeeper successfully completed the competency on 06/24/2020. According to the Center for Disease Control and Prevention (CDC), How to Properly Put on and Take off a Disposable Respirator included but was not limited to; Do not allow facial hair, hair, jewelry, glasses, clothing, or anything else to prevent proper placement or come between your face and the respirator. NJAC 8:39-19.4(a)(2);27.1(c)

Based on interview and record review it was determined that the facility failed to follow the care plan and failed to adhere to facility policy relating to the use of Sit to Stand (a mechanical lift device) for Resident #10 who sustained fall and fracture. This deficient practice was noted for 1 of 18 residents reviewed for adherence to care plans and was evidenced by the following: The surveyor reviewed the resident's quarterly Minimum Data Set Assessment ((MDS) dated [DATE] which indicated that the resident was totally dependent during transfer and required the assistance of 2 staff for transfer. The surveyor reviewed the resident's care plan titled, (The resident) is at risk for falls: Impaired mobility. The last intervention listed which was created on 10/23/12 and revised on 11/30/15 read: Assist (the resident) getting in and out of bed or w/c with the assist of two assist. On 8/2/16 at 9:50 a.m., the surveyor reviewed the resident's record. A progress note dated 6/26/16 read: (The resident) was being transferred to the bed from a wheelchair; while sitting on the side of the bed in the sit-to-stand (machine) the bed moved and (the resident) began to slide off the side of the bed; CNA (Certified Nursing Assistant) lowered (the resident) to the floor. (The resident) sustained a left lateral shoulder blade abrasion which (the resident) said is tender to the touch but no other pain reported at the site. On 8/2/16 the surveyor also reviewed the facility's investigation of the 6/26/16 fall. The investigation indicated that the resident fell on [DATE] at 6:00 p.m. There was one witness named, the CNA who transferred the resident. On 8/4/16 at 12:37 p.m. the surveyor interviewed the CNA that was transferring the resident at the time of the fall. The CNA stated, I was with the sit-to-stand and had already transferred (the resident) to the bed and unfortunately the bed moved. (The resident) was on the edge of the bed sliding down. When (the resident) started sliding I removed the pad and slid (the resident) down to the floor. The surveyor asked the CNA if she transferred the resident by herself. The CNA said yes. The CNA further stated, That day they cleaned this room . I didn't know that housekeeping didn't lock the bed. The bed was low. That's the mistake I made. I didn't check. I usually check. I didn't know the room was cleaned that day. If I knew I would have locked it. This is my assignment so all my beds are locked but they cleaned it that day. Further review of the progress notes on 8/4/16 at 1:00 p.m., found that Resident #10 started to complain of left leg pain on 6/28/16 which continued until 7/5/16 when the nurse found the resident in bed at 9:14 a.m., lethargic and pale. The resident was then transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. The surveyor reviewed the facility's policy and procedure titled, Safe Resident Handling/Transfer Equipment The section that addressed the Sit-To-Stand Lift read: Use of the Sit-To-Stand Lift requires two staff members. On 8/4/16 at 1:00 p.m., the survey team requested additional information from the Administrator and the DON and expressed concern for the CNA not following the care plan and the resident falling and sustaining a fracture. On 8/5/16 at 10:00 a.m., the administrative staff provided no further information. For further information refer to 323. NJAC 8:39-11.2 2 (bf)

Based on observation, interview, and record review it was determined that the facility failed to reduce safety hazards, follow the resident's care plan and follow the facility's policy when transferring a resident from a wheelchair to a bed. The resident fell and sustained a fractured femur (thighbone) requiring hospitalization . The fracture also resulted in increased pain and limitation of the resident's usual activities. This deficient practice was noted for Resident #10, 1 of 9 residents reviewed for falls and was evidenced by the following: On 8/1/16 at 6:50 p.m., during the initial tour, the surveyor observed the resident in bed with the privacy curtain pulled. The Unit Manager stated that the resident had previously fallen in the facility and sustained a fracture. On 8/2/16 at 9:35 a.m., the surveyor observed Resident #10 lying in bed. The bed was not in a low position. The surveyor asked the resident about falling at the facility. The resident replied, They say I had a fall but I don't remember having any fall. On 8/2/16 at 12:40 p.m., the surveyor observed the resident in a wheelchair at the bedside with a brace on his/her left leg. On 8/2/16 at 9:50 a.m., the surveyor reviewed the resident's record which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the resident's care plan titled, (The resident) is at risk for falls: Impaired mobility. The last intervention listed which was created on 10/23/12 and revised on 11/30/15 read: Assist (the resident) getting in and out of bed or w/c with the assist of two assist. The surveyor reviewed the resident's quarterly Minimum Data Set Assessment ((MDS) dated [DATE] which indicated that the resident was totally dependent during transfer and required the assistance of 2 staff for transfer. The resident's Brief Interview of Mental Status was scored at 9 out of 15 with 15 indicating that a resident would be very alert and oriented. The score of 9 reflects Resident #10 had cognitive deficits. A progress note dated 6/26/16 read: (The resident) was being transferred from w/c to bed; while sitting on the side of the bed in the sit-to-stand (machine) the bed moved and (the resident) began to slide off the side of the bed; CNA (Certified Nursing Assistant) lowered (the resident) to the floor. (The resident) sustained a left lateral shoulder blade abrasion which (the resident) said is tender to the touch but no other pain reported at the site. The surveyor reviewed the investigation into the fall that the facility had completed. The investigation indicated that the resident fell on [DATE] at 6:00 p.m. There was one witness named, the CNA who transferred the resident. Under the heading, Describe the circumstances of the event and immediate actions taken it read: (The resident) was being transferred to bed from wheelchair when the bed moved and (the resident) was lowered to the floor to break fall. (The resident) sustained a bruise to (the resident's) left shoulder. (The resident) is alert and able to make needs known. Staff will check to make sure that all brakes on bed and wheelchair are locked prior to all transfers. Under the heading, What preventative measures were in place prior to this fall? It read: Assist (the resident) getting in and out of bed or w/c (wheelchair) with the assist of two assist. Educate staff in utilizing sit to stand lift (the mechanical lift device). When interviewed by the surveyor on 8/4/16 at 12:37 p.m., the CNA that was transferring the resident at the time of the fall stated I was with the sit-to-stand and had already transferred (the resident) to the bed and unfortunately the bed moved. (The resident) was on the edge of the bed sliding down. When (the resident) started sliding I removed the pad and slide (the resident) down to the floor. The surveyor asked the CNA if she transferred the resident by herself. The CNA said yes. The CNA further stated That day they cleaned this room . I didn't know that housekeeping didn't lock the bed. The bed was low. That's the mistake I made I didn't check. I usually check. I didn't know the room was cleaned that day. If I knew I would have locked it. This is my assignment so all my beds are locked but they cleaned it that day. The CNA did confirm to the surveyor that she was aware Resident #10 was to be transferred with 2 staff. The surveyor confirmed with the CNA that the room had been carbolized (a more thorough cleaning) the day of the fall. The surveyor checked the carbolization schedule for June 2016. The day of the fall was Sunday 6/26/16. There were no rooms on the schedule for that day. According to the schedule the resident's room had been carbonized on 6/7/16. Further review of the progress notes on 8/4/16 at 1:00 p.m. found that the resident started to complain of left leg pain on 6/28/16 which continued until 7/5/16 when the nurse found the resident in bed at 9:14 a.m., lethargic and pale. The resident was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. The Physician's Assistant's progress note dated 7/6/16 from the hospital read: Discussed potential surgical intervention with patient and (patient's) emergency contact. Both patient and emergency contact feel surgery not a great option. Risks are too high and (the resident) will still not be ambulatory. The resident was readmitted to the facility on [DATE]. On 7/18/16 the nurse conducted a pain assessment which found that over the last 5 days the resident had experienced pain frequently and that this pain had limited the resident's day to day activities. The pain intensity was rated an 8 on a scale from 0 to 10. A nurses note dated 7/30/16 at 11:35 a.m. read, It was noted earlier in the month that (the resident) sustained a fracture, was sent to the hospital-but treatment was refused-(the resident) returned. (The resident's) left knee at this time is swollen, warm to touch, and there is a nodule that is protruding from the knee cap area. A progress note dated 8/1/16 at 4:01 p.m. read, (The doctor) informed on the situation with the resident's knee. Staff noted that the knee reduced in size and made it apparent to the bone fracture, which is red and could open at anytime. MD assessed the left knee, and made (the resident) aware of the implications if no surgery is done. Resident still made MD/staff aware that (the resident) does not want surgery or to be sent to the hospital for that. A progress note dated 8/2/16 at 8:21 p.m. read, Left knee reddened color with minimal swelling seen allowing a more visible area where the internal bone is pressing outward on the skin but not through the skin. The surveyor reviewed the facility's policy and procedure titled, Safe Resident Handling/Transfer Equipment The section that addressed the Sit-To-Stand Lift read: Use of the Sit-To-Stand Lift requires two staff members. On 8/4/16 at 1 p.m., the survey team spoke with the administrative staff about the concern with Resident # 10 being transferred by one staff person when all instructions were for two staff and the CNA failed to lock the bed leading to the resident falling and sustaining a fracture of the left femur. On 8/5/16 at 10 a.m., the administrative staff provided no information to dispute the findings of the survey team. NJAC 8:39-27.1 (a)

Based on interview and record review, it was determined that the facility failed to develop a plan of care reflecting a resident's exhibited behaviors of ingesting foreign objects, wandering throughout the facility, spitting and urinating in public areas (including other resident's rooms), as well as multiple incidents of aggressive behavior toward staff with unsuccessful attempts at re-direction. On 8/3/11 at 12:00 p.m., the facility was notified that failure to provide adequate supervision, failure to provide a safe environment and failure to develop a care plan to manage the resident's behaviors posed a serious and immediate threat to the resident and others. This deficient practice was identified for 1 of 15 sampled residents, Resident #16, as evidenced by the following: 1. On 8/3/11 at 9:00 a.m., the surveyor reviewed the medical record of Resident #16 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes from 3/11/11 to 8/3/11 revealed multiple incidents of behaviors, such as wandering throughout the facility, urinating and expectorating on furniture and floors, picking up and eating items from the trash and putting non edible items in his mouth. Review of the 3/11/11 care plan revealed that the IDC team identified "disruptive behavior as evidenced by wandering in other resident's rooms, resists care or treatment and being combative to staff and other residents." Some of the interventions included: "approach in a calm, friendly manner; assess and manage unmet needs such as pain, toileting, fatigue and hunger; familiarize with own belongings and surroundings and maintain a safe environment." The care plan did not identify the behaviors of urinating/expectorating on the floor/furniture or picking/eating items from the trash or putting non-edible items in his mouth. There were no interventions to address these behaviors to prevent recurrence. During an interview with the surveyor on 8/3/11 at 10:30 a.m., the unit manager stated that she was aware of the resident's behaviors but did not update the care plan to address them. During an interview with the surveyor on 8/3/11 at 11:00 a.m., the Administrator and DON stated that they knew the resident had behaviors, but were not aware of the severity and extent of the behaviors. They also stated that they had no knowledge of the PICA incidents and stated that these incidents should have been investigated. The DON told the surveyor that the evening and night shifts had not communicated these behaviors to her. The Immediate Jeopardy was identified on 8/3/11 at 12:00 p.m., and was corrected on 8/3/11 at 2:15 p.m., based on an acceptable plan of correction submitted by the facility, which included the following: 1. Resident #16's care plan was revised and individualized for his specific needs. 2. All residents with behavioral issues will be reassessed for appropriateness of behavioral care plans by 11:59 p.m., 8/3/11, by the DON or designees. 3. All staff will be re-educated on behavior management, non-pharmacological interventions and documentation of behaviors over the next three shifts. All nursing staff will document on the 24 hour report any behaviors that occur during their shift and the report will be reviewed by the interdisciplinary team at morning meeting beginning 3 p.m. on 8/3/11. Re-education will be conducted by NPE (Nurse Practice Educator) and Night Supervisor. 4. Random monthly audits will be conducted of behavioral care plans for appropriateness by unit manager or designee. Data collection to be submitted monthly to QA committee on the second Wednesday of the month x 3 months. Refer to F 323 for examples of how the facility failed to provide a safe environment and adequate supervision related to Resident#16's behavior. F279 remains a deficiency at s/s D, based on the following: Based on observation, interview and record review, it was determined that the facility failed to develop care plans, based on individual assessment to address the behavior of a resident with a history of resident to resident altercations, and for a resident with a history of wandering behavior and public urination. This deficient practice was identified for 2 of 15 sampled residents, Resident #9 and #17, as evidenced by the following: 1. The surveyor reviewed the medical record of Resident #9 on 8/1/11 at 10:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. Review of the medical record revealed nurses' notes which indicated that the resident was involved in several altercations with other residents. Examples are as follows: 12/24/10 at 20:58- "Resident at nurses' station talking inappropriately using foul language when reproached by staff became verbally and physically abusive screaming and cursing at staff and lightly hit another resident on the head who was laying on the couch where she wanted to be." 12/31/10 at 09:57- "Resident noted calling another female resident {Resident room # identified} names "stupid[***] " this am, while sitting on the couch in front of nsg. station." 2/22/11 at 22:40- "Resident is having behavioral issues the past two evenings. Last night she hit me in the stomach after I told her not to move a chart. This evening she verbally fought with {resident identified} and he almost hit her. Then she called {resident identified} the N word and the B word. She is compliant with taking her meds but she is very confrontational with the staff and some of the other residents." 6/14/11at 09:44- "Resident taunts residents especially when they are severe dementia. Resident sat next to a resident and poked at other resident and when resident did not respond to her, she slapped him on his arm. Resident had similar incident over the weekend, she pulled another resident's hair for no reason at all." At 11:40- "GEM ambulance in facility @11:15 a.m. to p/u resident for transport to St. Peters University hospital for behavioral problems (physically &verbally abusive to residents). Review of the care plan on 8/1/11 at 11:00 a.m., revealed that on 7/14/10 a focus was identified of "Exhibits behavior: resists care or treatment and can be verbally abusive and aggressive toward staff." The behaviors of multiple altercations with other residents as cited above, were not addressed on the care plan. On 8/2/11 at 11:45 a.m., the unit manager told the surveyor that she was not aware that the resident's abusive behavior toward other residents was not on the care plan. 2. The surveyor reviewed the medical record of Resident #17 on 8/2/11 at 10:00 a.m., which revealed [DIAGNOSES REDACTED]., and urinating on the floor and in the receptacle bin. On 8/2/11 and 8/3/11 at 1:30 a.m. the surveyor observed Resident #17 seated quietly in her room. The resident responded when her name was called and engaged in a simple conversation with the surveyor. An interview with the UMN,(Unit Manager Nurse), following the resident council meeting on 8/2/11 at 11:30 a.m., revealed that the facility was aware of Resident #17's behavior of wandering into other resident's rooms immediately following her admission on 6/28/11. Further review of the medical record revealed a psychiatry consult on 7/14/11, which identified the behavior of urinating on the floor and into the receptacle bin. On 8/2/11 at 12:30 p.m., the surveyor reviewed Resident #17's Care Plan, and observed that here was no intervention in place to address the behavior of urinating on the floor and into the receptacle bin. The Care Plan intervention for night time behavior was "attending activities" which were non existant for this time of day. Refer to F 272 for Resident #17 NJAC 8:39-1.2(e)(2)

Based on interview and record review, it was determined that the facility failed to provide adequate supervision to promote a safe environment and failed to investigate incidents for a resident with maladaptive behaviors. The resident had a history of [REDACTED]. The resident also exhibited multiple instances of urinating and spitting in public areas and in other resident's rooms which caused the potential for choking and falls for Resident #16 and environmental hazards for other residents. The resident had instances of aggressive behavior toward staff and was unable to be redirected. On 8/3/11 at 12:00 p.m., the facility was notified that the resident's behavior posed a serious and immediate threat to the resident and others. This deficient practice was identified for 1 of 15 residents reviewed for accident hazards, Resident #16, as evidenced by the following: During the group interview on 8/2/11 at 10:30 a.m., 3 of 7 residents identified Resident #16 by name and stated that this resident wandered unsupervised throughout the facility and into other resident rooms during the night. One resident stated that she had been awakened on a few occasions by the resident standing at the foot of her bed and tapping her feet. On 8/3/11 at 9a.m., the surveyor reviewed the medical record of Resident #16 which revealed the following: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes from 3/11/11 to the time of survey revealed multiple incidents of behaviors, such as wandering, expectorating/urinating on the furniture /floor and removing items from other resident rooms, nurses' station and the trash. On two occasions the resident was found with non edible items in his mouth and was non compliant and became agitated and aggressive when staff attempted re-direction. Examples of the uncontrollable behaviors as found in the progress notes included the following: On 3/11/11 at 3:36 a.m., "gets out of bed and goes to rooms across the hall, urinated on 105's floor." On 3/19/11 at 3:17a.m., "going into other rooms, combative to staff when redirected." On 3/21/11 at 10:30p.m., "aggressive to staff when redirecting him, gets out of bed and will void anywhere- floors, trash can or hall; sleeps in short naps." On 3/23/11 at 3:25a.m, "becomes aggressive pushing away staff raising his fist at staff while trying to show him where bathroom is, trying to void in trash cans or other resident rooms." On 3/31/11 at 6:33a.m, "alert but confused, requires constant supervision, seen walking down the hall in other patient's rooms, did not sleep during the night." On 4/17/11 at 8:03a.m, "resident was agitated on the shift. He kept on getting up from the wheelchair. He kept on unlocking his belt to get up; attempts were made to redirect patient. Patient was not compliant to redirections at all. He displays very poor safety awareness; staff were forced to keep a one on one watch on him." At 6:59a.m, "resident was found sitting on the floor." On 4/26/11 at 12:05 a.m., "confused and refused to listen to nursing staff, extremely agitated when assistance is provided; sits in wheelchair at the nurse's station and spits on the floor; told numerous times not to spit on the floor and was given tissues to spit into; threw the tissues on the floor and continued to spit on the floor throughout the entire shift." On 4/29/11 at 3:50 a.m., "remains non compliant to all care, must be watched continuously; up walking into other resident rooms removing items from the desk and cart and rooms." On 4/30/11 at 3:44a.m, "resident awake all nite unable to orientate nor redirect him, becomes combative tries to kick or punch staff members; threw table and chairs in dining room this nite; walking into other residents rooms and taking their possessions, spitting on floors and furniture; toileted and snacks given but not successful, trying to go out doors, voiding on floors even after taken to toilet; did not sleep all nite." On 5/1/11 at 3:05 p.m., "continues to be non compliant to all care, tried 3 x's to go outside, continues to spit everywhere, floors, med cart and furniture." On 5/2/11 at 12:27a.m, "when staff try to redirect resident, became very abusive by hitting them." On 5/5/11 at 11:10 p.m., "gets out of chair spontaneously and ambulates around unit without assistance; refuses redirection, uncooperative, resistive to care; ambulated down the hall to room 124 and urinated on the floor; became combative when staff attempted to direct him." On 5/9/11 at 3:16 a.m., "walking about, non compliant, threatened to hit anyone who goes near him, states he is going home, unable to orientate him." On 5/22/11 at 6:48 a.m., "resident continues to be non compliant, awake all night trying to go outside, going into other resident rooms and scaring them; would not sit nor stay in bed, urinates anywhere he wants, expectorates all over floors and furniture and becomes combative toward staff when redirected. Removes items from resident rooms and will not give them back to staff. When asked if he wants to go to bed just laughs and states he will do as he damn well pleases; and no use in redirecting him because of his combativeness." On 5/23/11 at 3:23a.m, "continues to be awake and roaming in and out of rooms or trying to go outdoors, unable to direct him, becomes aggressive, picked up wheelchair legs form a wheelchair in hallway and wanted to hit a staff member with them; did not sleep all night, unable to redirect or orientate him." On 5/25/11 at 3:31a.m, "continues to be awake at night, continues to roam all over and into other resident rooms, does get aggressive and will try to strike out when redirected; urinates and expectorates wherever he wants, unable to orientate or redirect." On 6/6/11 at 3:19a.m, "continues to roam about frequently, gets combative when redirected, continues to urinate all over or expectorates where he pleases; frequently tries to take things out of trash cans." On 6/8/11 at 3:04a.m, "continues to be awake and roaming all over the wing and in rooms and tries to go out the doors; unable to redirect, becomes very aggressive towards staff and will try to hit or curse at staff." On 6/11/11 at 11a.m, Resident #16 was "found on the floor in another resident's room (110) with his own urine around him." On 6/14/11 at 3:13a.m, "continues to walk entire building at night; tries to go in other rooms and tries to go out doors." On 6/19/11 at 10:21p.m, "resident tries to eat the garbage out of trash cans and picks up non-edible objects and puts them in his mouth; resident noted as having beads (the type found in costume jewelry) in his mouth shortly after getting up from a late afternoon nap." On 7/7/11 at 3:48 a.m., "resident awake all night, walking all over unit, going out doors; going into other rooms, very aggressive to staff when redirected; was eating something, when asked said pork chop- made resident spit object out of mouth-was a Styrofoam plate." On 7/29/11 at 3:42 a.m., "awake all night, going into other resident rooms and disturbing them; becomes agitated when told to sit down and will swear or raise his fists to staff members, unable to orientate nor redirect him." On 8/3/11 at 4:09a.m, " awake all night, states he has to go downtown to get his daughter, going out doors, gets angry when redirected, will try to hit staff; unable to orientate nor redirect him." Review of the care plan revealed that on 3/11/11, the IDC team identified behaviors such as "wandering in other resident rooms, resists care and combative to staff and other residents." The interventions included: "approach in a calm manor, assess and manage unmet needs such as pain, toileting, fatigue and hunger, familiarize with own belongings and surroundings, obtain psychiatric evaluation as ordered and to maintain safe environment." On 4/28/11, the care plan identified, "risk for elopement" as a problem. Interventions included to "redirect when security system sounds and/or resident attempts to leave the building; if unable to redirect, stay with resident and provide support and supervision until able to redirect." The care plan did not identify the behaviors of urinating/expectorating throughout the facility or the pica behaviors exhibited on 6/19 and 7/7/11. There was no behavior plan/interventions to attempt to modify these behaviors. On 8/3/11 at 10 a.m., an unsampled resident told the surveyor that Resident #16 wandered throughout the facility and into other resident rooms, especially during the night. The resident stated that Resident #16 had wandered into her room about a month ago. She told the surveyor she was frightened at that time, since he was a "big man." She said that she felt sorry for the night nurse, since the nurse had to constantly clean up after Resident #16 when he urinated and expectorated on the floors and the furniture. On 8/3/11 at 10:15a.m, the Certified Nurses' Assistant (CNA) caring for Resident #16, stated that the resident was usually continent and was toileted during the day. She stated that he was usually compliant during the day but was more of a problem at night. She said that she heard he wandered the halls and into other resident rooms at night and became aggressive with staff upon redirection. On 8/3/11 at 10:30a.m, the unit manager (UM) stated that Resident #16 exhibited "sundowning behaviors." She stated that the resident wandered throughout the facility and into other resident rooms during the night and became aggressive when staff attempted re-direction. She stated that Resident #16 urinated and expectorated whenever and wherever he pleased. The UM stated that she was aware of the pica incidents of 6/19/11 and 7/7/11, but investigations had not been done. She also stated that the physician and the Director of Nursing (DON) had not been notified of the incidents. She stated that Resident #16's care plan was not revised to address the behaviors. On 8/3/11 at 11a.m, the DON and Assistant Director of Nursing (ADON) stated that Resident #16 was not aggressive to other residents, so he was never sent out to a Crisis Center for an evaluation. They stated, that they were not aware of the frequency of the resident's behaviors and that they were not informed regarding the pica incidents. The DON stated that investigations of the pica incidents should have been done. On 8/4/11 at 10:00 a.m., the surveyor interviewed the Assistant Director of Nurses', (ADON), who stated that she was also the Infection Control Coordinator in the facility. The ADON stated that she was not aware of the extent of the spitting/urinating incidents and did not, therefore, take action from an infection control perspective. On 8/4/11 at 10:30a.m., the surveyor interviewed the social worker, who stated that she had been in contact with Resident #16's legal guardian, regarding a transfer to a Dementia Unit. Review of the social worker progress notes revealed 3 entries in the medical record as follows: On 3/22/11 was an initial care plan meeting, on 3/30/11, a room transfer note and on 8/3/11(while the survey was in progress), an entry regarding a possible transfer to a dementia unit. There were no other social service notes which indicated that the social worker had been in contact with the resident's legal guardian regarding alternate placement. The immediate jeopardy was identified on 8/3/11 at 12:00 p.m., and was corrected on 8/3/11 at 2:15 p.m., based on an acceptable plan of correction which included the following: 1. Resident #16 will have one to one supervision beginning 8/3/11 by an appointed CNA, 24 hours a day until behaviors are appropriate. 2. All residents with behavioral issues will be reassessed for appropriateness of behavioral care plans by 11:59 p.m., 8/3/11 by DON or designees. 3. All staff will be re-educated on behavior management, non-pharmacological interventions, and documentation of behaviors over the next three shifts. All nursing staff will document on the 24 hour report any behaviors that occur during their shift and the report will be reviewed by the interdisciplinary team at morning meeting beginning p.m. on 8/3/11. Re-education will be conducted by NPE (Nurse Practice Educator) and Night Supervisor. 4. Random monthly audits will be conducted of behavioral care plans for appropriateness by unit manager of designee. Data collection to be submitted to QA committee on the second Wednesday of the month x 3 months. NJAC 8:39-37.1(a)