Every finding on record at Phoenix Center for Rehabilitation and Pediatrics

Repeat DeficiencyComplaint # 2977054Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to show residents who were dependent on staff for activities of daily living (ADL) consistently received care assistance. This deficient practice was identified for 2 of 2 sampled residents who were dependent for ADLs, and was evidenced by the following: 1.) On 6/30/26 at 11:30 AM, the surveyor observed Resident #19 seated in a motorized wheelchair, dressed and conversant. Resident #19 stated that at times it took an hour for the staff to provide hygiene care after a bowel movement and was left in bed for 18 hours on Memorial Day weekend this year.The surveyor reviewed the medical record for Resident #19.According to the admission Record, (an admission summary) Resident #19 was admitted to the facility with diagnoses that included but were not limited to; quadriplegia (paralysis affecting all four limbs and the torso/trunk), chronic embolism and thrombosis (long term blood clots) of the lower extremity and benign prostatic hyperplasia (BPH; enlarged prostate causing urinary urgency or frequency).A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 6/5/26, included a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident's cognition was intact. Further review of the MDS revealed the resident was dependent on staff for toileting hygiene, shower/bathing, upper and lower body dressing, putting on and taking off footwear, personal hygiene.A review of the Individualized Comprehensive Care Plan (ICCP) included a focus area, dated 3/3/23, that the resident had an ADL self-care performance deficit related to quadriplegia, limited mobility, and musculoskeletal impairment. Interventions included: Total staff participation to reposition and turn in bed, dated 3/3/23. Further review of the ICCP reflected another focus area, dated 12/19/19, that the resident was resistive to care related to Post Traumatic Stress Disorder (PTSD) refused care offered by certain staff specifically [redacted] male. Interventions included have two (2) CNAs (or Nurse and CNA) present during care. No [redacted] male CNA, dated 6/16/21. Additionally, if the resident refused care, leave resident and return in 5 to 10 minutes, dated 12/19/19.A review of the Documentation Survey Report for May 2026 to June 2026 (Point of Care (POC) where the Certified Nursing Assistant (CNA) documented electronically care assistance provided to residents) revealed no care assistance was signed as provided on all three shifts for the following dates:-Sunday, May 10, 2026-Sunday, May 24, 2026-Sunday June 21, 2026.The unsigned tasks included oral care, personal hygiene, bathing, bed mobility, bladder continence, bowel elimination, dressing, toilet use, transferring, safety device of 2 (two) side rails, and skin observation.A review of the electronic Medication Administration Record (eMAR) revealed the following on the respective dates.- on Sunday May 10, 2026, no behaviors were documented on all three (3) shifts (7AM-3PM. 3PM-11PM and 11PM-7AM).-on Sunday May 24,2026, 2 behaviors of extreme fear with [redacted] male staff for the day shift and no behaviors were documented for the evening (3PM-11PM) and night shift (11PM-7AM).-on Sunday June 21,2026, no behaviors were documented on all three (3) shifts (7AM-3PM. 3PM-11PM and 11PM-7AM). 2.) The surveyor reviewed the closed medical record for Resident #216.According to the admission Record, (an admission summary) Resident #216 was admitted to the facility with diagnoses that included but were not limited to; Lennox-Gastaut Syndrome (LGS, severe, rare form of childhood-onset epilepsy), and gastrostomy (feeding tube inserted through the abdominal wall directly into the stomach).A review of the comprehensive MDS, dated [DATE], included that the resident was rarely/never understood, a BIMS score of 00 out of 15 which indicated the resident had severely impaired cognition. Further review of the MDS revealed the resident was dependent on staff for toileting hygiene, shower/bathing, upper and lower body dressing, putting on and taking off footwear, personal hygiene. Further review of the MDS reflected the following: Resident #216 was dependent for shower and bath, required substantial maximal assistance (helper provided more than half the effort) for oral hygiene, personal hygiene (such as combing hair, washing and drying hands ), toileting hygiene (perineal hygiene, adjusting clothes before/after voiding) , upper body dressing, lower body dressing) and putting on and taking off shoes.A review of the Individualized Comprehensive Care Plan (ICCP) included a focus area, dated 1/9/26, that the resident required assistance, dependent on ADL care in bathing, grooming, dressing, eating, bed mobility, transfer, locomotion, and toileting. Interventions included: Provide assistance for ADLs (toileting, ambulation, transfers, bathing, and dressing) dated 1/9/26.A review of the Documentation Survey Report (POC) from January 9, 2026, to March 16, 2026, revealed no care assistance was signed as provided on all three shifts for the following days:-January 9, 10, 11, 12, 13, 14, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, and 31. A total of 17 out of 23 days.-February 1, 2, 3, 4, 5, 6, 7, 8, 10, 14, 15, 16, 17, 18 19, 20, 21, 22, 24, 25, 26, 27, and 28. A total of 18 out of 28 days.-March 2, 6, 9, 10, 12, 13, 14, and 15. A total of 8 out of 15 days.The unsigned tasks included oral care, oral hygiene, personal hygiene, bathing, showers, bladder continence, bowel continence, bowel elimination, dressing, toilet use, transferring, bed mobility, dressing as needed, and eating.On 7/8/26 at 11:59 AM, during an interview with the surveyor, the Certified Nursing Assistant (CNA) stated residents were showered twice a week and bathed daily, care assistance provided to their assigned residents was signed in the POC.On 7/8/26 at 12:02 PM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM), showers were provided twice a week, residents were bathed at bedside daily. The LPN/UM stated she checked the CNAs POCs to ensure care assistance was rendered to the residents.At 12:06 PM, the surveyor and the LPN/UM reviewed the POC for Resident #19 and #216. At that time, LPN/UM stated based on the POC it does not look like they received daily care. The LPN/UM stated that it was getting done but not documented.On 7/8/26 at 1:18 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Administrator in Training, the surveyor discussed the concerns regarding care assistance with ADL for Resident #216 that were not signed as provided.On 7/9/26 during a meeting with the surveyors, the LNHA, the AIT and the Assistant Director of Nursing, the surveyor discussed the concern regarding care assistance with ADL for Resident #19 that were also not signed as provided. At that time, the LNHA stated that she conducted ADL audits, and that the care assistance was provided but were not signed.A review of the facility provided policy, titled Resident Showers, dated/revised 1/2025 included that residents would be provided showers as per requests, given partial baths in between regular shower schedules as per facility policy.A review of the facility provided policy, titled, Activities for Daily Living dated/revised 1/2026, included: Tell the resident you are going to help him learn how to do the task, but until he can do it himself, it will be done for him. The policy did not reflect a section for total dependent residents and documentation requirement after care was rendered. NJAC 8:39-27.2

Complaint #2580072Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing report was accurately posted within the facility for the residents and the visitors to view for 2 of 2 observations.This deficient practice was evidenced by the following: On 11/3/25 at 8:20 AM, the surveyor entered the facility and observed that the Nursing Home Resident Care Staffing Report (NHRCSR) that was posted on the receptionist desk was dated 11/2/25, day shift. The NHRCSR was not up to date. On 11/3/25 at 2:18 PM, both the surveyor and the Unit Clerk/Certified Nursing Aide (UC/CNA), observed the posted NHRCSR was dated 11/2/25 for day shift. The UC/CNA informed the surveyor that she was covering for the Receptionist. She stated that she was unsure if she can update the posted NHRCSR because it was the responsibility of the Receptionist to post updated NHRCSR. On 11/3/25 at 2:21 PM, the surveyor notified the Director of Nursing (DON) of the above findings and concerns with regard to NHRCSR posted dated 11/2/25. On that same date at 2:45 PM, the DON informed the surveyors that the NHRCSR should be posted timely and updated for nursing staffing by whoever covering for the Receptionist. She confirmed that the NHRCSR reflected the staff to resident ratio and should comply with the requirements. A review of the facility's Posting of Nurse Staffing Information Policy that was provided by the DON, with a revision date of 6/2025, revealed, on a daily basis the nursing facility will post nurse staffing data for the licensed and unlicensed staff directly responsible for resident care in the facility. Procedure: 1. Data requirements: the facility must post the following information on a daily basis: facility name, current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurse, licensed practical nurses or licensed vocational nurses, certified nurses aide, and resident census. N.J.A.C. 8:39-41.2 (a)(b)(c)

Complaint #: NJ00186369Based on interviews, record review, and review of pertinent facility documents on 07/23/25, it was determined that the facility failed to ensure a ventilator tubing/circuit and tracheostomy tube were changed as deemed necessary and consistent with the professional standards of practice for Resident #7. This deficient practice was identified in 1 of 9 residents reviewed for tracheostomy care and services and was evidenced as follows: A review of Resident #7's admission Record (AR) revealed the resident was admitted to the facility with the following diagnoses which included but were not limited to: chronic respiratory failure, epilepsy (condition characterized by sudden, uncontrolled jerking or stiffening of the body), aphasia (an impairment in the ability to comprehend or formulate language because of a disorder in specific brain areas), Rett's syndrome (a genetic condition affecting the brain development in children), tracheostomy (a hole made by doctors through the front of neck which allows air to pass into the windpipe to help with breathing), gastrostomy (an opening into the stomach to allow the introduction of food through a feeding tube), and aspiration of fluids (accidental inhalation of liquid into the lungs). A review of the resident's Minimum Data Set (MDS), an assessment tool dated 03/19/25, under Section C revealed that the resident's cognitive skills for daily decision making was severely impaired. The resident's MDS further showed that the resident was totally dependent on staff for the completion of their Activities of Daily Living (ADLs). A review of the resident's individual comprehensive care plan (ICCP) dated initiated 9/11/24, included a focus area that the resident had a tracheostomy (trach) tube for respiratory needs/airway management and at risk for tracheitis and trach dislodgement. The ICCP further revealed that the resident was being maintained on continuous ventilator settings appropriate for the resident's needs. A review of the resident's Respiratory Therapy Record (RTR) for the month of March 2025 reflected an order: Change tracheostomy tube size 4.5 PED [pediatric] every month and further reflected that the tracheostomy tube was changed on 3/1/25. A review of the resident's progress notes (PN) dated 4/3/25 at 12:36 AM indicated that the resident was sent out to hospital due to continuous seizures and fever of 100.8 degrees Fahrenheit around 11:35 PM. The PN dated 4/3/25 at 5:56 AM, revealed that the resident was admitted in PICU (pediatric intensive care unit) hospital [name redacted] with diagnosis of seizure. A PN dated 4/15/25 at 2:31 PM, indicated the resident was received back to facility at around 12:35 PM from the hospital. A review of a document submitted by facility titled, Monthly Trach Change List, Month of April Year 2025, revealed that Resident #7's tracheostomy tube was changed for the month of April on 4/16/25, a day after the resident was readmitted to the facility. The above document had not reflected that the resident's tracheostomy tube was changed as scheduled on 4/1/25, prior to resident's transferred out to hospital on 4/2/25. A review of documents submitted by the facility titled, Ventilator Circuit Change Record Sheet (VCCRS) with dates range with scheduled weekend changes as follows:-The weekend of 2/1/25 and 3/29/25.-The weekend of 2/8/25 and 4/5/25.-The weekend of 5/24/25 and 7/19/25.The VCCRS did not include Resident #7's name. A review of Resident #7's ED [emergency department] to hospital admission notes in PICU dated 4/3/25, revealed the following present on admission: seizure, epilepsy, chronic respiratory failure, C. difficile colitis (inflammation of bowel caused by the bacteria, C. difficile), pneumonia due to Serratia marcescens (respiratory infection caused by the bacteria, S. marcescens), and pneumonia of right upper lobe (right upper part of lung) due to Klebsiella pneumoniae (a bacteria causing respiratory infection). On 7/23/25 at 11:31 AM, during a tour of the ventilator (vent) unit with the Assistant Director of Nursing (ADON), the surveyor interviewed the Head Respiratory Therapist (HRT). The HRT stated every resident on ventilator had schedules for changing the ventilator tubing every eight weeks by the Respiratory Therapist (RT). The HRT further stated the changing of the tracheostomy tubes for the pediatric residents were once a month on the first week of the month by the RT, and that the RT had a schedule. On 7/23/25 at 12:15 PM, during a continued tour of the vent unit with the ADON, the ADON stated that the blue ventilator tubing that was connected to the residents and attached to the ventilators were called the ventilator circuits. The ADON further said the ventilator circuits and the tracheostomy tubes were changed by the RT. On 7/23/25 at 12:30 PM, the surveyor requested from the ADON and HRT the March, April, and May 2025 ventilator circuit and tracheostomy tube changing schedules or log. On 7/23/25 at 2:22 PM, the surveyor interviewed the Director of Nursing (DON) and the Registered Nurse Unit Manager (RNUM) together with the ADON. The RNUM and DON stated the tracheostomy tubes were changed by the RT once a month and as needed. They further stated that the ventilator tubing or circuits which consisted of the blue tubing were changed by the RT according to the schedule. At that time, the surveyor showed the ventilator circuit schedules log submitted by the HRT for the scheduled months which revealed that Resident #7 was not included in the schedule. The ADON stated she would check again. On 7/23/25 at 4:23 PM, during exit conference with the facility, the ADON provided the surveyor with an additional VCCRS, which included Resident #7. According to that VCCRS, Resident #7's ventilator circuit was changed during the weekend of 2/8/25, on 2/8/25, and during the weekend of 4/5/25, on 4/5/25. Both changes were initiated and signed by RT #1 and RT #2. Resident #7 was transferred out to hospital on 4/2/25, and returned to the facility on 4/15/25. The surveyor questioned the accuracy of that VCCRS specifically for Resident #7's ventilator circuit on 4/5/25, because the resident was not in the facility at that time. The facility had no response. A review of facility policy titled, Vent Circuit Changes dated 2/10/22, under Policy: The following outlines the procedure used to change ventilator circuit; Indication: Circuit changes shall be done on an 8 week cycle or may be changed sooner if damaged or for any other reason that would require it; Documentation: Document circuit change in circuit change book and make a progress note; Change Frequency: every 8 weeks or PRN. A review of facility policy titled, Trach Change dated 1/31/22, under Policy: The following policy outlines the procedure used to institute the changing of trach tubes; Scope: Tracheostomy tubes shall be changed once per month on or about the 1st. N.J.A.C. 8:39-25.2 (c)4,6

Based on observation, interview, review of medical records, and other facility documentation, it was determined that the facility failed to complete post-dialysis assessments for residents on dialysis (a treatment that replicates the kidney's function and cleans the waste from blood for individuals with kidney disease or kidney failure). This deficient practice was identified for 2 of 2 residents (Resident # 127 and #179) reviewed for dialysis and was evidenced by the following: 1. On 1/21/25 at 11:00 AM, during the initial tour of the 4th floor unit, the surveyor observed that Resident #127 was not in his/her room. The Charge Nurse (CN) stated that the resident was at dialysis. The CN stated that the resident received renal dialysis three times a week. On 1/27/25 at 8:00 AM, the surveyor observed Resident #127 in bed on a specialty mattress. The resident did not respond to the surveyor's greeting. The surveyor reviewed the medical record for Resident #127. A review of the Admission Record reflected Resident #127 was admitted to the facility with diagnoses that included but were not limited to; dependence on renal dialysis. A review of the most recent Minimum Data Set (MDS), an assessment tool dated 12/27/24, revealed Resident #127 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident's cognition was severely impaired. A review of Resident #127's medical record revealed that the resident was scheduled for hemodialysis (HD) on Tuesday, Thursday, and Saturday at 10:00 AM. An active Physician's Order, dated 11/24/23, indicated Blood Pressure monitoring pre and post-HD every Tuesday, Thursday, and Saturday; check BP prior to leaving for Dialysis and upon returning from Dialysis. A review of the HD communication log revealed that the facility completed the pre-dialysis assessments and the HD center completed the assessment while the resident was at the HD center. There was no portion on the communication log which reflected if the facility completed a post-HD assessment. On 1/27/25 at 8:10 AM, the surveyor interviewed the Registered Nurse (RN) on the 4th-floor unit, who stated that the dialysis communication binder would be sent with the resident on dialysis days. The nurse would complete the top section of the form, and the dialysis center would complete the bottom section. When the resident returned from dialysis the facility nurse would sign the bottom of the form and document the time the resident returned to the facility. The receiving nurse would then document the vital signs and post HD assessment in the Progress Notes. The surveyor reviewed Resident #127's Progress Notes, which revealed that the facility nurses documented a post-HD assessment for some of the dates when the resident returned from the HD center, but the documentation was not consistent. There were no post-HD assessments, which included vital signs for the dates of 1/4/25, 1/7/25, 1/11/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, and 1/25/25. 34421 2. On 1/22/25 at 10:30 AM, the surveyor observed Resident #179 in their room and upon interview, the resident stated that they received renal dialysis three times a week. The resident stated that they could not recall if the resident was assessed when they returned to the facility from the dialysis center. The surveyor reviewed the medical record for Resident #179. According to the Admission Record, Resident #179 was admitted with diagnoses that included but were not limited to; end stage renal disease and dependence on renal dialysis. A review of the Admission Minimum Data Set (MDS), an assessment tool used to manage care, dated 11/5/24, revealed Resident #179 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated that the resident was moderately impaired for cognition. A review of Resident #179's medical record revealed that the resident was scheduled for hemodialysis (HD) on Tuesday, Thursday and Saturday at 10:15 AM. A review of the HD communication log revealed that the facility completed the pre-dialysis assessments and the HD center completed the assessment while the resident was at the HD center. There was no portion on the communication log which reflected if the facility completed a post-HD assessment. The surveyor reviewed Resident # 179's Progress Notes (PN), which revealed that the facility nurses documented a post-HD assessment for some of the dates when the resident returned from the HD center, but it was not consistent. There were no post-HD assessments for the dates of 2/19/24, 12/26/24, 12/28/24, and 1/9/25 in the PN's. On 1/27/25 at 1:45 PM, the surveyor discussed the above concerns with the Director of Nursing (DON) and the Administrator. On 1/28/25 at 10:16 AM, the Administrator stated that the facility is aware that the residents should have post-HD assessments done by the nursing staff and they will address this concern. A review of the facility provided policy End-Stage Renal Disease, Care of a Resident dated/revised 1/28/24 reflected that Agreements between this facility and the contracted ESRD facility included all aspects of how the resident's care will be managed, including how information will be exchanged between the facilities. The general medical nurse should document in the resident's medical record every shift as follows: location of catheter, condition of dressing (interventions if needed), if dialysis was done during shift, any part of report from dialysis nurse post-dialysis being given and observation post dialysis. NJAC 8:39 - 27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain a dignified living environment for 1 of 35 residents reviewed (Resident # 83). The deficient practice was evidenced by the following: On 1/21/25 at 12:55 PM, the surveyor observed Resident # 83 in bed which was in a low position, with a sheet covering the resident. There was a staff member in the room seated next to the resident and the staff member stated that he was an aide who provided one-to-one care for Resident # 83. There were no personal belongings in the resident's room, and the wall in the resident's room were bare and had nothing on them. There was brown colored cardboard and tape covering over the air conditioning unit in the resident's room. The floor tiles were discolored and mismatched and there was an approximately 8-inch hole in the wall. At 1:00 PM, the surveyor interviewed the aide, who could not explain what happened and why the hole was there. The aide stated that Resident # 83 gets one to one supervision, 24 hours a day because the resident has behaviors of aggression, pulling things off the wall and has a history of knocking furniture over. The aide stated that the resident is blind in both eyes and cannot have furniture or belongings in the room as Resident # 83 will feel around the room and knock them down. At 1:10 PM, the surveyor interviewed the Licensed Practical Nurse, Charge Nurse, (LPN,CN) who stated that Resident # 83 is blind and has aggressive behaviors. She stated that the resident disrobed often and often became destructive of property as well. The LPN, CN stated that the resident cannot have personal belongings in their room. The LPN, CN stated that the air conditioning unit was covered and taped as Resident # 83 often tried to pull parts of the unit apart. The LPN, CN also stated that she did not know why there was a hole in the wall or why the floors looked like they did. A review of the resident's Admission Record revealed diagnoses which included, but were not limited to; behavioral and emotional disorders, autistic disorder, blindness to right and eft eye, schizophrenia, anxiety, and intellectual disabilities. The resident has care plans in place for impaired visual function and disruptive and aggressive behaviors. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 11/1/24, revealed Resident # 83 had no Brief Interview for Mental Status, as the resident was assessed as rarely or never understood. On 1/22/25 at 12:27 PM, the surveyor discussed the above concerns with the Director of Nursing (DON) and the Administrator. The DON who stated that the resident is uncontrollable when they are angry, and the resident cannot have belongings in the room because they get ripped down and destroyed. The DON and Administrator stated that they could have done other things to make the room more homelike but had the resident's safety in mind. The DON and Administrator stated that they would look into why there was a hole in the room and will observe the floors too. On 1/22/25 at 1:14 PM, the surveyor interviewed the Maintenance Director (MD), who stated that he was aware of the hole in the resident's wall and the mismatched tiles. The MD did not know how long the hole was in the resident's wall and stated it should have been fixed. The MD stated that the facility does need to replace the flooring. The MD also stated that the facility put the cardboard and tape onto the air conditioning unit and there might be a way to make it look more homelike. A review of the facility's policy titled, Safe and Homelike Environment, dated 10/25/24 revealed that a homelike environment is one that de-emphasizes the institutional character of the setting. NJAC 8:39-4.1(a)12

Based on observation, interview, and record review, it was determined that the facility failed to store 1 of 35 residents (Resident # 83) personal clothing in a sanitary manner. This deficient practice was as evidenced by the following: On 1/21/25 at 12:55 PM, the surveyor observed Resident # 83 in bed which was in a low position, with a sheet covering the resident. There was a staff member in the room seated next to the resident and the staff member stated that he was an aide who provided one-to-one care for Resident # 83. The surveyor observed that inside the resident's bathroom, the resident's clothing was on hangers and located hanging on the shower curtain rod, which was approximately 5 feet from the resident's toilet. At 1:00 PM, the aide stated that Resident # 83 gets one to one supervision, 24 hours a day because the resident has behaviors of aggression, pulling things off the wall and has a history of knocking furniture over. The aide stated that the resident is blind in both eyes and cannot have furniture or belongings in the room as Resident # 83 will feel around the room and knock them down. The aide stated that Resident # 83 uses the toilet in the bathroom on occasion and is incontinent at times too but gets showers in the communal shower room. At 1:10 PM, the Licensed Practical Nurse, Charge Nurse, stated that the resident's clothing was stored in their bathroom, on the shower rod because the resident could not have a dresser or closet in their room, but stated that there could be a better way to store it more hygienically, like in a container. On 1/22/25 at 12:27 PM, the surveyor discussed the above concerns with the Director of Nursing (DON) and the Administrator. The DON stated that the clothing was stored in the resident's bathroom because the resident knocks over furniture in their room and they will look into storing the clothing in a different way to prevent concerns with infection control. N.J.A.C. 8:39-19.4(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that urinary drainage bags were stored and secured in a manner to prevent contamination and infection control. This deficient practice was identified for 2 of 3 residents reviewed (Resident # 39 and #70), and was evidenced by the following: 1.On 1/21/25 at 11:10 AM, the surveyor observed Resident #70 in bed. The surveyor observed the resident had a tracheostomy with a large portable oxygen tank infusing at 6 Liters per minute (lpm) via trach collar tubing and two urinary drainage bags lying on top of the resident ' s bed, one on each side of the resident. The surveyor observed there were two privacy bags affixed to the lower aspect of the upper left and right-side rails. The surveyor reviewed the medical record for Resident #70. A review of Resident # 70 ' s Admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; acute kidney failure, nephrostomy catheter (a small flexible tube that drains urine from the kidney into a bag outside the body), a suprapubic catheter (a small flexible tube that drains urine from the bladder through a small incision in the lower abdomen and connected to a drainage bag outside the body), tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help air and oxygen reach the lungs), gastrostomy (tube surgically inserted into the stomach to deliver nutrition), aphasia (language disorder that affects a person ' s ability to communicate) and respiratory failure. A review of Resident #70 ' s quarterly Minimum Data Set (MDS), an assessment tool dated 12/27/24, revealed Resident #70 had severely impaired cognition. The MDS further assessed that the resident was dependent on staff for Activities of Daily Living (ADL) care and had an indwelling nephrostomy tube and suprapubic catheter. A review of Resident #70's Individualized Care Plan (CP) included a focus that indicated the resident had a right nephrostomy tube and a suprapubic catheter due to obstructive uropathy from kidney stones initiated on 2/28/20 with interventions that included keeping the drainage bag below bladder level. On 1/21/25 at 11:20 AM, the surveyor asked the Licensed Practical Nurse (LPN) assigned to Resident #70 ' s care (7 AM-3:00 PM shift) to accompany her to Resident #70 ' s room. The surveyor and LPN entered the resident ' s room and observed the two urinary drainage bags on the bed. The surveyor asked the LPN if the drainage bags should be stored in the privacy bags located on the lower aspect of the right and left upper side rails located below the bladder for privacy and proper drainage. The LPN again stated that the resident ' s mother wanted the bags in the bed. On 1/21/25 at 11:25 AM, the surveyor interviewed Resident #70 ' s Certified Nursing Assistant (CNA #1), who stated that the urinary drainage bags should be contained in the privacy bags that were affixed to the lower part of the side rails to ensure privacy and proper drainage. CNA#1 further stated that she had not provided care to the resident that morning and had not observed the urinary drainage bags in the bed. On 1/21/25 at 11:32 AM, the surveyor interviewed the Charge Nurse (CN), who confirmed that the urinary drainage bags should always be stored in privacy bags for privacy and below the bladder level for gravity and to prevent urinary tract infections. 2. On 1/21/25 at 11:38 AM, the surveyor observed Resident #39 in bed on a specialty mattress. The resident responded to the surveyor ' s greeting with a thumbs up and a smile. Resident #39 did not respond verbally. The surveyor observed that Resident #39 had a tracheostomy, with an oxygen concentrator in place, infusing 1.5 Liters per minute (lpm) via trach collar tubing. The surveyor observed the urinary drainage bag was affixed to the lower aspect of the bedframe, not contained within the privacy bag that was hanging on the bedframe next to the drainage bag. The surveyor reviewed the medical record for Resident #39. A review of Resident #39's Admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; tracheostomy, gastrostomy, aphasia, respiratory failure, paraplegia (a condition that causes paralysis in the lower half of the body) urinary tract infection, and hemiplegia (a condition that causes weakness or paralysis on one side of the body) affecting their right dominant side. A review of Resident #39's quarterly MDS dated [DATE], revealed Resident #39 had severely impaired cognition. The MDS further assessed that the resident was dependent on staff for Activities of Daily Living (ADL) care and had an indwelling urinary catheter. A review of Resident #39's CP included a focus that indicated the resident had an Indwelling catheter; initiated on 1/18/22 with interventions that included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door initiated. On 1/21/25 at 11:45 AM, the surveyor and CN entered the Resident ' s room and observed the urinary drainage bag affixed to the left lower aspect of the bed frame with the privacy bag hanging next to the urinary drainage bag. The CN confirmed that the urinary drainage bag should have been stored properly within the privacy bag, not next to it. On 1/21/25 at 11:45 AM, the surveyor interviewed the CNA ( CNA #2) assigned to Resident #39 ' s care (7 am-3:00 pm shift), who confirmed that the resident ' s urinary drainage bag should have been stored in the privacy bag that was affixed to the lower left side of the bed for privacy and infection control. On 1/21/25 at 11:50 AM, the surveyor interviewed the LPN assigned to Resident #39 ' s care (7 am-3:00 pm shift). The LPN acknowledged that she should have placed the urinary drainage bag inside the privacy bag for dignity and infection control. A review of the facility ' s Catheterization (Foley) policy and procedure revised 10/2024 indicated .Position tubing and hang the drainage bag on the bed frame to provide optimal gravity drainage .always keep the catheter bag below the level of the bladder . On 1/27/25 at 1:45 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The DON confirmed that all urinary drainage bags should be kept below the level of the bladder and stored in privacy bags. NJAC 8:39- 31.8 (c)(9)

NJ 175442 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain timely assistance with breakfast, and morning care (assistance with, but not limited to feeding, continence care, dressing, and grooming) for a resident who was totally dependent on staff for activities of daily living (ADL). This deficient practice was identified in 1 of 2 residents (Resident #169) reviewed for ADL and was evidenced by the following: On 1/21/25 at 11:07 AM, during the initial tour, the surveyor, from the hallway, observed Resident #169 in their room, seated in a wheelchair, well dressed, and was in the middle of a video conference call. The video conference device utilized by Resident #169 appeared mounted on a stand. The surveyor reviewed the medical record for Resident #169. According to the Admission Record, (an admission summary), reflected that Resident #169 was admitted to the facility with diagnoses that included the following: unspecified injury of the cervical spinal cord (damage to spinal cord), and neuromuscular dysfunction of the bladder (urinary incontinence). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 11/7/24 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. In addition, the MDS further revealed there were no behaviors related to rejection of care, had the ability to understand staff, and the ability to be understood by staff. Resident #169 was totally dependent on staff for all activities of daily living (ADL; include eating, bathing, dressing, mobility and continence care). A review of the resident's individual comprehensive care plan (CP) included a focus area, that Resident #169 had difficulty with self-feeding related to paraplegia, initiated on 8/26/24. The associated intervention included a one-to-one feeding assistance by staff, initiated on 8/26/24. Further review of the CP reflected a focus on the resident's bowel and bladder incontinence, initiated on 2/2/24. The associated intervention included frequent and as required checks, cleansing, rinsing, drying of personal areas, change of clothing after incontinence episodes. A review of Resident #169's grievance form, dated 7/7/24 at 11:41 AM, revealed that the Social Worker (SW) was notified by the resident that they had not received any care, breakfast was not offered, and had not been fed. A review of the Certified Nursing Assistant (CNA #1's ) signed statement revealed that Resident #169 was originally assigned to a different CNA (CNA #2) who at that time was not in the building. CNA #1 was not informed that Resident #169 was added to her assignment of 19 residents in total. Resident #169 was not fed and not cleaned by 11:00 AM. The SW went to the facility to ensure care was rendered and the resident ate lunch. On 1/23/25 at 10:25 AM, during an interview with the surveyor, the SW stated that she had initially taken the complaint and notified the Assistant Director of Nursing (ADON) of the grievance. On 1/23/25 at 11:28 AM, during an interview with the surveyor, the ADON stated that she was informed by the SW and the incident had occurred on a Sunday. The ADON also stated that there was miscommunication, wherein the nurse on duty did not inform CNA #1 of the additional assigned residents that included Resident #169. The ADON stated that the breakfast was offered to the resident, but the resident refused since it was almost lunch time. The ADON confirmed that the resident had to be fed and was totally dependent for ADLs. At that time, the surveyor and the ADON reviewed the provided assignment sheet for 7/7/24. The ADON confirmed CNA #1 had 19 assigned residents and acknowledged that they were short staffed on that day. On 1/23/25 at 1:34 PM, in the presence of the survey team, and the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) stated that every resident needed to received care and staffing was a challenge, but they worked hard to meet the staffing needs. The DON acknowledged awareness of the staffing shortage for that day. The DON also stated that the staff was overwhelmed that day, and that the CNA did not know that the resident was re-assigned to her, all of which were summarily contributors to the delayed morning care and feeding of Resident #169, who was totallhy dependent on staff. A review of the provided facility policy, Activities of Daily Living dated/revised 6/1/23, revealed that resident will gain/ or maintain as much independence as possible in ADLs which are essential to the individual's lifestyle. NJAC 8:39-4.1(a)22, 17.2(f)

Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice by not following a physician's order for 2 of 35 of the residents (Resident #39 and #50) reviewed. The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 1/21/25 at 11:38 AM, the surveyor observed Resident #39 in bed on a specialty mattress. The resident responded to the surveyor's greeting with a thumbs up and a smile. Resident #39 did not respond verbally. The surveyor observed Resident #39 had a tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help air and oxygen reach the lungs), with an oxygen concentrator in place with humidifier infusing at 1.5 Liters per minute (lpm) via trach collar tubing. The surveyor reviewed the medical record for Resident #39. A review of Resident #39's Admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; tracheostomy, gastrostomy (tube surgically inserted into the stomach to deliver nutrition), aphasia (language disorder that affects a person's ability to communicate) respiratory failure, paraplegia (a condition that causes paralysis in the lower half of the body) urinary tract infection, and hemiplegia (a condition that causes weakness or paralysis on one side of the body) affecting their right dominant side. A review of Resident #39's Order Summary Report (OSR) reflected Resident #39 had an active Physician's order (PO) Oxygen 28% FIO2 (fraction of inspired oxygen), the percentage of oxygen that a person inhales) to infuse at 3 Liters per minute (lpm) via a trach collar every shift with a start date of 11/11/24. A review of Resident #39's quarterly Minimum Data Set (MDS), an assessment tool dated 12/18/24, revealed Resident #39 had severely impaired cognition. The MDS assessed that the resident was dependent on staff for Activities of Daily Living (ADL) care. The MDS further assessed that the Resident received Respiratory Care, which included Tracheostomy care and Oxygen Therapy. A review of Resident 39's Individualized Care Plan (CP) included a focus that indicated the resident had a Tracheostomy r/t respiratory failure with interventions, which included giving humidified oxygen as prescribed with an initiated date of 3/22/23. On 1/21/25 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #39's care (7 am-3:00 pm shift). The LPN confirmed that the Oxygen gauge was set at 1.5 lpm. The surveyor asked the LPN if that was what the physician ordered. The LPN replied that she would check the doctor's order. The LPN and surveyor reviewed the PO which indicated that the Oxygen was ordered to be delivered at 3 lpm. The LPN confirmed that she had not checked the oxygen settings that morning to ensure the resident had received the proper lpm. A review of the facility's Oxygen Therapy policy and procedure revised 10/2024 indicated .Adjust the rate of flow according to the doctor's orders. A review of the facility's Physician Order policy and procedure revised 10/7/24 indicated .Admission orders are verified with the physician . Any order that is in question must be repeated to the physician .Notify the nursing administration and medical director whenever an order that is questioned cannot be verified . On 1/27/25 at 1:45 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The DON stated that the respiratory therapists sometimes change the Oxygen settings but confirmed that the LPN should have been knowledgeable regarding the Oxygen order and administration. On 1/28/25 at 10:16 AM, the survey team met with the LNHA, DON, and Director of Respiratory Therapy (DOR). The DOR stated that the resident had received the appropriate FiO2 at 28% and that the respiratory therapists changed the gauges on the concentrators to ensure the resident received the proper concentration. The DOR further stated that the doctor should not write the order to include the lpm, that the orders come from the hospital, and that was why they were written that way. The DOR confirmed that the order should have been clarified with the physician and followed accordingly. The LNHA confirmed that the LPN should have clarified and followed the PO.

Based on observation, interview, and record review, it was determined that the facility failed to accurately develop and implement a person-centered comprehensive care plan for care and service needs. This deficient practice was observed for 1 of 35 residents reviewed, Resident # 28, as evidenced by the following: 1. On 1/21/25 at 1:16 PM, the surveyor observed Resident # 28, in the dayroom and the resident was unable to answer the surveyor's questions. The surveyor reviewed Resident #28's Electronic Medical Records. Resident #28's face sheet revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; pulmonary embolism. The Quarterly Minimum Data Set (MDS) an assessment tool dated 10/11/24, which revealed that there was no Brief Interview for Mental Status, as the resident was assessed as rarely or never understood. A review of the Physician's Order Sheet (POS) revealed the resident had a physician's order for Apixaban 5 mg 1 tablet by mouth twice daily. The surveyor reviewed the resident's current care plans. There was no comprehensive care plan developed regarding the resident's order for the anticoagulant medication. On 91/27/25 at 1:45 PM, the surveyor interviewed the Director of Nursing (DON), who stated that a care plan for the anticoagulant medication which was prescribed to Resident # 28 should have been created. The DON was unable to locate the care plan for the anticoagulant medication. The surveyor with the policy titled Care Plan, dated 12/2024, which revealed that the comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment. NJAC 8:39- 11.2 (e)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 1 of 35 residents reviewed for the accommodation of needs (Resident # 39), and was evidenced by the following: On 1/21/25 at 11:38 AM, the surveyor observed Resident #39 in bed on a specialty mattress. The resident responded to the surveyor's greeting with a thumbs up and a smile. Resident #39 did not respond verbally. The surveyor observed Resident #39 had a tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help air and oxygen reach the lungs), with an oxygen concentrator in place infusing at 1.5 Liters per minute (lpm) via trach collar tubing. The surveyor observed that the resident's call bell (used to summon staff for assistance) was affixed to the left siderail, not within his/her reach. The surveyor reviewed the medical record for Resident #39. A review of Resident #39's Admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; tracheostomy, gastrostomy (tube surgically inserted into the stomach to deliver nutrition), aphasia (language disorder that affects a person's ability to communicate) respiratory failure, paraplegia (a condition that causes paralysis in the lower half of the body) urinary tract infection, and hemiplegia (a condition that causes weakness or paralysis on one side of the body) affecting their right dominant side. A review of Resident #39's quarterly Minimum Data Set (MDS), an assessment tool dated 12/18/24, revealed Resident #39 had severely impaired cognition. The MDS further assessed that the resident was dependent on staff for Activities of Daily Living (ADL) care. A review of Resident 39's Individualized Care Plan (CP) included a focus that indicated the resident was unable to verbalize his/her preferences with a goal that he/she would be asked questions that would allow him/her to utilize a thumbs-up/down for communication and facial expression. The CP did not include an intervention that addressed keeping their call bell within reach on their left side (diagnoses of right-sided hemiplegia). On 1/21/25 at 11:40 AM, the surveyor asked the Charge Nurse (CN) to accompany her to Resident #39's room. The surveyor and CN entered the Resident's room and observed the resident in bed and the call bell affixed to the left side rail, not within the resident's reach. The CN confirmed that the resident's call bell should have been placed within the resident's reach. On 1/21/25 at 11:45 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) assigned to Resident # 39's care (7 am-3:00 pm shift), who confirmed that the resident was able to use their call bell and that he should have placed it within the resident's reach. On 1/21/25 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #39's care (7 am-3:00 pm shift). The LPN acknowledged that the call bell should have been placed within Resident #39's reach. The LPN confirmed that Resident #39 was nonverbal and needed their call bell in order to summon staff assistance. A review of the facility's Call Bell Response policy and procedure revised 10/2024 indicated .the CNA will place the call bell within easy access for the resident . On 1/27/25 at 1:45 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The LNHA confirmed that the call bells should be placed within the residents' reach. NJAC 8:39- 31.8 (c)(9)

Complaint# NJ00173746 Based on interview, document review, and review of facility policy, the facility failed to ensure it reported the results of their findings for an injury of unknown origin to the State Survey Agency that ruled out abuse and neglect for 1 (Resident #2) of 3 sampled residents. This deficient practice is evidenced by the following According to the Admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Cerebral Palsy, Disorders of Psychological Development, Hypothyroidism, and Aphasia. A review of the Resident #2 Physician Progress Notes (PPN), dated 05/08/2024 at 11:50, indicated Resident #2, was .Awake, alert, nonverbal, baseline. The PPN further revealed, Pt [resident] noted with discoloration to forehead and A/P [assessment/plan]: Head injury to frontal lobe of unknown cause without LOC [loss of consciousness] . A review of the document presented to the surveyor by facility staff revealed the following: Resident #2's Incident Report (IR) #1185 Skin Injury dated 05/08/24 at 12:01p.m., documented by Licensed Practical Nurse (LPN) #1, under Nursing Description: Resident has multiple discoloration on his forehead and headline and under Resident Description: Resident Unable to give Description. The IR further revealed under Notes and signed by Unit Manager Registered Nurse (UMRN) showed under the Summary of Incident: During AM [morning] care, [Resident #2] was found to multiple discolorations on his forehead. Conclusion: [Resident #2] is an alert, active child. He has history of rocking himself. He could have hit his forehead on a siderail, head board, or foot board. No substantiated evidence of abuse or neglect. The IR further revealed under Witnesses Statement on 5/8/2024 indicated [CNA #1] went into [Resident #2] room [#] at 8:30 am to do AM [morning] care and to get him ready for school .CNA#1 noticed knots and a small scrape on his [Resident #2] forehead .went to look for his nurse .and called the clinical manager [UMRN] to look at . During the tour and interview with the surveyors on 05/15/24 at 9:40 a.m., the UMRN stated on 5/8/24 at around 8:10 to 8:15 a.m., CNA #1 called her/him to look at Resident #2. UMRN further stated she noted discoloration on his [Resident] forehead, dark bluish with a little abrasion, no bleeding. UMRN stated she investigated immediately. UMRN affirmed the incident was not witnessed and stated that Resident #2 had behavior of rocking back and forth and flailing of arms which were not new. According to UMRN, CNA#1 did not witness the incident and that [Resident #2] was aphasic [cannot talk] and cannot explained what happened. During an interview with the surveyors on 05/15/24 at 3:34 p.m. with the LNHA, DON, and ADON, LNHA stated DON and her/him were responsible for reporting all allegations of abuse, neglect, or misappropriation to the New Jersey (NJ) DOH. LNHA stated that she/he was aware of Resident #2's incident in the morning meeting. Both LNHA and DON asserted that incident was caused by Resident #2 behavior of rocking his [Resident #2] head back and forth. DON stated she/he was aware of the child [Resident #2] behavior. LNHA affirmed that Resident #2's incident was not witnessed, Resident #2 was nonverbal, no staff could explain what happened, and there was injury to the Resident. The facility was unable to provide further explanation. A review of the facility's policy titled Abuse Prevention, revised 01/2024 indicated under REPORTING: In response to allegations of abuse .the facility must ensure that: All allegations of abuse must be immediately reported to the Director of Nursing and or Administrator and no later than 2 hours to other officials (including to the State Survey Agency) after the allegation is made, if the event that caused the allegation involve abuse or result in a serious bodily injury. The alleged violations must be reported no later than 24 hours to the State Survey Agency if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. NJAC 8:39-9.4(f)

C#: NJ00169635 Based on interviews and record review, as well as a review of pertinent facility documents on 12/14/23 and 12/15/23, it was determined that the facility staff failed to immediately report an allegation of abuse to New Jersey Department of Health (NJDOH) and follow the facility policy titled Abuse Prevention for 1 of 3 residents (Resident #1) reviewed for reporting. This deficient practice is evidenced by the following: According to the Admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: Cerebral Palsy and Convulsions. A Minimum Data Set (MDS), an assessment tool, dated 11/17/23, revealed that Brief Interview for Mental Status (BIMS) for Resident #1 was unable to be conducted due to resident was resident is rarely/never understood and the resident required assistance with activities of daily living (ADLs). A review of the facility's Grievance Form (GF) dated 11/30/23 at 4:55 p.m. and signed on 12/8/23 by the Social Worker (SW), the GF reflected, Resident's [family member] (FM) called SW [Social Worker] stating [Resident #1] was in a horrible condition and possibly going to not make it the night. [FM] further stated it was 'abuse' that [he/she] is in [his/her] current condition and that [he/she] smells bad. The GF further reflected that the GF had to be redirected to Nursing, and the facility had scheduled to call the FM to discuss care. Furthermore, the GF revealed that Based on the above investigative summary, the facility is able to conclude that no abuse, neglect, mistreatment or misappropriation of Resident property has been identified. A review of the form Summary, dated 12/1/23, documented by the Licensed Nursing Home Administrator (LNHA), reflected On 11/30/2023, social worker spoke to [Resident's family member] and informed [SW] how upset [family member] was on the overall care for [Resident] and that it was abuse and neglect .[SW] informed the Administrator of the phone conversation she had with [family member]. [SW] informed the Administrator that there was no specification on allegation of physical, mental, or verbal abuse but that she was very upset about the overall care for [Resident #1]. The Administrator told DON [Director of Nursing] and started to interview staff to confirm there were no signs of abuse. After interviewing staff on 11/30/23, there were no signs of abuse substantiated. The Summary, After reviewing the interviews with the staff that cared for the [Resident] .there was no evidence of abuse substantiated. Attached to the Summary was a statement from the SW signed on 12/1/23, indicated that Resident #1's FM called and was crying. The FM reported that baby was going to die because [of] our abuse and neglect to [her/him] medically. [FM] did not mention any allegation of physical, mental or psychological abuse but overall was upset on [her/his] care. [SW] assured [FM] we did not abuse or neglect [him/her] .[RFM] was crying during call. During an interview with the surveyors on 12/14/23 at 1:52 p.m., the SW stated that she received the allegation of abuse and neglect from the FM when Resident #1 was admitted to the hospital on 11/30/23. The SW further stated that she reported the allegation of abuse and neglect to the DON and LNHA on 11/30/23 after speaking to the FM. During an interview with the surveyor on 12/14/23 at 2:56 p.m. with the DON and the SW, the DON stated that she was not aware of any abuse allegation until today (12/14/23) and that she did not investigate and reported to the NJDOH. The surveyors conducted an interview with on 12/15/23 at 1:01 p.m., the LNHA revealed that any allegation of abuse would need to report to NJDOH. The LNHA confirmed that she was made aware of the allegation of abuse and neglect from the SW on 11/30/23 (unable to recall exact time). The LNHA explained that on 11/30/23, she investigated the allegation of abuse and neglect by collecting verbal statements from staff. The LNHA revealed that she did not report to NJDOH and stated If I felt like there's abuse, I would report it or any suspicion of abuse, but there was no abuse. A review of the facility's policy titled Abuse Prevention, dated 10/4/2023 indicated . IDENTIFICATION: The facility will investigate all incidents involving actual or alleged abuse, complaints/grievances .INVESTIGATION: The facility will investigate all incidents involving actual or alleged abuse, complaints/grievances .PROTECTION: the facility will protect all residents during any abuse investigation by removing staff from direct care and/or removing from schedule pending conclusion. REPORTING: In response to allegations of abuse .the facility must ensure that: all allegations of abuse must be immediately reported to the Director of Nursing and or Administrator and no later than 2 hours to other officials (including to the State Survey Agency) after the allegation is made, if the event that caused the allegation involve abuse or result in a serious bodily injury . NJAC 8:39-9.4(e)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least every 60 days. This deficient practice continued over several months for 9 of 35 residents (Resident #58, 101, 141, 37, 158, 32, 24, 51, and #113) reviewed and was evidenced by the following: 1. On 10/17/23 at 11:06 AM, the surveyor observed Resident # 58 in bed. The surveyor interviewed the resident who was able to respond verbally using yes and no answers while nodding head. The surveyor reviewed Resident #58's hybrid medical records. The resident was admitted to the facility with diagnoses which included but not limited to Spinal Muscular Atrophy, Dependence on respirator and Chronic Respiratory Failure. A review of the Physician Progress Notes revealed that from July 2023 through 2023, the Nurse Practitioner (NP) documented that she had seen and examined the resident. There was no documentation that Resident #22's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. 2. On 10/17/23 at 11:00 AM, the surveyor observed Resident #101 in bed with eyes closed. The resident had a tracheostomy in place connected to continuous oxygen via trach collar. The resident was non-verbal. The surveyor reviewed Resident #101's hybrid medical records. The resident was admitted to the facility with diagnoses which included but not limited to Cerebral Palsy, Encephalopathy and Chronic Respiratory Failure. A review of the interdisciplinary progress notes revealed that from June 2023 through October 2023, the NP documented that she had seen and examined the resident. There was no documentation that Resident #101's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. 3. On 10/18/23 at 11:39 AM, the surveyor observed Resident #141 in bed with eyes open. The resident was non-verbal and unable to respond to the surveyor. The surveyor further observed a tracheostomy in place that was connected to a continuous oxygen via trach collar. The surveyor reviewed Resident #141's hybrid medical records. The resident was admitted to the facility with diagnoses which included but not limited to Anoxic Brain Damage and Acute Respiratory Failure. A review of the interdisciplinary progress notes revealed that there were no documented progress notes from Resident #141's primary physician nor NP since March 2023. 4. On 10/17/23 at 11:20 AM, the surveyor observed Resident #37 in bed with closed. The surveyor further observed that the resident had tracheostomy in place that was connected to a continuous oxygen via trach collar. Resident #37 was non-verbal. The surveyor reviewed Resident #37's hybrid medical records. The resident was admitted to the facility with diagnosis which included but not limited to Chronic Respiratory Failure, Aphasia and Cerebral Palsy. A review of the interdisciplinary progress notes revealed that there were no documented progress notes from Resident #37's primary physician nor NP since October 2022. 5. On 10/17/23 at 10:51 AM, the surveyor observed Resident #158 in bed with eyes closed. The surveyor further observed that the resident had a tracheostomy in place that was connected to a continuous oxygen via trach collar. Resident #158 was non-verbal. The surveyor reviewed Resident #158's hybrid medical records. The resident was admitted to the facility with diagnosis which included but not limited to Cerebral Palsy, Spastic Quadriplegia, and Scoliosis. A review of the interdisciplinary progress notes revealed that from July 2023 through October 2023, the NP documented that she had seen and examined the resident. There was no documentation that Resident #101's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. 48273 6. On 10/17/23 at 10:48 AM, surveyor observed Resident #32 in bed with eyes open, non-responsive to verbal stimuli. The resident had a tracheostomy on continuous oxygen via trach collar. Observed on feeding tube with feeding Peptamen 1.5 administered by gravity. The resident was non-interviewable. A review of the Resident #32's Admission Record (a one-page summary of important information about the patient) that documented the resident's diagnosis which included but was not limited to Acute Respiratory Failure, Dependence on Respirator [Ventilator] Status, Quadriplegia, Tracheostomy, Gastrostomy. A review of the Progress Notes revealed that from April 2023 through September 2023, the Nurse Practitioner (NP) documented that she had seen and examined the resident. There was no documentation that Resident #32's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. 7. On 10/17/23 at 11:13 AM, surveyor observed Resident #24 in bed with eyes open, non-responsive to verbal stimuli. The resident had a tracheostomy on continuous oxygen via trach collar. Observed on feeding tube with feeding Jevity 1.2 administered at 60cc/hr. The resident was non-interviewable. A review of the Resident #24's Admission Record (a one-page summary of important information about the patient) that documented the resident's diagnosis which included but was not limited to Anoxic Brain Damage, Chronic Respiratory Failure, Dependence on Respirator [Ventilator] Status, Convulsions, Tracheostomy, Gastrostomy. A review of the Progress Notes revealed that from April 2023 through September 2023, the Nurse Practitioner (NP) documented that she had seen and examined the resident. There was no documentation that Resident #24's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. 8. On 10/17/23 at 10:53 AM, surveyor observed Resident #51 on specialized mattress with eyes open and non responsive to verbal stimuli. The resident had a tracheostomy on continuous oxygen via trach collar. Observed on feeding tube with feeding PediaSure Peptide 1.0 administered at 90cc/hr. The resident was unable to respond to surveyor. A review of the Resident #51's Admission Record (a one-page summary of important information about the patient) that documented the resident's diagnosis which included but was not limited to Anoxic Brain Damage, Chronic Respiratory Failure, Dependence on Respirator [Ventilator] Status, Convulsions, Tracheostomy, Gastrostomy. A review of the Progress Notes revealed that from April 2023 through September 2023, the Nurse Practitioner (NP) documented that she had seen and examined the resident. There was no documentation that Resident #51's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. 9. On 10/17/23 at 11:15 AM, surveyor observed Resident #113 in room with eyes closed on a specialized wheelchair. Observed resident with seatbelt and trunk vest in place. The resident had a tracheostomy on continuous oxygen via trach collar. A review of the Resident #113's Admission Record (a one-page summary of important information about the patient) that documented the resident's diagnosis which included but was not limited to Epilepsy, Cerebral Palsy, Hydrocephalus, Chronic Respiratory Failure, Respiratory Disorder. A review of the Progress Notes revealed that from April 2023 through September 2023, the Nurse Practitioner (NP) documented that she had seen and examined the resident. There was no documentation that Resident #113's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the NP visits. On 10/20/23 at 11:49 AM, surveyor interviewed Nurse Practitioner (NP), who collaborates with Primary Physician related to the process of monthly documentation of visits. NP stated she alternates with the primary physician for completing monthly visit progress notes. NP further stated it is expected for the progress notes to be completed every other month for her and documented in the progress notes. On 10/23/23 at 11:23 AM, the surveyors interviewed Assistant Director of Nursing (ADON) related to the concerns above. ADON acknowledged primary physician visit documentation is not up to date. No further information was provided. On 10/24/23 at 01:28 PM, the surveyor discussed with ADON, Administrator, and DON, who couldn't provide information why primary physician visit documentation was not up to date. On 10/25/23 at 10:40 AM, surveyor interviewed Primary Physician related to the process of visitation and documentation frequency in visit. Physician acknowledged that physician visit documentation is not up to date. No further information provided. A review of the facility's policy titled Physician Visits states, The resident should be seen by his/her attending physician, at least monthly for the first ninety days following the resident's admission, and, at least, once every 60 days there after. further review of the policy under Procedure . 2. Once attending physician determines that a resident needs not to be seen by him/her monthly, an alternate schedule of visit maybe established but at least every 60 days. NJAC 8:39-27.1

Based on record review and interview it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice continued over several months for 13 of 35 residents (#110, 182, 87, 129, 58, 101, 141, 37, 158, 113, 32, 24, and #51) reviewed and was evidenced by the following: 1. Resident #110's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. 2. Resident #182's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. 3. Resident #87's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for August 2023, and September 2023. 4. Resident #129's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for August 2023, and September 2023. 39399 5. Resident #58's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023 and September 2023. 6. Resident #101's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023 and September 2023. 7. Resident #141's hybrid medical record revealed that resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023 and September 2023. 8. Resident #37's hybrid medical record revealed that resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023 and September 2023. 9. Resident #158's hybrid medical record revealed that the resident's physician had not hand signed or electronically signed the monthly physician's orders for April 2023, May 2023, June 2023, and August 2023. 48273 10. Resident #113's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. 11. Resident #32's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. 12. Resident #24's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. 13. Resident #51's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for July 2023, August 2023, and September 2023. On 10/23/23 at 11:23 AM, the surveyor in the presence of another surveyor interviewed the Assistant Director of Nursing (ADON) regarding the process of signing the resident's monthly physician's order. The ADON stated that the physicians are expected to review the physician orders monthly and sign on the order tab to acknowledge that the medications were reviewed. The ADON further stated that the last medication review date could be found in the history section. On 10/24/23 at 01:28 PM, the survey team discussed the above concerns to the facility's ADON, Licensed Nursing Home Administrator (LNHA), and Director or Nursing (DON). The LNHA, DON and ADON could not provide further information as to why physician order review was not signed. On 10/25/23 at 10:40 AM, the surveyor in the presence of another surveyor interviewed the Physician via telephone related to the process of signing the resident's monthly physician's order. The physician stated that the medication review as well as the signing is done electronically in each resident's medical record. The physician acknowledged that the monthly medication review signature was not done. A review of the facility's document titled Physician Order revised on 1/5/23 under procedure states, .13. All monthly physician orders must be reviewed, updated as needed, and signed off. NJAC 8:39-11.2(a);23.2(b)

Based on observation, interview, record review, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 1 of 2 residents (Resident #39) reviewed for dialysis. This deficient practice was evidenced by the following: On 10/17/23 at 11:09 AM, the surveyor observed the resident was not in their room. The assigned LPN for Resident #39 stated the resident was currently at dialysis and was scheduled for dialysis every Tuesday, Thursday, and Saturday. A review of Resident #39's electronic health record (EHR) revealed the following: According to the Admission Record (an admission summary), Resident #39 was admitted with diagnoses that included but were not limited to, End Stage Renal Disease, and Dependence on Renal [kidney] Dialysis. An Annual Minimum Data Set (MDS) assessment, a tool used to facilitate management of care, dated 7/27/23, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #39 scored a 14 out of 15, which indicated the resident was cognitively intact. A physician's order dated 8/6/22 read: Dialysis Binder to accompany Resident to Dialysis each visit one time a day every Tue, Thu, Sat A physician's order, dated 7/28/23 read: [dialysis center's name, address and phone number] Pick-up by [transport company name] at 5AM Chair time: 6:15am A physician's order, dated 4/11/23 read: Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth two times a day for pain A physician's order, dated 6/19/23 read: Lidocaine External Patch 5 % (Lidocaine) Apply to back topically one time a day for pain and remove per schedule A physician's order, dated 8/10/23 read: Metoprolol Tartrate Oral Tablet (Metoprolol Tartrate) Give 25 mg by mouth every 12 hours for HTN hold for sbp<100 hr<60 A physician's order, dated 8/28/23 read: ZyrTEC Allergy Oral Tablet 10 MG (Cetirizine HCl) Give 1 tablet by mouth one time a day for allergy A review of the October 2023 MAR revealed the resident was scheduled to receive the following medications at 9am every day: Lidocaine External Patch 5 % (Lidocaine) Apply to back topically one time a day for pain and remove per schedule which was scheduled to be administered at 0900 [9AM]. ZyrTEC Allergy Oral Tablet 10 MG (Cetirizine HCl) Give 1 tablet by mouth one time a day for allergy which was scheduled to be administered at 0900. Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth two times a day for pain which was scheduled to be administered at 0900 and 1700 [5PM]. Metoprolol Tartrate Oral Tablet (Metoprolol Tartrate) Give 25 mg by mouth every 12 hours for HTN hold for sbp<100 hr<60 which was scheduled to be administered at 0900 and 2100 [9pm]. A review of nursing progress notes from 10/1/23 to 10/23/23 indicated that Resident #39 was out of the facility and returned from dialysis during the scheduled medication times as follows: -A progress note dated 10/21/23 documented the resident returned from dialysis at 11:25 AM. -A progress note dated 10/19/23, documented the resident returned from dialysis at 11:22 AM. -A progress note dated 10/17/23 documented the resident returned from dialysis at 11:25 AM. On 10/23/23 at 11:25 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) who had cared for Resident #39. The LPN stated medications would be scheduled to accommodate for when residents went to dialysis. The surveyor reviewed with the LPN the MAR of Resident #39. The LPN confirmed her signatures on the medications that were scheduled for 9am and documented as administered. The LPN stated that most of the time Resident #39 returned from dialysis at 10 am. The LPN acknowledged the medications should have been scheduled as the resident's other medications, to accommodate for when the resident had dialysis. On 10/23/23 at 11:31 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM), who stated the resident usually returned from dialysis at about 11AM to 12PM. The RN/UM further stated it was expected for medications to be timed to account for the resident's dialysis schedule. The surveyor informed the RN/UM about the interview with the LPN and reviewed the resident's MAR. The RN/UM acknowledged the zyrtec, gabapentin, metoprolol and lidocaine patch medications scheduled at 9am should have been plotted at a time to accommodate the resident's dialysis schedule. The RN/UM further acknowledged that it could not be guaranteed that the resident would return to the facility from dialysis by 10 AM to administer the medications as scheduled. On 10/23/23 at 1:06 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Assistant DON of the concerns for the timing of the resident's medication. There was no verbal response at this time. The surveyor requested any policy related to scheduling of medications for dialysis residents. On 10/24/34 at 9:54 AM, the LNHA provided the policy titled Medication Administration Time for Dialysis, dated 11/2017 with a revised date of 10/23/23. Under Procedure, the policy read: 3. Resident's medication administration time will be accommodated to reflect the days the resident is out of the facility during dialysis days. On 10/24/23 at 10:39 AM, the surveyor interviewed the DON who acknowledged the medications should have been timed to accommodate the resident's dialysis schedule and for when the resident was out of the facility. On 10/24/23 at 12:40 PM, the surveyor interviewed Resident #39 who was alert, oriented, and verbally responsive. The resident stated the time they returned from dialysis varied, could be 10 o'clock, 11, 12 .it depends. Resident stated they had no concerns with their care. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care, in accordance with federal guidelines. This deficient practice was identified for 2 of the 38 residents reviewed for resident assessment (Resident#81 and Resident#171). The deficient practice was evidenced by the following: 1. On 10/17/23 at 10:50 AM, the surveyor observed the resident sleeping in bed, covered with a blanket, with an aide sitting in the chair beside the resident's bed. The aide stated the resident was on 1:1 observation since Feb. 2023. The surveyor reviewed the hybrid medical record for Resident #81. The Admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to unspecified intellectual disabilities. A review of the quarterly MDS dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 3 out of 15, indicating that the resident had severe cognition. A review of the annual MDS dated [DATE] did not reflect the resident's Preadmission Screening and Resident Review (PASSR) - Is the resident currently considered by state level II PASSR process to have serious mental illness and/or intellectual disability or a related condition? Enter code 0 (zero) No. On 10/20/23 at 11:54 AM, the surveyor interviewed the MDS Coordinator and stated that the resident is PASSR Level 2 (two) and should be captured in the annual MDS assessment on 6/14/23. The form PASSR Level II determination notification dated 09/4/2018 revealed that The Level II for Developmental Disability Evaluation was completed. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual updated October 2023. All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions. 34033 2. On 10/17/23 at 12:22 PM, the surveyor observed Resident #171 in bed with a cover over his/her head. The resident had not responded to surveyor's attempts to interview. The surveyor reviewed the medical record for Resident #171. The Admission Record (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to quadriplegia. A review of the electronic MDS entries reflected that the resident had a reentry date of 5/25/23. A review of the quarterly Minimum Data Set (QMDS) with an Assessment Review Date (ARD) of 7/20/23, reflected a BIMS score of 15 out of 15, indicating that the resident had an intact cognition. In addition, in Section A: Most Recent Admission/Entry or Reentry into this Facility reflected that the resident had a reentry date of 5/25/23. A review of a nursing progress note dated 5/24/23 at 19:45 (7:45 PM) reflected that the resident had returned to the facility at 7:45 PM via stretcher. On 10/23/23 at 10:17 AM, the surveyor interviewed the MDS Coordinator who stated that he based the admission or readmitted s of a resident from the notice that he received. At that time, the surveyor with the MDS Coordinator reviewed the MDS entries and the progress note dated 5/24/23 for Resident #171. The MDS Coordinator acknowledgd that Resident #171 was readmitted to the facility on [DATE]. The MDS Coordinator acknowledged that the MDS reentry date of 5/25/23 was incorrect. The MDS Coordinator then stated that he would have to complete a modification to correct the error. On 10/25/23 at 9:57 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA). The LNHA acknowledged Resident #171 had an incorrect readmitted entered on the MDS. The LNHA stated that the MDS Coordinator had corrected the date. The LNHA stated that the facility followed the Resident Assessment Instrument manual for instructions completing the MDS. NJAC 8:39-11.1, 11.2(e)(1), 33.2(d)

Based on the interview and record review, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment for 1 of 38 residents, (Resident #149) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. Resident #149 was observed to have a Quarterly MDS of 6/06/23 and was due to betransmitted no later than 6/19/23. The Quarterly MDS was not transmitted until 8/28/23. 2. Resident #149 was observed to have a Quarterly MDS of 3/06/23 and was due to be transmitted no later than 3/19/23. The Quarterly MDS was not transmitted until 4/04/23. 3. Resident #149 was observed to have an Admission MDS of 12/6/22 and was due to be transmitted no later than 12/19/23. The Admission MDS was not transmitted until 1/17/23. 4. Resident #81 was observed to have an Annual MDS of 6/14/23 and was due to be transmitted no later than 6/27/23. The Annual MDS was not transmitted until 8/02/23. On 10/19/23 at 09:10 AM, the surveyor interviewed the facility's Registered Nurse (RN)/MDS Coordinator (MDSC), who was responsible for completing and transmitting the MDS assessments and agreed that the above MDS assessment was transmitted late due to the transition of their system in July 2023. On 10/24/23 at 10:19 AM, the RN/MDSC provided the surveyor a copy of the form titled MDS 3.0 Final Validation Report, which revealed the above resident's name and confirmed the late MDS assessment submission. NJAC 8:39 - 11.1

Based on interviews, medical records (MR), and other pertinent facility documentation on 10/4/2023,10/5/2023, 10/6/2023, and 10/11/23, it was determined that the facility failed to adequately supervise a resident with a known history of behaviors for self-harm and suicidal ideation and follow the facility policy titled Suicidal Residents for 1 of 1 resident (Resident #4) reviewed for incident and accident. This deficient practice was evidenced by: According to the Admission Record (AR), Resident #4 was admitted to the facility on [DATE], with diagnoses that included but were not limited to Schizoaffective Disorder, Borderline Personality Disorder, Major Depressive Disorder, and Anxiety. The Minimum Data Set (MDS), an assessment tool dated 8/18/23, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS also indicated Resident #4 needed help in Activities of Daily Living (ADLs) and was able to feed herself/himself. A review of Resident #4's Care Plan (CP) initiated on 8/15/20, indicated that Resident #4 had mood and behavior problems related to Schizoaffective and Borderline Personality Disorder, emotional irritability, throwing objects (cellphone, remote control, etc.) to the staff, agitated, feeling of worthlessness and impaired social relationship, intentionally falling onto the floor, and suicidal gestures. The CP initiated on 5/5/23, revealed that Resident #4 had attention-seeking/injurious behavior as evidenced by inappropriate behavior of screaming at staff. A review of Resident #4's progress notes (PN) dated 8/31/23 at 3:32 p.m. was documented by a Registered Nurse (RN #1). The PN indicated that during morning care, Resident #4 had suicidal ideation by verbalizing I don't want to live anymore; I don't want to be alive. The PN indicated that the tray was delivered, and after lunch, during the collection of the trays, RN #1 responded to Resident #4 who was yelling and calling for a nurse for an emergency. Resident #4 reported that she/he cut her wrist with the butter knife. The PN indicated that the Primary Care Physician (PCP), the Nurse Practitioner, and the family member were notified, and Resident #4 was transferred to the hospital for further evaluation. There was no indication in the MR that Resident #4 was being monitored and interventions were put in place on 8/31/23 to prevent harming herself/himself when he/she had suicidal ideation according to the facility policy. On 08/31/2023 at 4:02 p.m., it was documented by Resident #4's PCP that Resident #4 became agitated and had a superficial wrist laceration. The PCP further documented that Resident #4 was transferred to the hospital for further evaluation and a possible suicide attempt management. On 08/31/2023 at 9:02 p.m., documented by Resident #4's Psychologist, the Psychologist wrote Resident was seen for an individual therapy session to address a very recent incident of cutting her scratching her wrist superficially with a plastic butter knife. The resident was sent to the hospital for evaluation. A review of Resident #4's Psychiatric Follow-Up Form (PFUF) dated 8/31/23 indicated that Resident #4 cut her/his left wrist with a plastic butter knife and was transferred to the hospital for a suicidal attempt. The Hospital record (HR) revealed that Resident #4 arrived at the hospital on 8/31/23 at 4:27 p.m. The HR indicated that Resident #4 was evaluated by the Psychiatrist and noted to have a medical history of self-harm and was presented to the emergency department for suicidal ideations. The HR further indicated that Resident #4 presented with superficially cutting self left wrist with a butter knife. Resident #4 stated she/he was upset with the staff for not helping her/him get into a Geri chair to join an activity, she/he was upset and yelled so she used the butter knife to cut herself/himself to get the attention of the staff. On 09/01/2023 at 12:40 a.m., documented by RN #2, Resident #4 returned to the facility and provided 1:1 supervision for the night. The surveyor conducted the interview with the Social Workers (SW #1 and SW #2) on 10/6/23 at 10:01 a.m. The SWs were not aware of Resident's suicidal ideation on 8/31/23. SW #1 stated that she was made aware of the incident after Resident #4 had sliced herself/himself. According to SW #1, she had to be notified of any forms of suicidal ideation. SW #1 explained that when there is a suicidal ideation the resident had to be supervised closely, to stay with the resident so that they would not have the opportunity to execute the suicidal ideation, to remove any objects that can be used to harm themselves. The surveyor conducted the interview with the Restorative CNA (RCNA) on 10/6/23 at 10:43 a.m. The RCNA stated that she did not provide supervision and/or any care to Resident #4. She explained that on 8/31/23, she dropped off the Resident's tray and left and did not see anyone inside the resident's room. The RCNA confirmed that the Resident's suicidal ideation was not communicated to her. The surveyor conducted an interview with the Charge Nurse LPN (CNLPN) on 10/6/23 at 11:09 a.m. The CNLPN stated that RN #1 reported that Resident #4 cut herself/himself. The CNLPN further stated that after the incident, she instructed RN #1 to call the PCP and ask an aide to stay with the resident. However, according to CNLPN, she was never made aware that the Resident had suicidal ideation before she/he cut her/his wrist. The surveyor conducted the interview with RN #1 on 10/6/23 at 1:46 and 3:15 p.m. RN #1 confirmed what was written on the PN dated 8/31/23. RN #1 further stated that she did not provide one-on-one monitoring after Resident #4 had the suicidal ideation, instead, she stayed outside Resident #4's room (measuring 11 feet and 5 inches apart) looking at the computer and did not communicate with other staff members in the unit of Resident #4 suicidal ideation. RN #1 further stated that when RCNA delivered the lunch tray, she did not check for any item that was potentially hazardous that the Resident could use to harm herself/himself. According to RN #1, she should have removed and/or stayed close (an arm length) with the resident to prevent her/him from harming herself/himself. However, the RN admitted that the resident used a plastic knife that was not sharp, and the resident was allowed to have a plastic knife delivered from the kitchen. The surveyor conducted an interview with ADON #2 and LNHA on 10/11/23 at 12:05 p.m., they stated that Resident #4's abovementioned incident was considered a suicidal ideation, and staff were expected to initiate the facility policy on suicidal protocol. A review of the facility's policy titled SUICIDAL RESIDENTS, undated, indicated POLICY Every suicide threat and/or attempt will be acted upon to prevent intentional or accidental suicides from occurring .2. When you determine there is clear intent on the resident's part, check the resident's environment for potential hazards. 3. Assign a staff member for one to one observation, and to stay within the distant of an arm length of the resident until determination of the course of treatment has been made by a physician .4. Notify the attending physician, administrator, DON and the director of social work, of resident's potential for suicides and details if the resident has expressed a suicidal plan . NJAC 8:39-27.1(a)

Based on interviews and record review, as well as a review of pertinent facility documents on 10/4/23, 10/4/23, 10/6/23, and 10/11/23, it was determined that the facility staff failed to report an allegation of verbal abuse to the New Jersey Department of Health (NJDOH) and follow their policy titled Abuse Prevention for 1 of 3 residents (Resident #4) reviewed for incident and accident. This deficient practice is evidenced by the following: On 10/4/23 at 9:16 a.m., during the entrance conference with the Administrator and the Director of Nursing (DON), the facility provided the Resident's Scabies Case Line Listing which included Resident #4. During an interview with the surveyor on 10/4/23 at 12:01 p.m. Resident # 4 made an allegation of verbal abuse. Resident #4 reported that About a month ago I asked [CNA #1] to take me out of bed and she said 'NO' then I started yelling at her. Resident #4 stated that the CNA called her/him homeless b*t*h, nobody wants to work with you, nobody wants you, and that she/he was a problem. Resident #4 stated that she felt like a less person after hearing the CNA's comments. According to Resident #4, he/she reported this allegation to the nurse (unable to recall the name of the nurse), and to the Assistant Director of Nursing (ADON #1) was also aware. According to the Admission Record (AR), Resident #4 was admitted to the facility on [DATE], with diagnoses that included but were not limited to Schizoaffective Disorder, Borderline Personality Disorder, Major Depressive Disorder, and Anxiety. The Minimum Data Set (MDS), an assessment tool dated 8/18/23, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS also indicated Resident #4's Activities of Daily Living (ADLs) required assistance and was able to feed herself/himself. A review of Resident #4's Care Plan (CP) initiated on 8/15/20, indicated that Resident #4 had mood and behavior problems related to Schizoaffective and Borderline Personality Disorder, emotional irritability, throwing objects (cellphone, remote control, etc.) to the staff, agitated, feeling of worthlessness and impaired social relationship, intentionally falling onto the floor, and suicidal gestures. Further review of Resident's CP initiated on 5/5/23, indicated that Resident #4 had attention seeking/injurious behavior as evidenced by inappropriate behavior of screaming at staff. During an interview with the surveyor on 10/4/23 at 12:15 p.m., ADON #1 stated that on 8/31/23, Resident #4 reported that CNA #1 would not transfer Resident #4 out of bed and told Resident #4 Nobody likes you, you are homeless that's why you are here, and nobody likes to work with you. The ADON further stated that the CNA was educated and was assigned to other residents to provide care. She further stated that the DON was made aware, however, she was not sure if the verbal allegation was reported to the NJDOH. The ADON explained that any allegation of any form of abuse should be investigated thoroughly and reported to the NJDOH. There was no indication in the MR that Resident #4 allegation of verbal abuse was thoroughly investigated and reported to the NJDOH which was not according to the facility policy. The surveyor conducted the interview with the Administrator and Director of Nursing (DON) on 10/4/23. 10/5/23, and 10/6/23. They stated that they were not aware the allegation of abuse involving Resident #4 and CNA #1 occurred 8/31/23 until 10/4/23. The Administrator stated that the aforementioned incident should have been investigated and reported to the NJDOH. A review of the facility's policy titled Abuse Prevention, dated 10/4/2023 indicated . IDENTIFICATION: The facility will investigate all incidents involving actual or alleged abuse, complaints/grievances .INVESTIGATION: The facility will investigate all incidents involving actual or alleged abuse, complaints/grievances .PROTECTION: the facility will protect all residents during any abuse investigation by removing staff from direct care and/or removing from schedule pending conclusion. REPORTING: In response to allegations of abuse .the facility must ensure that: all allegations of abuse must be immediately reported to the Director of Nursing and or Administrator and no later than 2 hours to other officials (including to the State Survey Agency) after the allegation is made, if the event that caused the allegation involve abuse or result in a serious bodily injury . NJAC 8:39-9.4(e)

Based on record review and interviews, the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met quarterly and consisted of the Pediatric Medical Director or his designee. This failure had the potential to affect the 185 residents in the facility at the time of the survey. On 11/17/18 at 06:18 PM, the facility's Administrator and Regional Director of Clinical Services were notified that an Immediate Jeopardy situation had been identified due to the failure to ensure that Quality Assessment and Performance Improvement (QAPI) activities to develop an action plan and failed to have a process in place to measure the success and sustained improvement of high risk problems. This failure to identify quality deficiencies and implement performance improvement projects contributed to the delay in identification and containment of adenovirus outbreak affecting 33 residents, 1 staff and resulted in 11 pediatric resident deaths. The facility provided an acceptable plan for removal of the immediate jeopardy which was accepted by the team. Findings include: An interview with the Administrator on 11/16/18 at 11:00 AM, revealed the facility designated a Pediatric Medical Director (PMD) to the 90-bed pediatric ventilator unit of the facility on 06/18/14. The Administrator stated, He (the PMD) does not attend the Quality Assurance and Performance Improvement (QAPI) meetings, but his nurse practitioner comes. The last time we met was (MONTH) of this year. We didn't meet in (MONTH) because of the outbreak. We usually meet in January, April, July, and October. On 11/16/18 at 11:15 AM, the PMD stated, I have never attended the QAPI meetings. I have never been invited but, my nurse practitioner does attend the meetings. She has never reported anything to me from the meetings. Review of Quarterly Meeting Attendance Record, dated 01/27/17 through 07/31/18, revealed the PMD had not attended a meeting. According to the attendance records, the medical director's nurse practitioner attended a total of 4 meetings in 18 months. The PMD's nurse practitioner did not attend the QA meeting on 07/28/17, 04/27/18 or 07/31/18. On 11/17/18 at 2:45 PM, the Administrator confirmed the facility could provide no evidence of communication of the content of the meetings to the PMD, with his acknowledgement of the information.

Based on observation, interview, record review, and review of facility policies and other infection control-related documentation, the facility failed to implement an effective Infection Prevention and Control Program (IPCP) to help prevent the development and transmission of communicable diseases and infections in the facility. This system failure of adequate surveillance lead to a delay in the prevention, identification, reporting, investigation, and control of an outbreak of a communicable adenovirus infection within the facility's pediatric ventilator unit, which, as of [DATE], had caused adenovirus-positive infections in 17 of 35 sampled residents, (Resident (R) 3, R63, R76, R114, R146, R166, R167, R168, R346, R347, R348, R349, R350, R351, R352, R354, and R355), and in 17 non-sampled residents, (R5, R38, R67, R75, R78, R79, R110, R111, R115, R159, R191, R195, R600, R601, R602, R603, and R604). Nineteen additional residents, eight sampled (R42, R45, R66, R70, R113, R164, R193, and R353), and 11 non-sampled (R6, R37, R43, R64, R65, R68, R142, R161, R162, R163, and R605) also exhibited symptoms of infection, but had negative, or no culture results, documented. This deficient practice resulted in the development of infections involving 53 residents, 11 of which, died , and placed the facility's other 150 residents in immediate jeopardy of contracting adenovirus infections, with the likelihood to cause serious harm, impairment, or death. On [DATE] at 03:11 PM, the facility's Administrator, Regional Director of Clinical Services, and Regional Director of Operations were notified that an Immediate Jeopardy situation had been identified due to the facility's failure to have an adequate Infection Prevention and Control Program (IPCP) to help prevent the development and transmission of communicable diseases and infections in the facility which contributed to the delay in identification and containment of adenovirus outbreak affecting 33 residents, 1 staff and resulted in 11 pediatric resident deaths. The facility provided an acceptable plan for removal of the immediate jeopardy which was accepted by the team. Findings include: According to the Centers for Disease Control and Prevention (CDC) webpage titled, Principles of Epidemiology in Public Health Practice, Third Edition, An Introduction to Applied Epidemiology and Biostatistics ([DATE]), an outbreak is defined as, . the occurrence of more cases of disease, injury, or other health condition than expected in a given area or among a specific group of persons during a specific period. Usually, the cases are presumed to have a common cause or to be related to one another in some way. (Accessed online [DATE] at: https://www.cdc.gov/OPHSS/CSELS/DSEPD/SS1978/Glossary.html#O) Review of an email, dated [DATE] at 11:13 AM, indicated that an epidemiologist with the New Jersey Department of Health (NJDOH) Communicable Disease Service (CDS), who spoke with members of the facility's administration on a conference call on [DATE], provided the facility with a list of NJDOH-recommended infection prevention and control actions to implement, and a list of disinfectants recommended by the Centers for Disease Control and Prevention (CDC). During an interview on [DATE] at 11:37 AM, with the facility's Infection Control Nurse (ICN), Infection Preventionist (IP), Consultant Pharmacist (CP), Pediatric Assistant Director of Nursing (PADON), Pediatric Medical Director (PMD), and the Geriatric Medical Director (GMD), the ICN stated she attended a training by the New Jersey APIC (Association for Professionals in Infection Control and Epidemiology), but had not yet completed the process for certification. The ICN stated she is also responsible for staff development, and that she spends only two to four hours per week on infection prevention and control activities. The ICN stated the nursing staff have been trained in the use of the McGeer criteria (the specific symptoms and other diagnostic criteria that must be present for an illness to be classified as an infection) to identify infections. The ICN stated she conducts weekly infection surveillance to obtain information on any resident that exhibit signs and symptoms of a potential infection, and that she tracks all types of infections by using an antibiotic line list (a spreadsheet that lists residents with symptoms of infection, any antibiotic medications administered, and the results) to monitor and track the infections, and antibiotic use in the facility. However, the ICN stated she only places a resident on the line list if they have a positive culture, and then counts it as an infection. The ICN stated she discusses information from her surveillance rounds during the facility's weekly risk meeting. The ICN stated she shares the information from the line list with the Director of Nursing (DON) and the Administrator monthly, but she does not provide them with information on the root-causes of the residents' infections. During the same interview, the IP stated the facility hired her on a consultant basis to assist the ICN with the implementation of the IPCP. The IP stated that although the ICN had completed APIC training, she did not know, or use, all the guidelines recommended by the CDC. Review of the documentation in an Infection Control Report, dated [DATE], indicated the ICN established benchmarks for the acceptable rates of infection in the facility. However, the ICN did not use a professionally-accepted source for the medical criteria or symptoms, which must be present for an illness to be recognized as an infection. Instead, the ICN based her weekly surveillance documentation on antibiotic use; if a resident was placed on antibiotics, the ICN added the resident to the QI (Quality Improvement) Summary Report for review by the QI Action Team during the QI Meeting. However, the Infection Control Report had no documentation of a review by the QI Action Team and no evidence to indicate the QI Action Team had developed action plans when the facility's infection rate exceeded the benchmarks established by the ICN. Review of the line list, initiated by the ICN on [DATE], and last updated on [DATE], indicated for each of the 53 residents that developed symptoms indicative of infection, the ICN entered the resident's demographic information, the date of onset, their signs and symptoms, the dates and results of any cultures obtained, the dates of hospitalization (if applicable), other resident-specific comments, and a column for indicating a resident had expired. Further review of the line list, indicated that as of [DATE], the following 17 sampled residents, and 17 non-sampled residents, had culture results positive for adenovirus: Sampled residents: 1. R3: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE]. No documentation related to antibiotic therapy. 2. R63: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE], and antibiotic therapy. 3. R76: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization on [DATE] for pneumonia. No documentation related to antibiotic therapy or of the resident's status since hospitalization . 4. R114: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE], and antibiotic therapy. 5. R146: Symptom onset: [DATE]. Positive culture for adenovirus. Required antibiotic therapy. 6. R166: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE]. No documentation related to antibiotic therapy. 7. R167: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE]. No documentation related to antibiotic therapy. 8. R168: Symptom onset: [DATE]. Positive culture for adenovirus. Required antibiotic therapy. No documentation of hospitalization . 9. R346: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization on [DATE]. expired on [DATE]. 10. R347: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE]. expired on [DATE]. 11. R348: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization on XXX[DATE]. expired on [DATE]. 12. R349: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE]. expired on [DATE]. 13. R350: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization on [DATE]. expired on [DATE]. 14. R351: Physician's Progress Note from electronic medical record dated [DATE] at 14:05 patient seen and examined, stable, no fever, roommate is sick, under contact precaution . Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization on [DATE] due to pneumonia. expired on [DATE]. 15. R352: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE]. expired on [DATE]. 16. R354: Physician's note in electronic medical record from [DATE] at 14:06 patient seen and examined .roommate is sick, under contact precaution .Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE]. expired on [DATE]. 17. R355: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE]. expired on [DATE]. Non-sampled residents: 18. R5: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE] for the treatment of [REDACTED]. No documentation related to antibiotic therapy. 19. R38: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization [DATE]. expired on [DATE]. 20. R67: Symptom onset: [DATE]. Positive culture for adenovirus. Required antibiotic therapy. 21. R75: Symptom onset: [DATE]. Positive culture for adenovirus. Required additional ventilator support and [MEDICATION NAME][MEDICATION NAME] medication. No documentation related to antibiotic therapy. 22. R78: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE], and antibiotic therapy. 23. R79: Symptom onset: [DATE]. Positive culture for adenovirus. admitted to the hospital on [DATE] with a temperature of 104 degrees Fahrenheit (F) for treatment of [REDACTED]. No documentation related to antibiotic therapy or of the resident's status since hospitalization . 24. R110: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE]. No documentation related to antibiotic therapy. 25. R111: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE], and antibiotic therapy. 26. R115: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE], and antibiotic therapy. 27. R159: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization on [DATE], and steroid therapy. No documentation related to antibiotic therapy or of the resident's status since hospitalization . 28. R191: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization from [DATE] to [DATE]. No documentation related to antibiotic therapy. 29. R195: Symptom onset: [DATE]. Positive culture for adenovirus. Required emergency room (ER) evaluation on [DATE]. No documentation related to antibiotic therapy. 30. R600: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization on [DATE]. No documentation related to antibiotic therapy or of the resident's status since hospitalization . 31. R601: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization on [DATE]. No documentation of the resident's status since hospitalization . 32. R602: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization on [DATE]. No documentation related to antibiotic therapy or of the resident's status since hospitalization . 33. R603: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization on [DATE] for pneumonia. No documentation related to antibiotic therapy or of the resident's status since hospitalization . 34. R604: Symptom onset: [DATE]. Positive culture for adenovirus. Required hospitalization on [DATE] for pneumonia. No documentation related to antibiotic therapy or of the resident's status since hospitalization . The line list also included 19 residents (eight sampled and eleven non-sampled) that exhibited symptoms of infection, but had negative, or no culture results documented. Sampled residents: 35. R42: Symptom onset: [DATE]. No culture documentation. Required antibiotic therapy. 36. R45: Symptom onset: [DATE]. No culture documentation. Required antibiotic therapy. 37. R66: Symptom onset: [DATE]. No culture documentation. Required antibiotic therapy. 39. R70: Symptom onset: [DATE]. No documentation of culture or antibiotic therapy. 40. R113: Symptom onset: [DATE]. Negative culture for adenovirus. Required antibiotic therapy. 41. R164: Symptom onset: [DATE]. Negative culture for adenovirus. Required ER evaluation for pneumonia and antibiotic therapy. 42. R193: Symptom onset: [DATE]. No culture documentation. Required antibiotic therapy. 43. R353: Symptom onset: [DATE]. No culture documentation. Required antibiotic therapy. expired on [DATE]. Non-sampled residents: 44. R6: Symptom onset: [DATE] (non-respiratory). Culture specimen obtained on [DATE]. No results available on [DATE]. No documentation of antibiotic therapy. 45. R37: Symptom onset: [DATE]. Two negative cultures for adenovirus. Required antibiotic therapy. 46. R43: Symptom onset: [DATE]. No culture documentation. Required antibiotic therapy. 45. R64: Symptom onset: [DATE]. No culture documentation. Required antibiotic therapy. 47. R65: Symptom onset: [DATE]. No culture documentation. Required antibiotic therapy. 48. R68: Symptom onset: [DATE]. No culture documentation. Required antibiotic therapy. 49. R142: Symptom onset: [DATE]. Negative culture for adenovirus. Required hospitalization from [DATE] to [DATE]. No documentation of antibiotic therapy. 50. R161: Symptom onset: [DATE]. Negative culture for adenovirus. Required antibiotic therapy. 51. R162: Symptom onset: [DATE]. No culture documentation. Required hospitalization from [DATE] to [DATE] and antibiotic therapy. 52. R163: Symptom onset: [DATE]. No culture documentation. Required antibiotic therapy. 53: R605: Symptom onset: [DATE]. Negative culture for adenovirus. Required hospitalization from [DATE] to [DATE]. No documentation of antibiotic therapy. During interviews on [DATE] at 11:37 AM, and [DATE] at 11:15 AM, the Pediatric Medical Director (PMD) stated, I have been here [AGE] years . (and) have a pediatric intensive care background . I have not participated in the surveillance of infection control and I can't give you any numbers. I know my patients and I can tell if they are having more pneumonias than usual (but) I have no formal method of measuring the pneumonia rate or infection rate. I have never been shown the 'Infection Control Report' and I am not aware of the facility's acquired infection rates . Regarding the outbreak of [MEDICAL CONDITION], I thought the state was overreacting, . I knew we had a problem after the 4th death . I agree 100 percent that we need to tighten up our process for infection control . The PMD also stated that he had not attended any of the facility's Quality Assessment and Assurance (QAA) meetings, and had not been invited to attend the QAA meetings. (Cross-reference F835, F841, and F868.) Review of the facility's policy titled, Infection Control Program, dated ,[DATE], provided the following information: . There is an active, facility-wide infection control program with effective measures to identify, control and prevent infections acquired or brought into the long-term care facility from the community or other health care facilities . (the) Elements of the Infection Control Program include but are not limited to: . definitions of facility acquired infections . provision of early uniform identification and reporting of infections . exposure control plan . antibiotic usage and stewardship . On [DATE] at 01:05 PM, observed a tracheal dressing change performed by respiratory therapist (RT) 1, noted that she didn't wash/sanitized her hands in-between dirty to clean dressing 4 times. Observation on [DATE] at 10:15 AM on the pediatric ventilator unit of 2 environmental services employees performing a terminal clean of an empty resident room. Interview with the 2-staff revealed that they used only 2 of the Dispatch Hospital Cleaner Disinfectant Towels with Bleach (a hospital grade cleaner) to clean an entire room. Interview with the Healthcare Services Group District Manager (HSG DM) at 10:30 AM on [DATE] he stated staff should use as many wipes as necessary to clean a room. He stated they environmental services staff had not been given a set number of wipes to use to clean and sanitize surfaces in resident rooms. Observation on [DATE] at 1:07 PM observation of respiratory therapy supervisor (RTS) [MEDICAL CONDITION] services to R 70. The RTS finished a task, removed her gloves, used hand sanitizer then moved a package of wipes off a box of gloves on a dresser in the room, removed a new pair of gloves and re-gloved to provide additional care. Interview with the RTS at 1:15 PM on [DATE] confirmed that she had touched the wipes after performing hand hygiene and had contaminated her hands as a result. Observation on [DATE] at 10:00 AM of three environmental services staff and the HSG DM performing a terminal cleaning of a resident room on the pediatric ventilator unit. The plastic container of Dispatch Hospital Cleaner Disinfectant Towels with Bleach had the lid removed and all the wipes were exposed to the air. Interview with the HSG DM at 10:22 AM on [DATE] he stated the wipes should have the lid on except when starting a new container and feeding the wipes through the lid dispenser. He further stated he was informed of the outbreak on [DATE] and increased the environmental services rounds at that time. He instructed his staff to clean the high touch areas (doorknobs, tray tables, bed rails) twice daily with the Dispatch Hospital Cleaner Disinfectant Towels with Bleach.

Based on facility policy review and interview, the facility administration failed to use resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to identify quality deficiencies and implement performance improvement projects when problems were identified. The facility failed to include the facility Pediatric Medical Director in the facility's quality assurance process and failed to designate specific responsibilities of oversight to professional staff providing medical services to the residents. On 11/17/18 at 06:18 PM, the facility's Administrator and Regional Director of Clinical Services were notified that an Immediate Jeopardy situation had been identified related to inadequate administrative oversight and failure to identify quality deficiencies and implement performance improvement projects which contributed to the delay in identification and containment of adenovirus outbreak affecting 33 residents, 1 staff and resulted in 11 pediatric resident deaths. The facility provided an acceptable plan for removal of the immediate jeopardy which was accepted by the team. Findings include: An interview with the Administrator on 11/16/18 at 11:00 AM, revealed the facility designated a Pediatric Medical Director to the 90-bed pediatric ventilator unit of the facility on 06/18/14. According to the Administrator, the Pediatric Medical Director (PMD) was in place when she started working at the facility. The Administrator stated, He does not attend the QAPI meetings. I have been here four years and have never received a monthly report from him. We have not had formal meetings to discuss issues. I have never asked him to review or approve a resident care policy and he has not been involved in the facility's infection control surveillance. We have two medical directors, the Geriatric Medical Director (GMD) does not provide services to the pediatric patients. On 11/16/18 at 11:15 AM, the PMD stated, I have been here [AGE] years. I have never attended the Quality Assurance and Performance Improvement (QAPI) meetings. I have never been invited. I have not participated in the surveillance of infection control and I can't give you any numbers. I know my patients and I can tell if they are having more pneumonias than usual. I have no formal method of measuring the infection rate. I have never been shown the Infection Control report and I am not aware of the facility acquired infection rates. I haven't provided input in the policies of the unit and I have never been asked to review or sign a policy. No one at the facility has given me the regulations regarding the medical director and I have never read them. I didn't understand what medical director meant. On 11/16/18 at 11:30 AM, an interview with the GMD, revealed he provided oversight to the geriatric population. The GMD stated, I am the medical director for all residents in the facility except for those who reside on the pediatric unit. I do not oversee the PMD or any professional staff on that unit. I attend the QAPI meetings quarterly and provide consultation. Review of the Quality Assurance and Performance Improvement (QAPI) Plan, dated 07/2018, included, Establish and implement plans to correct identify quality deficiencies . establish systems and processes to maintain documentation relative to the QAPI program, as a basis for demonstrating that there is an effective ongoing program. The owner and/or governing body of our facility shall be ultimately responsible for the QAPI program. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements. The QAPI plan did not include documentation that the facility medical directors or the Director of Nursing (DON) would be included in the QAPI committee. On 11/17/18 at 8:30 AM, the Administrator stated, I wrote the QAPI plan in (MONTH) as we were anticipating our state survey and I knew we were in the 15th month. I used a med pass document and wrote it myself to customize to our facility. The GMD did not review or approve the plan. No one from corporate office approved the plan. Yes, I wrote the plan and documented the QAPI committee would begin meeting monthly after July, but we didn't meet in (MONTH) because of state survey and we didn't meet in (MONTH) or (MONTH) because of the outbreak. On 11/17/18 at 9:00 AM, the DON stated, I didn't know we had two medical directors until this past (MONTH) when we had our state survey. I thought the PMD was the pediatrician for the vent unit, not the medical director. He has never attended the QAPI meetings. The undated Organizational Chart included a diagram outlining the facility's internal structure. (An organizational chart is a visual representation of how a company intends authority, rank and positions). The chart documented the Administrator at the top with arrows pointing to those positions/jobs to which the Administrator provided oversight. The chart documented the GMD provided oversight to the PMD. According to the chart, the PMD did not provide oversight or rank to any other professional on the chart. The chart reflected the PMD was the attending physician Vent Unit. On 11/17/18 at 11:00 AM, the Administrator stated, The chart is not right. The GMD is not responsible for the PMD. We have to make a new chart. On 11/17/18 at 11:15 AM, the Regional Director of Clinical Services stated, I knew as soon as I looked at it (referring to the organizational chart) that there was a problem. This is the first time I have seen it. I also agree that the QAPI plan written by the Administrator does not document the participation of the medical director or the DON. I'm not sure if I knew the Administrator added QAPI would meet monthly. No, I did not approve the plan. Review of the Adenovirus Work Plan, dated 10/12, revealed there were no follow up recommendations documented. Column A of the work plan documented CDC (Centers for Disease Control) ICAR (Infection Control Assessment and Response program) recommendations. The work plan documented supplies, person responsible and completed date. The last column to the right of the document entitled Comments, reflected Done or ongoing. The last date under the completed date column was 10/30/18. On 11/17/18 at 11:15 AM, the Regional Director of Clinical Services was interviewed regarding the Adenovirus Work Plan, The Regional Director of Clinical Services stated, The Administrator and I put the plan together based on the recommendations of the CDC and ICAR. We did not involve anyone else and we didn't get it approved by the Medical Director. I realize now after looking at it there should have been more about follow up to the recommendations.

Based on review of the facility capacity statement, quality assessment data, and interview, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) committee developed improvement activities based on systemic analysis of data, failed to develop an action plan based on the data, and failed to have a process in place to measure the success and sustained improvement of high risk problems. Specifically, the facility failed to develop a QAPI action plan to evaluate corrective actions to assure that efforts by the facility were effective to contain the high-risk problem of respiratory infections in the pediatric ventilator unit where 90 residents resided. Thirty-three of 53 sampled residents in the pediatric ventilator unit tested positive for adenovirus which resulted in 34 transfers to emergency room and/or hospitalization s and 11 deaths. On [DATE] at 06:18 PM, the facility's Administrator and Regional Director of Clinical Services were notified that an Immediate Jeopardy situation had been identified due to the failure to ensure that Quality Assessment and Performance Improvement (QAPI) activities to develop an action plan and failed to have a process in place to measure the success and sustained improvement of high risk problems. This failure to identify quality deficiencies and implement performance improvement projects contributed to the delay in identification and containment of adenovirus outbreak affecting 33 residents, 1 staff and resulted in 11 pediatric resident deaths. The facility provided an acceptable plan for removal of the immediate jeopardy which was accepted by the team. Findings include: Review of the Quality Assurance and Performance Improvement Plan, dated ,[DATE], included, Establish and implement plans to correct identified quality deficiencies . establish systems and processes to maintain documentation relative to the QAPI program, as a basis for demonstrating that there is an effective ongoing program. This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality related activities of all departments, services or committees. The QAPI committee shall oversee and authorize QAPI activities, including data-collection tools, monitoring tools, and monitor the effectiveness of QAPI activities. The owner and/or governing body of our facility shall be ultimately responsible for the QAPI program. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements. The QAPI plan did not include documentation of who would be required to attend the meetings such as the medical director or the Director of Nursing (DON), or what data collection reports would be reviewed. An interview with the Administrator on [DATE] at 11:00 AM revealed the facility designated a Pediatric Medical Director (PMD) to the 90-bed pediatric ventilator unit of the facility on [DATE]. The Administrator stated, He does not attend the Quality Assurance and Performance Improvement QAPI meetings. I have been here four years and have never required a monthly report from him. We have not had formal meetings to discuss issues. I have never asked him to review or approve a resident care policy and he has not been involved in the facilities infection control surveillance program. I have not received data collection from the infection control nurse regarding facility acquired infection rate. This has not been provided to the QAPI committee. The QAPI committee has not taken minutes and I have none to provide. On [DATE] at 11:15 AM, the (PMD) stated, I have never attended the QAPI meetings. I have never been invited. I have not participated in the surveillance of infection control and I can't give you any numbers. I know my patients and I can tell if they are having more pneumonias than usual. I have no formal method of measuring the infection rate. I have never been shown the Infection Control report and I am not aware of the facility acquired infection rates. I haven't provided input in the policies of the unit and I have never been asked to review or sign a policy. On [DATE] at 12:50 PM, the Director of Nursing (DON) stated, I have not invited the PMD to the QAPI meetings. I didn't know he was the PMD until this past (MONTH) when we had our state survey. We have not had a QAPI meeting since (MONTH) of this year. I have not been informed of the facility acquired infection rate. I know we have not done the QAPI process correctly. I have not seen the QAPI dated (MONTH) of this year and had no input in the development of the plan. Review of the facility capability statement, dated [DATE], titled General Capabilities (a capability statement is a list of services the facility can provide). The capability statement included, Respiratory Therapist Onsite and when needed, [MEDICAL CONDITION] Management, Respiratory Program, and Pediatric Vents (Ventilators). Review of an undated Agenda for QAPI Meeting revealed a list of items for discussion. The QAPI agenda included, infection control and respiratory. The QAPI meeting agenda did not include [MEDICAL CONDITION] management or pediatric ventilators. On [DATE] at 10:30 AM, the Administrator stated, We have a quality improvement program for pediatrics and respiratory. The Respiratory Therapist completes the report quarterly. I have the report for the first quarter, but I don't have anything past (MONTH) of this year. We do an infection control audit quarterly. I don't have a report of monthly rates for facility acquired infections or antibiotic stewardship. Review of an undated Quality Improvement Program for Pediatrics, revealed the areas documented were specific to admissions, discharges, and occupancy. The Quality Improvement Program for Pediatrics, included, (MONTH) (YEAR). There were 2 new admissions and three re-admissions. There were 4 discharges to the hospital, one child expired in the hospital. One child expired here in the pediatric unit. Occupancy was 85%. (MONTH) (YEAR). There were 4 readmissions from the hospital. There were 3 discharges. 2 discharged to the hospital and 1 discharged to another nursing facility in NYC. No referrals for this month. Occupancy was 85%. (MONTH) (YEAR). For the month of (MONTH) there were 2 readmissions. There were 5 discharges. 2 discharged to home and 3 to the hospital. Occupancy was 83%. Review of Respiratory Quality Improvement Program, dated [DATE], included, A member of the Respiratory QI Action Team will review residents receiving mechanical ventilator management . problem areas reporting continually low scores must be noted and reported at QI meetings. Action plans must be formed. Responses will be recorded on the appropriate form . the QI team will determine compliance to the QI criteria as follows: Criteria: more than 95% . score 100%. On [DATE] at 2:00 PM, the Administrator stated, The only report we have for the quality improvement program for pediatrics is the one I gave you. Yes, it only covers admissions, discharges, and occupancy. I don't have any other documentation. I don't know what the criteria is for the respiratory quality improvement plan. We have no documentation of minutes or any proof of analysis. I don't have a performance improvement plan based on those reports. We were meeting every day and discussing each sick child, but I don't have any documentation or an action plan for the increase in infections on the pediatric ventilator unit. 1. Cross-reference F868 L: QAA Committee Based on record review and interviews, the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met quarterly and consisted of the Pediatric Medical Director or his designee. This failure had the potential to affect the 185 residents in the facility at the time of the survey. 2. Cross-reference F880 L: Infection Prevention and Control Based on observations, interview, record review, and review of facility policies and other infection control-related documentation, the facility failed to implement an effective Infection Prevention and Control Program (IPCP) to help prevent the development and transmission of communicable diseases and infections in the facility. This system failure lead to a delay in the prevention, identification, reporting, investigation, and control of an outbreak of a communicable adenovirus infection within the facility's pediatric ventilator unit, which, as of [DATE], had caused adenovirus-positive infections in 17 of 35 sampled residents, (Resident R3, R63, R76, R114, R146, R166, R167, R168, R346, R347, R348, R349, R350, R351, R352, R354, and R355), and in 17 non-sampled residents, (R5, R38, R67, R75, R78, R79, R110, R111, R115, R159, R191, R195, R600, R601, R602, R603, and R604). Nineteen additional residents, eight sampled (R42, R45, R66, R70, R113, R164, R193, and R353), and 11 non-sampled (R6, R37, R43, R64, R65, R68, R142, R161, R162, R163, and R605) also exhibited symptoms of infection, but had negative, or no culture results, documented. This deficient practice resulted in the development of infections involving 53 residents, 11 of which, died , and placed the facility's other 150 residents in immediate jeopardy of contracting adenovirus infections, with the likelihood to cause serious harm, impairment, or death.

Based on interview, observation and record review, the facility failed to evaluate resident population and identify the resources needed to provide the necessary care and services required for residents during [MEDICAL CONDITION] outbreak. Specifically, 33 of 53 symptomatic residents tested positive for adenovirus (adenoviruses are a group of [MEDICAL CONDITION] that infect the lining of your eyes, airways and lungs, intestines, urinary tract, and nervous system and is a common cause of fever, coughs, sore throats, diarrhea, and pink eye) which resulted in 34 transfers to emergency room and/or hospitalization s and 11 deaths. The failure placed the facility's other residents in immediate jeopardy of contracting adenovirus infections, with the likelihood to cause serious harm, impairment, or death. On [DATE] at 06:18 PM, the facility's Administrator and Regional Director of Clinical Services were notified that an Immediate Jeopardy situation had been identified related to inadequate administrative oversight and failure to identify quality deficiencies and implement performance improvement projects which contributed to the delay in identification and containment of adenovirus outbreak affecting 33 residents, 1 staff and resulted in 11 pediatric resident deaths. The facility provided an acceptable plan for removal of the immediate jeopardy which was accepted by the team. Findings Include: The facility assessment must include an evaluation of diseases, conditions, physical, functional or cognitive limitations of the resident population's, acuity (the level of severity of residents' illnesses, physical, mental and cognitive limitations and conditions) and any other pertinent information about the residents that may affect the services the facility must provide. This assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. A review of the facility - wide assessment revealed that it lacked a facility and community based all hazards risk assessment in regards to active recognition, management, and mitigation of an active infectious disease outbreak. This deficient practice contributed to the failure to contain and control [MEDICAL CONDITION] outbreak in the pediatric ventilator unit. This deficient practice impacted 17 of 35 sampled residents, (Resident R3, R63, R76, R114, R146, R166, R167, R168, R346, R347, R348, R349, R350, R351, R352, R354, and R355), and in 17 non-sampled residents, (R5, R38, R67, R75, R78, R79, R110, R111, R115, R159, R191, R195, R600, R601, R602, R603, and R604). Nineteen additional residents, eight sampled (R42, R45, R66, R70, R113, R164, R193, and R353), and 11 non-sampled (R6, R37, R43, R64, R65, R68, R142, R161, R162, R163, and R605) also exhibited symptoms of infection, but had negative, or no culture results, documented. This deficient practice resulted in the development of infections involving 53 residents, 11 of which, died . The facility - wide assessment document detailed average daily census trending analysis for special treatments and conditions in the facility. The assessment failed to address physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population. The assessment failed to address staff competencies that are necessary to provide the level and types of care needed for the resident population. Review of the Staff Resources section of the facility - wide assessment documented vendors/contracts for radiology/x-rays, pharmacy services, housekeeping, laundry services, dietary services, and other maintenance/environmental contracts. However, the section failed to identify competencies and roles during an active infectious disease outbreak. The Facility - wide Assessment Organizational Chart failed to recognize and update personnel in key positions. The facility assessment failed to address recognition, mitigation and management of an active infectious outbreak. Cross References F835: Administration F867: QAPI/QAA Improvement Activities F880: Infection Prevention and Control F881: Antibiotic Stewardship Program

Based on observation, interview, and record review, it was determined that the facility failed to provide timely interventions and care in accordance with professional standards of practice to allow for the highest level of practicable well-being for 4 of 4 residents (R166, R167, R346, R351). Delays in identification and treatment of [REDACTED]. Findings include: The facility was notified by the State Department of Health on [DATE] of an adenovirus outbreak in the facility. The adenovirus can cause . illnesses such as the common cold, sore throat, pneumonia, pink eye, and fever . People with weakened immune systems, or existing respiratory or [MEDICAL CONDITION], are at higher risk of developing severe illness from an adenovirus infection. https://www.cdc.gov/adenovirus/about/symptoms.html 1. Review of R166's Admission Record from the Profile tab of the electronic medical record (EMR) revealed he/she was admitted on [DATE] with [DIAGNOSES REDACTED]. R166 was afebrile on [DATE] without any isolation precautions in place and received his influenza vaccine. The Weights/Vitals tab of the EMR recorded temperatures for the following dates [DATE] at 9:51 AM 99.9 degrees Fahrenheit (F), at 8:30 PM 101.3 degrees F; [DATE] at 9:38 AM 100.4 degrees F; [DATE] at 8:36 AM 97.8 degrees F; [DATE] at 12:30 AM 100.8 degrees F; [DATE] 5:13 AM 101.1 degrees F, [DATE] at 8:51 AM 97.3 degrees F; [DATE] at 9:47 AM 101.2 degrees F, [DATE] at 9:56 AM 101.2 degrees F; [DATE] at 10:45 AM 99.6 degrees F; [DATE] at 4:14 PM 97.3 degrees F; [DATE] at 1:55 AM 101.6 degrees F; [DATE] at 9:30 AM 97.6 degrees F; [DATE] at 12:56 PM 101.1 degrees F; [DATE] at 8:48 AM 99.5 degrees F; [DATE] at 10:42 AM 100.9 degrees F; [DATE] at 11:56 AM 98.8 degrees F; and [DATE] at 1:15 PM 99.1 degrees F. Review of Progress Notes revealed on [DATE], R166's gastrostomy tube (GT) feeding site was .noted with scant bleeding and excoriation around GT stoma . On [DATE] a nurse documented, Md (medical doctor) made aware of child's status with orders to transfer to (hospital location) for evaluation. Rp (responsible party) made aware of child's status .transport here picked child up, and transported to hospital . At 11:30 PM on [DATE] nursing documented, .Pt (patient) was pick (sic) up at 5:30, sent to (hospital name) for high temp (temperature) on ,[DATE] . (sic) He returned to the facility on [DATE] per note written at 1:55 AM, .Temp. 101.6 .O2 (oxygen) sat (saturation) 99% on vent (ventilator) at prescribed rate, [MEDICATION NAME] PRN (as needed) given as ordered noted effective .informed Pediatric Medical Director (PMD) regarding child's return .clarified new orders of [MEDICATION NAME] 292 milligrams (mg) via GT daily 2 days and [MEDICATION NAME] 1320 mg via GT BID (twice a day) x 10 days . The nurse Progress Note identified R166 was transferred on [DATE] to the hospital for tracheal bleeding and low-grade fever. HeShe returned to the facility on [DATE] with a likely [MEDICAL CONDITION] infection. Although R166 had a low-grade fever on eight occasions between [DATE] and the late afternoon of [DATE], the PMD and Nurse Practitioner (NP) did not act until [DATE] to send R166 out for an evaluation. The transfer was because R166 developed tracheal bleeding. On [DATE] the NP documented, .transferred .evaluation of tracheal bleeding. Returned to facility, not admitted .P (plan) continue droplet precautions (likely [MEDICAL CONDITION] infection) . The PMD saw R166 on [DATE] documenting that he was . febrile, desated today, required to increase his oxygen to 40% .mildly lethargic, positive blood tinged tracheal secretion, . decrease air entry left>right, positive wheezing . The NP ordered [MEDICATION NAME], a steroid. At 2:00 PM, R166 was again transferred to the hospital by ambulance. The Pediatric Assistant Director of Nursing (PADON) documented at 6:07 PM on [DATE] . Called (hospital) and admitted with [DIAGNOSES REDACTED]. R166 returned to the facility on [DATE]. 2. Review of R167's Admission Record from the Profile tab of the EMR revealed he/she was admitted on [DATE] with [DIAGNOSES REDACTED]. R167's temperature records from the Weights/Vitals tab in the EMR revealed his/her temperatures were as follows: [DATE] at 1:24 AM 103.1 degrees F; [DATE] at 4:58 AM 102.5 degrees F; [DATE] at 10:30 AM 102.4 degrees F; [DATE] at 5:18 PM 103 degrees F; [DATE] at 6:26 AM 104.1 degrees F; [DATE] at 12:55 AM 101.5 degrees F; [DATE] at 9:04 AM 102.5 degrees F, [DATE] at 8:13 AM 102.6 degrees F; [DATE] at 10 AM 102.1 degrees F; [DATE] at 5:03 PM 102.5 degrees F; [DATE] at 10:43 PM 102.2 degrees F; [DATE] at 1 AM 102.1 degrees F; [DATE] at 5:45 AM 102.6 degrees F; and [DATE] at 2:21 PM 102.4 degrees F. Review of the Progress Notes of the EMR revealed R167 ran fevers at other times. He/She was medicated for fever with [MEDICATION NAME] and [MEDICATION NAME] alternating doses. This brought his/her fever down for short period however, R167's temperature was elevated every day from [DATE] through [DATE]. Documentation by the NP on [DATE] revealed R167 . continues with persistent fever x 4 days .BP (blood pressure) ,[DATE] .A/P (assessment/plan) fever, resp (respiratory distress) . Discussed with (doctor's name), send to (name of hospital) ER (emergency room ) for evaluation . At 2:37 PM a nurse documented .breathing heavily labored; with O2 (oxygen) sat ranging from 87% - 94% .noted with wheezing; prn [MEDICATION NAME] given; ineffective .to be sent out to (hospital name) . At 7:51 PM on [DATE] a nurse documented, . received a call from . (hospital) . informed that child is admitted for Pneumonia and respiratory distress . R167 returned from the hospital on [DATE] with a [MEDICAL CONDITION] (creating an opening in the neck to place a tube into a person's windpipe. This allows air to enter the lungs). Review of the EMR identified the PMD/NP waited one week before sending R167 to the hospital. This delay in treatment and transfer resulted in the resident returning with a [MEDICAL CONDITION]. 3. Review of R346's Admission Record from the Profile tab of the electronic medical record revealed he/she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Weights/Vitals tab in the EMR revealed her temperatures on [DATE] were 100.5 degrees F at 12:55 PM; 102.5 at 3:05 PM; and 101.5 degrees F at 4:43 PM. Review of the Progress Notes tab nursing documented on [DATE], At 5:47 AM noted . patient with slight congestion. O2 sat(saturation) 93% . suctioned orally . moderate amount of thick white secretions tinged with blood . On [DATE] at 3:41 PM, . still has slight congestion . [DATE] at 6:30 AM . congestion noted . at 3:10 PM on [DATE] . saturation at ,[DATE]% on 30% oxygen Cont. (continuous) with cooling measures . wheezing congestion and occ. (occasional) coughing . and at 5:05 PM . left facility via stretcher .Saturation at 92% on 3 Liters .crying . On [DATE] at 5:56 AM, follow up on pt . admitted for respiratory distress . Resident expired at the hospital. Licensed Practical Nurse (LPN) clinical unit manager for the pediatric ventilator unit in an interview on [DATE] at 9:10 AM stated, .[MEDICATION NAME] contact precaution was used for R167 because he did not show signs and symptoms of anything. Once the adenovirus was identified all residents were moved to droplet precautions from contact. Contact was started for those who had signs and symptoms of fever etcetera . In an interview on [DATE] at 11:37 AM with the PMD, Infection Preventionist (IP), Infection Control Nurse (ICN) and the pediatric Assistant Director of Nursing (ADON) revealed the PMD stated, .Never had a colonized (occurs when bacteria is present but does not cause infection) resident until now and roommates usually end up colonized with the same organism. My first antibiotic of choice is [MEDICATION NAME] (most common antibiotic sensitive), then Bactrim,[MEDICATION NAME] .When a resident starts showing signs and symptoms I order a CBC (complete blood count) with differential, chest x-ray, trachea culture, a steroid medication and a broad-spectrum antibiotic. When sensitivity is received I may change the medication .treat the patient not the lab . 4. Review of R351's Admission Record from the Profile tab of the EMR revealed he/she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes of the EMR revealed that R351 was placed on contact precautions on [DATE] at 23:12. Although R351 was afebrile and asymptomatic on [DATE] at 14:05, it was noted that his/her roommate was ill. On [DATE] at 16:52, R351 spiked a fever of 103.5 with a heart rate of 140. R351's temperature was elevated every day from [DATE] through [DATE]. He/She was medicated for fever with [MEDICATION NAME] and [MEDICATION NAME] alternating doses which brought the fever down for short periods. Maximum temperature noted was 103.9 degrees F on [DATE] at 17:24. Nursing note on [DATE] at 15:00indicates Gt. (gastric tube) with 8ml coffee ground aspirate. (indicative of gastric bleeding) .temp 102.2, Nursing note on [DATE] at 11:51 states . moderate amount of frank tracheal bleeding. R351 was transferred to the hospital via ambulance on [DATE] at 11:50 am. R351 expired in the emergency roiagnom on [DATE] at 3:10 pm. Review of the EMR identified the PMD/NP waited eight days before sending R351 to the hospital to seek evaluation and treatment. This delay in treatment and transfer resulted in the resident returning with a [MEDICAL CONDITION]. Review of R351's Progress Notes tab of the EMR reflect, in part, the following: [DATE] at 23:12 Nursing Note Pt started on contact precaution. [DATE] at 06:01 Nursing Note Contact Precaution in place and observed. Temp. 96.8/ 96.9 [DATE] at 14:05 Physician's Progress Note patient seen and examined stable, no fever, roommate is sick, under contact precaution [DATE] at 16:52 eMar - Medication Administration Note Note Pt noted with T 103.5 HR 140 O2sat 99 prn [MEDICATION NAME] given droplet precautions in place [DATE] at 09:26 eMar - Medication Administration Note T-101.3 HR-138 [MEDICATION NAME] x1 given with cooling measures. Will continue to monitor [DATE] at 17:24 eMar - Medication Administration Note child noted with T 103.9 prn [MEDICATION NAME] given md aware with new orders ,[DATE] p 136 RR 28 [DATE] at 21:29 Nursing Note child started on [MEDICATION NAME] LT 99.3 remains on droplet precautions lung sounds clear at this time attached to vent on prescribed setting.[MEDICAL CONDITION] intact and patent. [DATE] at 11:24 eMar - Medication Administration Note temp 101.1; administered PRN Tylenol as per order; will monitor [DATE] at 22:56 eMar - Medication Administration Note patient noted with an elevated temo (sic) of 103.8 prn given will endorse for further monitoring [DATE] at 02:35 eMar - Medication Administration Note Rechecked T 102.1 Tylenol given and cooling measures maintained. [DATE] 12:41 eMar - Medication Administration Note temp 102; will alternate with Tylenol; will monitor [DATE] at 22:53 eMar - Medication Administration Note Noted with elevated HR 140 warm to touch T 101.5 cont. with cooling measures PRN [MEDICATION NAME] for disc./pain given .will monitor. [DATE] at 10:25 eMar - Medication Administration Note Tylenol administered for temp 101.5; cooling measures ineffective; will monitor [DATE] at 14:38 Nursing Note Rec'd in bed febrile; temp 100.1; cooling measures ineffective; PRN [MEDICATION NAME] administered as per order at 830am; (-) effect; alternated with Tylenol for temp 101.5 at 10am; (-) effect; at 2:30pm temp 100.5; alternated with [MEDICATION NAME]; to monitor latest temp; HR remains in 140s; copious amount of thick yellowish secretions; lung sounds clear with mild wheezing on expiratory; NP made aware of childs conditions, MD also aware; kept child comfortable and cool in bed; will monitor [DATE] at 00:46 eMar - Medication Administration Note PRN [MEDICATION NAME] given for temp 102.3, HR 170bpm. Child on cooling and comfort measures. CN aware and will continue to monitor [DATE] at 00:00 Respiratory Note Received Pt with Oxygen Saturation between ,[DATE]% Pt was suctioned for copious amount thick tan secretion. Pt's Heart rate was elevated, Nurse stated that the patient had spiked a temp. Pt's EtCo2 was 33 mmHg, HR 164, RR 29. Pt was put on 3 Lpm bled in Oxygen to maintain saturation above 94%. Pt was auscultated for crackles in the bases bilaterally. Physician was notified by charge nurse. Physician ordered to increase PT's PEEP to 8 from 6 And increase Oxygen to maintain saturation > 94%. At 0400 was able to wean the pt down to 2Lpm Oxygen, Pt maintaining O2 Saturation above 95%. Pt does not seem to be in any respiratory discomfort. [DATE] at 13:58 eMar - Medication Administration Note Temp 102.2, face flushed, HR150's [DATE] at 05:12 eMar - Medication Administration Note Patient noted HR 147 T 101.7 [MEDICATION NAME] given and cooling measures rendered. [DATE] at 11:51 Nursing Note patient noted at 11am with moderate amount of frank tracheal bleeding . Patient suctioned and ice lavaged with no good effect. HR - ,[DATE] B/P ,[DATE] T-100.6 post [MEDICATION NAME] at 1030am, RR-44 Eto2 30 sats 93% on 4 liters O2. Dr PMD called and notified of patients condition. new orders received to transfer to hospital. supervisor aware. RP aware (dad) of patients transfer to (hospital name) ER via stretcher via ambulance with paramedics, Patient left at 1150am.

Based on record review and interview, the facility failed to ensure that the Pediatric Medical Director (PMD) provided medical input and support to the Administrator for services related to quality of care, Quality Assessment and Performance Improvement (QAPI), implementation of facility policies, and monitored infection control surveillance for prevention of facility acquired infections specifically related to the pediatric care of the facility. On [DATE] at 06:18 PM, the facility's Administrator and Regional Director of Clinical Services were notified that an Immediate Jeopardy situation had been identified related to inadequate administrative oversight and failure to identify quality deficiencies and implement performance improvement projects which contributed to the delay in identification and containment of adenovirus outbreak affecting 33 residents, 1 staff and resulted in 11 pediatric resident deaths. The facility provided an acceptable plan for removal of the immediate jeopardy which was accepted by the team. Findings include: The facility's contract with the Medical Director, signed [DATE], documented, Facility wishes to engage Physician to provide services as a medical director of the Facility and to ensure the provision of high quality medical care for the Facility residents and to ensure compliance with the Medicare Conditions of Participation for Skilled Nursing Facilities . in consideration for the performance of the Physician's Services the Facility agrees to compensate Physician a monthly fee . for the actual performance of the Services. All time must be documented with a description of the services on the Medical Director Monthly Report. No compensation shall be paid to Physician for services until the Physician completes and submits, and the Facility approves, the Medical Director Monthly Report. Physician shall coordinate medical care .this function shall include . participating in monthly meetings with the Administrator, the facilities Medical staff, governing body, director of nursing . to discuss clinical issues . specific patient care problems and professional staff needs for education or consultants, as well as offering solutions to problems and identify areas where policies should be developed . monitoring that all necessary medical services appropriate to the Physician's specific field of expertise that are being provided to residents are adequate, appropriate, and reflect best practices within the Facility's setting and capabilities. Physician shall advise, review, approve and consult with respect to resident care policies including . admissions, transfers and discharges of residents with health conditions, responsibilities of . nursing staff, respiratory care staff, rehabilitation therapies, dietary services, emergency care and resident assessment. Physician shall actively participate and consult in the Facility's quarterly quality assurance process to ensure the quality of medical and medically related care . actively participate and consult in continuous quality improvement program as well as any relevant committees such as pharmacy and therapeutics committee, and the infection control committee. The Medical Director Agreement, included a document entitled, Medical Director Monthly Report, The report included areas for documentation of the current month, description of services, notes and hours column, policy development, physician & community education, staff training, quality assurance program activities, and other administrative services. An interview with the Administrator on [DATE] at 11:00 AM, revealed the facility designated a Medical Director to the 90-bed pediatric ventilator unit of the facility on [DATE]. According to the Administrator, the Pediatric Medical Director (PMD), was in place when she started working at the facility. The Administrator stated, He does not attend the QAPI meetings. His nurse practitioner attends. I have been here four years and have never received a monthly report from him. We have not had formal meetings to discuss issues with the children on the unit. I have never asked him to review or approve a resident care policy and he has not been involved in the facilities infection control surveillance. On [DATE] at 11:15 AM, the PMD stated, I have been here [AGE] years. I was one of several pediatricians and now I'm the only one left. They all bailed on me. When they asked me to be the medical director I agreed. No one gave me a job description and I signed the contract. I have a pediatric intensive care background. I have never attended the Quality Assurance and Performance Improvement (QAPI) meetings. I have never been invited. My nurse practitioner attends. When I have an issue, I speak to the clinical manager or the respiratory therapy director. I have not participated in the surveillance of infection control and I can't give you any numbers. I know my patients and I can tell if they are having more pneumonias than usual. I have no formal method of measuring the pneumonia rate or infection rate. I have never been shown the Infection Control report and I am not aware of the facility acquired infection rates. I have no idea what the pressure ulcer development rate is for the pediatric unit. I can't give you numbers or statistics. I haven't provided input in the policies of the unit and I have never been asked to review or sign a policy. Regarding the outbreak of [MEDICAL CONDITION], I thought the state was over reacting, I said how is it going to spread? That was in October. I knew we had a problem after the 4th death. The root cause of the deaths is the deadly adenovirus 7. We did not know about [MEDICAL CONDITION] until (MONTH) 8th. I agree 100 percent that we need to tighten up our process for infection control. No one at the facility has given me the regulations regarding the medical director and I have never read them. I didn't understand what medical director meant. On [DATE] at 11:30 AM, the Director of Nursing (DON) stated, I didn't know Dr. (Dr.'s name) was the medical director over the pediatric unit. I just found out when we had our state survey this August. He has never attended the QAPI meetings and I have never asked him to attend. I thought he was the pediatrician for the vent unit. 1. Cross-reference F835 L: Administration The facility failed to ensure the administration of the facility performed in a manner efficiently and effectively to identify quality deficiencies and implement performance improvement projects when problems were identified. The facility failed to include the facility medical director in the facility's quality assurance process and failed to designate specific responsibilities of oversight to professional staff providing medical services to the residents. 2. Cross-reference F867 L: QAPI/QAA Improvement Activities Based on review of the facility capacity statement, quality assessment data, and interview, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) committee developed improvement activities based on systemic analysis of data, failed to develop an action plan based on the data, and failed to have a process in place to measure the success and sustained improvement of high risk problems. Specifically, the facility failed to develop a QAPI action plan for the high-risk problem of respiratory infections in the pediatric ventilator unit. 3. Cross-reference F880 L: Infection Prevention and Control Based on observation, interview, and record review, the facility failed to implement an effective Infection Prevention and Control Program (IPCP) to help prevent the development and transmission of communicable diseases and infections in the facility. This system failure lead to a delay in the prevention, identification, reporting, investigation, and control of an outbreak of a communicable adenovirus infection within the facility's pediatric ventilator unit, which, as of [DATE], had caused adenovirus-positive infections in 17 of 35 sampled residents, (Resident (R) 3, R63, R76, R114, R146, R166, R167, R168, R346, R347, R348, R349, R350, R351, R352, R354, and R355), and in 17 non-sampled residents, (R5, R38, R67, R75, R78, R79, R110, R111, R115, R159, R191, R195, R600, R601, R602, R603, and R604). Nineteen additional residents, eight sampled (R42, R45, R66, R70, R113, R164, R193, and R353), and 11 non-sampled (R6, R37, R43, R64, R65, R68, R142, R161, R162, R163, and R605) also exhibited symptoms of infection, but had negative, or no culture results, documented. This deficient practice resulted in the development of infections involving 53 residents, 11 of which, died , and placed the facility's other 150 residents in immediate jeopardy of contracting adenovirus infections, with the likelihood to cause serious harm, impairment, or death. 4. Cross-reference F881 L: Antibiotic Stewardship Program Based on interview, record review, and facility policy review, the facility failed to implement an antibiotic stewardship program. This failure had the ability to impact all residents by not having an antibiotic protocol or system for monitoring antibiotic usage.

Based on observations, interviews, record review, and policy review the facility failed to turn and reposition, initiate pressure relieving devices, and implement pressure relieving devices in the plan of care to prevent an avoidable pressure sore for 2 of 51 sampled residents, (Resident (R 104, R347). Findings include: 1. The Admission Record (face sheet) with a print date of [DATE], for R104, indicated the facility admitted the resident on [DATE]. The [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS - an assessment tool completed by the facility staff used to identify resident problems and assist with care planning), with an Assessment Reference Date (ARD) the end-point of the evaluation period of [DATE], under Section G for functional status with activities of daily living, indicated R104 was totally dependent on two persons for bed mobility, toilet use, and bathing. R104 was unable to transfer, stand or walk. Section M of the MDS for skin conditions, indicated R104 had no pressure ulcers. Review of a Braden Scale for Predicting Pressure Sore Risk, dated [DATE], type quarterly, indicated the resident was moderate risk of pressure sore development. Review of the Comprehensive Care Plan, with a print date of [DATE], included, Resident is at risk for skin impairment due to: limited mobility and incontinent of bladder and bowel .Resident's skin will remain intact .apply lotion to skin as needed .heel booties as tolerated-remove for care .monitor skin integrity every shift .reposition in bed every 2 hours. On [DATE] at 8:23 AM, R104 was observed in bed on her left side. The resident was contracted and in the fetal position. The resident was observed to have no pressure reduction device on her feet, between her knees where there was skin to skin contact and she was not lying on a pressure prevention mattress. Review of Progress Notes, dated [DATE], included, Nursing students were doing care to resident and noted a dried blood blister to left foot lateral. Supervisor .notified .Dr. notified with orders for skin prep q (every) shift for 14 days and evaluate treatment on (MONTH) 29, (YEAR). Bilateral feet elevated with pillows. Review of Skin Injury report dated [DATE] at 8:40 PM, indicated, Student nurses were doing PM care and noted to left foot lateral side with dried blood blister measuring 1.5 x 1 centimeter (cm) .supervisor notified. Resident unable to describe .interventions: evaluate for heel lift boots .therapy screen for wheelchair positioning. Observation on [DATE] at 9:46 AM identified R104 in bed on her left side. There were no pressure reduction devices on her feet or between her knees. On [DATE] at 4:30 PM, R104 was observed in bed on her left side. There were no pressure reduction devices on her feet or between her knees. Review of PT/OT (Physical Therapy/Occupational Therapy) Screen, dated [DATE], indicated, Patient was screened due to nursing referral for a dried blood blister on the left plantar aspect. Patient was seen in bed with proper bed positioning bilateral heel booties .inspected wheelchair to see if there's any cause for the blood blister. Wheelchair deemed appropriate and is not the cause for the blood blister. Recommended to continue with heel booties for skin integrity. On [DATE] at 3:15 PM, the Director of Nursing (DON) stated, I was not aware of the pressure sore. We haven't had our clinical meetings this week and I haven't talked to the unit manager. She has no history of pressure sores that I know of and she has been here for many years. The DON confirmed R104 was not provided the bilateral heel booties per the care plan. On [DATE] at 3:40 PM, an interview with the Registered Dietitian (RD), revealed she was not aware of R104's pressure sore. The RD stated, Pressure sore? Where? I didn't know. We have not had our clinical meetings this week and I am usually informed of skin breakdown then. We meet Monday through Friday usually but not this week because of survey. She should not have developed a pressure sore she is a well-nourished patient. Her weight has been stable, and she is receiving an adequate amount of protein via her tube feedings. Her nutritional needs are adequate for skin integrity. I would say the pressure sore is avoidable. Review of Wound Prevention and Management Policy, dated Revised ,[DATE], included, Each resident receives the care and services necessary to retain or regain optimal skin integrity to the extent possible .each resident is evaluated to determine his or her risk for skin compromise or the presence of wounds and/or pressure ulcers. A plan of care is developed and implemented based on this evaluation with ongoing review. If skin compromise occurs, evaluation is conducted by the interdisciplinary team to ensure appropriate measures are in place to minimize further compromise .residents identified as at risk for development of pressure ulcers will have a plan and intervention included in the care plan to address risk factors for development of pressure ulcers. 2. Review of the Admission Record in the profile area of PointClickCare (electronic medical record used by the facility) for R347 shows that the resident was admitted to the facility [DATE]. Admission [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS - an assessment tool completed by the facility staff used to identify resident problems and assist with care planning), dated [DATE], Section G (functional status with activities of daily living, indicated R347 was totally dependent on two persons for bed mobility, toilet use, and bathing. R347 was unable to transfer, stand or walk. Section M of the MDS for skin conditions, indicated R347 had no pressure ulcers but was noted with Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated [MEDICAL CONDITION] (IAD), perspiration, drainage). Review of a Braden Scale for Predicting Pressure Sore Risk, dated [DATE], indicated the resident was at high risk of pressure sore development. Review of the Comprehensive Care Plan, which was initiated [DATE] and revised [DATE], included, (R347) is at risk for skin breakdown, scratch, abrasion & bruises secondary to:[MEDICAL CONDITION] held in place [MEDICAL CONDITION]; Poor secretion control . and interventions include Apply skin barrier to neck during [MEDICAL CONDITION] change, and use soft sponge dressing [MEDICAL CONDITION]. Check skin integrity daily, and weekly documented skin checks. Keep skin integrity clean, and dry at all times, apply moisturizing lotion as needed. Review of Progress Notes section of PointClickCare electronic record reveals: [DATE] at 11:03 Nursing Note While doing [MEDICAL CONDITION] change noted reopen area on pt neck measuring L-0.5cm,W-1.2cm.No sign symptom of discomfort noted.Scent (sic) bleeding noted TX ordered cleanse reopen area with nss pat dry apply [MEDICATION NAME] then pad with soft foam dressing X 7days then evaluate. Will continue to monitor endorsed. [DATE] at 22:26 Weekly Skin Check Note Weekly skin check done. Pt. remains with reopen area to back of neck. Tx. rendered as order. Tx. renewed for another 7 days. 0 s/s of pain and discomfort. [DATE] at 12:32 Nursing Note Noted with open area on coccyx measuring 0.8 cm in length x 0.6 cm in width and 0.7 cm in depth; Md notified with orders; carried out; Cleansed area with wound cleanser, pat dried, applied hydrogel saturated gauze and covered with flexicol dressing. No s/s of discomfort noted. Area around open area excoriated, [MEDICATION NAME] ointment applied. [DATE] at 07:01 Nursing Note Treatment to excoriated (reddened, irritated, abraded) buttocks renewed, No s/s of pain noted. [DATE] at 13:13 Nursing Note Weekly assessment/evaluation to coccyx (tail bone area); will continue with existing tx (treatment); wound measures L-2.3cm, W-1cm, D-0.9cm; no drainage; no signs of improvement to area; will monitor [DATE] at 11:27 Nursing Note Open area on coccyx evaluated; Length 2 cm., width 1 cm, depth 0.5 cm; New treatment started, cleansed with wound cleanser, pat dried packed with [MEDICATION NAME] (dressing) and left open to air; no discomfort noted. [DATE] at 22:41 Nursing Note Treatment to a coccyx and left side of the neck rendered as ordered , no s/s having a pain or discomfort, will continue to monitor [DATE] at 23:19 Nursing Note [MEDICAL CONDITION] change resident been found having re-open area on right side of the neck as medical device injury , L=0.6cm, W=0.5cm, with scant blood , no smell , no s/s having a pain or discomfort, all Treatments rendered as ordered, will continue to monitor [DATE] at 22:23 Nursing Note Treatments on left and right area of the neck rendered as ordered, right area almost healed, Treatment on coccyx area on progress with some improvement, T=98 no s/s (signs or symptoms) having a pain or discomfort, will continue to monitor [DATE] at 22:06 Nursing Note New treatment for [REDACTED]. [DATE] at 15:03 Nursing Note eval. (evaluate) coccyx area now measures 1cm x1cm depth is 0.2cm no s/s of discomfort no s/s of infection. [DATE] at 22:25 Nursing Note remains with Treatment on right ,left side of the neck and coccyx area, healing on re-open area right side of the neck in progress, no bleeding or any drainage noted, treatment extended for next 7 days, re-open area left side of the neck clean and dry remains open, healing improving. open area on coccyx in progress L=0.4cm, W=0.2cm, depth 0.1cm, with scant blood on at.no s/s having a pain or discomfort, resident turned every 2 hr, diaper kept clean and dry, will continue to monitor [DATE] at 23:13 Nursing Note Tx to Left side of neck healed. Endorsed. [DATE] at 14:48 Nursing Note Treatment on [DEVICE] site for redness and open area on coccyx evaluated ,no redness on [DEVICE] site, new preventative treatment rendered as ordered,coccyx area has significant progress , no s/s having a pain or discomfort, Treatment continues for next 7 days, [DEVICE] out and reinserted with no difficulties, placement verified by auscultation and aspiration, medication and feeding tolerated well,T=97.3 will continue to monitor [DATE] at 19:56 Weekly Skin Check Note Routine weekly skin check done, Child remains with open areas to coccyx and right thumb with treatment in progress. Endorsed to continue to monitor. [DATE] at 09:33 Nursing Note Coccyx area is healed no treatment needed. We will continue the standing perineal care to prevent excoriation. [DATE] at 22:40 Weekly Skin Check Note Routine weekly skin check done, skin intact no open areas. Endorsed to continue to monitor. [DATE] at 14:33 Nursing Note Pt. noted with reopen area left neck, measuring 0.5cm x 5cm.treatment in progress. to evaluate in 7 days. Area cleansed with nss/ pat dry [MEDICATION NAME] applied and covered with hydrsorb. [DATE] 23:02 Weekly Skin Check Note Routine weekly skin check done, child remains with treatment to left neck, applied as ordered. Endorsed to continue to monitor. [DATE] at 13:45 Nursing Note . re-open area on left side of the neck with scant blood on at, wound margins intact and attached ,no s/s having a pain or discomfort, treatment rendered as ordered, will continue to monitor [DATE] at 15:44 Nursing Note Open area in the Left side of neck length 0.5cm and width 2.5 cm , new treatment ordered. [DATE] at 22:24 Nursing Note Skin intact, no open or red area noted. [DATE] 22:32 Nursing Note Called in the room by CNA as she noticed something on child's right elbow. Upon further examination noted a discoloration to right elbow measuring 5cm. Skin remains intact. Temp:97.6 Mom made aware. Endorsed. [DATE] at 14:27 Nursing Note Discoloration to right elbow persist, no discomfort noted. [DATE] at 06:50 Nursing Note Discoloration to right elbow persist, no discomfort noted. [DATE] at 14:58 Nursing Note child with reddened area to right inner ankle, treatment on progress. [DATE] at 22:14 Weekly Skin Check Note Pt. skin assessment done. Remains with R inner ankle open area with tx. in progress. [DATE] at 15:32 Nursing Note pt. noted with reopen area at back of neck measuring 1cm x4cm. treatment started. to re eval in 7 days. [DATE] at 22:59 Weekly Skin Check Note Weekly skin check done. Open area noted to back of neck. TX in progress and carried out. No other open areas observed. R347 was hospitalized [DATE] to [DATE] [DATE] at 16:05 Nursing Note Received in bed, skin warm and dry, color pale.[MEDICAL CONDITION] and patent to vent. GT intact and patent, tolerating feeding via pump. Treatment to neck done as ordered, slight bleeding. Treatment to coccyx done as ordered, slight bleeding no drainage. VSS Voiding qs SG 1.020. Resting comfortably at present. [DATE] at 22:41 Nursing Note Child remains on palliative care. O2 sats throughout shift 94%-96% on vent settings with 70% o2 R-19 P-109 T-97.9 No discomfort observed. All due meds/feedings given and tolerated. Evaluation of sacrum wound (0.5cm deep) and back of neck (3cm x 1cm x 0cm depth) done with TX started to both areas. Right labia swollen, will continue to monitor and endorse to following shift. Charge nurse aware. R347 expired at the facility on [DATE]

C#: NJ 8, NJ 8, NJ 1, NJ 5, NJ 9, NJ 4 Based on observations, interviews, and record review, as well as review of pertinent facility documents on 11/13/18, it was determined that the facility failed to ensure infection control measures were implemented for 1 of 1 residents (Resident #16) observed during wound care. On 11/13/18, Registered Nurse #1 (RN #1) and Licensed Practical Nurse #1 (LPN #1) donned their Personal Protective Equipment (PPE), to perform wound care on Resident #16's right ankle. RN #1 with the LPN #1, removed the dressing on the right ankle. The surveyor observed moderate amount of dark yellow drainage on the dressing. RN #1 while wearing the same gloves, immediately took a Single Dose Saline Vial (SDSV) from inside a box that contained 36 individual 15 milliliter (ml) Single Dose Saline Vials used for tracheal lavage (wash), [MEDICAL CONDITION] care, and wound care for Resident #16 and available for use for the roommate (Resident #11). RN #1 continued with the same gloves on, opened the tip of the Single Dose Saline Vial and poured the saline solution from within the SDSV onto the wound and cleansed it with gauze. RN #1 without hand hygiene and glove changing, applied the Santyl ointment and foam dressing and secured it with an Opsite dressing. This deficient practice of not changing gloves during wound care, entering a box of multiple Single Dose Saline Vials while wearing gloves used to perform the wound care created the potential for the spread of infection and the Immediate Jeopardy (IJ) situation for both Resident #16 and Resident #11 who reside in the same room. The box of multiple Single Dose Saline Vials were designated to be used for both Residents #11's and 16's wound care, tracheal lavage, and [MEDICAL CONDITION] care. Both Resident #16 and Resident #11 were on contact and droplet precautions at the time of survey. This deficient practice was identified as Immediate Jeopardy (IJ) situation at 3:28 p.m., on 11/13/18. The Administration was notified of the IJ. The Immediacy was lifted on 11/13/18 at 5:00 p.m., when the facility implemented an acceptable Plan of Correction (P[NAME]). Reference: According to the CDC, Morbidity and Mortality Weekly Report (MMWR) Guideline for Hand Hygiene in Health-Care Settings, dated (MONTH) 25 2002, under Recommendations: 1. Indications for handwashing and hand antisepsis . C. Decontaminate hands before having direct contact with patients . H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care . J. Decontaminate hands after removing gloves . 2. Hand-hygiene technique A. When decontaminating hands with an alcohol-based hand rub, apply products to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry . B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse the hands with water and dry thoroughly with a disposable towel . A review of the undated facility's policy Infection Prevention and You, showed under the section Droplet precautions: Wear mask. Change when moist. Remove before leaving the room .wash hands! The same policy under the section Standard precautions include: 1. Hand hygiene 2. Use of personal protective equipments . 1. According to the Admission Record, Resident #16 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum data Set (MDS), an assessment tool, dated 8/29/18, showed that the Resident was severely impaired and was totally dependent on staff for Activities of Daily Living (ADL). Resident #16's Care Plan (CP), showed an actual skin impairment related to a wound on the right lateral foot initiated on 8/20/18, and a wound on the back of the neck initiated on 10/1/18. Interventions included but were not limited to: daily treatment as ordered, and [MEDICAL CONDITION] stoma, and neck care every shift. The Progress Notes (PN) for Resident #16, dated 11/2/18, documented by the Nurse Practitioner (NP) that the Resident was readmitted to the facility on [DATE], from the Hospital for Adenovirus. The Order Summary Report (OSR), dated 11/2018, showed the following Physician's orders: On 11/3/18, an order to apply [MEDICATION NAME]-AG Foam Pad on the back of the neck every shift, cleanse with Normal Saline Solution (NSS), pat dry, apply [MEDICATION NAME] and cover with [MEDICATION NAME] Border Life (dressing) and pad with foam dressing under the [MEDICAL CONDITION] tie. On 11/3/18, an order to cleanse right ankle with NSS, pat dry, apply Santyl ointment, then apply foam dressing and cover with Opsite clear dressing daily. On 11/13/18 at 10:34 a.m., the surveyor observed the following during the wound care treatment for [REDACTED]. RN #1 gathered her treatment supplies and placed them on the overbed table. RN #1 and LPN #1 performed hand hygiene, donned their Personal Protective Equipment (PPE) and proceeded to reposition Resident #16. RN #1 with assistance from LPN #1 removed the [MEDICAL CONDITION] tie, the [MEDICAL CONDITION] dressing, and the wound dressing on the back of Resident #16's neck. RN #1 removed the dirty gloves, her PPE, and performed handwashing. Then RN #1 donned new PPE, then returned back to Resident #16. RN #1 proceeded to wet the gauze using a Single Dose Saline Vial and cleansed the wound on the back of the Resident's neck. RN #1 while wearing the same gloves, wet another gauze with a Single Dose Saline Vial and performed [MEDICAL CONDITION] care. RN #1 continued with the same gloves on, applied [MEDICATION NAME] Border Life dressing, and a foam pad on the back of the Resident's neck, then applied the Hydrosorb dressing around the [MEDICAL CONDITION] and secured it with the [MEDICAL CONDITION] tie. RN #1 gathered her dirty dressings, threw it in the garbage bin inside the bathroom, and performed hand hygiene. LPN #1 also removed her PPE and performed hand hygiene. The wound care observation continued. RN #1 and LPN #1 donned new PPE, to perform wound care on Resident #16's right ankle. RN #1 with LPN #1, removed the dressing on the right ankle. The surveyor observed moderate amount of dark yellow drainage on the dressing. RN #1 while wearing the same gloves, immediately took a Single Dose Saline Vial inside a box that contained 36 individual 15 milliliter (ml) SDSV. RN #1 while wearing the same gloves, opened the tip of the SDSV and poured the saline solution from within the SDSV onto the wound and cleansed it with gauze. RN #1 without hand hygiene and glove changing, applied Santyl ointment and foam dressing then secured it with an Opsite dressing. RN #1 gathered her dirty dressings, threw it into the garbage bin, removed her PPE and performed handwashing. LPN #1 removed her PPE and performed handwashing. Further observation on 11/13/18 at 11:22 a.m., the surveyor with RN #1 and LPN #1, while inside the room of Residents' #11 and #16, observed that the box where RN #1 took the SDSV had 36 SDSV in it. Each SDSV was 15 milliliter (ml) in size, was not in a sealed container, and would require a twisting motion to open. The SDSV was marked with 0.9 % Sodium Chloride, Inhalation Solution. Both RN #1 and LPN #1 stated that these SDSV in a box were being used for tracheal lavage, [MEDICAL CONDITION] care, and wound care. Both RN #1 and LPN #1 also stated that these SDSV inside the box were used for both Residents' #11 and #16. RN #1 and LPN #1 revealed that each residents' room had the same set up. The surveyor took the box that contained 36 SDSV and instructed RN #1 to not use it and to dispose of it. During an interview with the Assistant Director of Nursing (ADON) on 11/13/18 at 12:55 p.m., the ADON confirmed that each residents' room had a box/container of SDSV used for both residents in the room. She further confirmed that the SDSV was used for tracheal lavage, [MEDICAL CONDITION] care, and wound care. The ADON revealed that the facility would rather use the SDSV than the bottled Normal Saline Solution (NSS). On 11/13/18 between 2:03 p.m. to 2:20 p.m., the surveyor observed that there were 27 rooms on the first floor Pediatric Unit with a box of SDSV used for tracheal lavage, [MEDICAL CONDITION] care, and wound care for both residents in each room. During an interview with the Head of the Respiratory Department (HRD) on 11/13/18 at 2:28 p.m., the HRD confirmed that the SDSV were used for tracheal lavage and trachesotomy care. The HRD stated that he was not aware that the nursing staff were using the SDSV for wound care. However, he stated that nurses were permitted to use the SDSV for wound care. A review of the facility policy, titled Treatment Procedure, dated 1/2017, showed the following: Policy .#4. Clean technique is to be used on all dressing changes. The same policy under the Treatment section: .#7. Place prepared ointments or liquids in medicine cups on barrier. Solution and/or ointments should be prepared at the Treatment Cart by pouring solution into medicine cup or directly onto gauze .Normal Saline: When 100 ml Normal Saline pre-portion cups are used, the remainder should be disposed . #11. Remove soiled dressing, remove gloves and place in plastic bag. #12. Wash hands or use hand sanitizer then re-glove (second pair). #13. Irrigate or clean wound as ordered . #14. Remove gloves and discard. #15. Wash hands or use hand sanitizer then re-glove (third pair) . #16. Apply medication and prepared medication as ordered. #17. Discard all soiled dressings, . #20. Discard plastic bag in designated area. #21. Wash hands. The Administration was notified of the IJ situation on 11/13/18 at 3:23 p.m., regarding the deficient practice of not changing gloves during wound care, entering a box of multiple Single Dose Saline Vials while wearing the same gloves used to perform the wound care which created the potential for the spread of infection and the Immediate Jeopardy (IJ) situation for both Resident #16 and Resident #11 who reside in the same room. The box of multiple Single Dose Saline Vials were designated to be used for both Residents #11's and 16's wound care, tracheal lavage, and [MEDICAL CONDITION] care. An acceptable P[NAME] was received on 11/13/18 at 5:00 p.m., as follows: 1. The resident affected by the deficient practice of the nurse not changing gloves and washing her hands or sanitizing between treatment steps was assessed and there was no negative outcome to the resident. The RN and the LPN who were involved in the deficient practice were reeducated on how to properly perform wound care following infection control protocols including changing gloves and washing hands/sanitizing in between treatment steps. 2. All saline bullets(vials) that are currently stored inside the residents's rooms were thrown away on 11/13/18. All saline bullets(vials) will be stored separately in the nursing treatment carts by the Unit Manager and respiratory carts by the Respiratory Therapy Supervisor and will no longer be stored in the resident rooms. 3. All licensed staff will be reeducated on 11/13/18 by the Infection Control Nurse/designee on how to properly perform wound care following infection control protocols. 4. Staff Development Coordinator/designee will conduct random weekly observation of licensed staff performing wound care to ensure infection control protocols are followed. Weekly findings will be reported monthly to the QAPI Committee until 100% compliance is reached. The committee will provide review and oversight for further evaluation and recommendations. 5. Completion Date: 11/13/18 The deficiency continued at a lower Scope and Severity: E A. Based on observation, interviews and record review, as well as review of pertinent facility documents on 10/21/18 and 11/13/18, it was determined that the facility failed to ensure that hand hygiene was performed according to facility policy and acceptable standards of infection control practice according to Centers for Disease Control and Prevention (CDC). This deficient practice was identified on 10/21/2018 for 4 of 6 Employees ( E #1, #2, #3, and #4) and on 11/13/18 for 1 of 6 Employee (CNA #3) observed for hand hygiene. This deficient practice is evidenced by the following: 1. On 10/21/18 at 11:00 a.m., while observing the Licensed Practical Nurse ( LPN, E #1), inside the room of Resident #1, E #1 donned gloves, touched the Resident's gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach), repositioned the Resident, and then removed her gloves, and without benefit of performing hand hygiene, E #1 then touched the tubing connected to the Resident's [MEDICAL CONDITION] and the ventilator machine. E #1 stepped out of the room without first performing hand hygiene and went to another resident's room to open the window and without performing hand hygiene, E #1 went to her medication cart. In an interview with E#1 on 10/21/18 at 11:11 a.m., she confirmed that all residents assigned to her were on standard and droplet precautions and the importance of hand hygiene before and after Resident's care and acceptable standards of infection control. 2. On 10/21/18 at 11:17 a.m., while observing Respiratory Therapist ( RT, E #2), E #2 donned a gown and gloves and applied a breathing mask on Resident #2. E #2, then removed her gloves and mask failed to perform hand hygiene and touched her own hair. E #2 stepped out of the room, went to Resident #3's room, picked up the pulse oximetry on the floor and attached it to Resident #3's foot. E #2 stepped out of the room without performing hand hygiene and went to another resident's room. 3. On 10/21/18 at 11:29 a.m., the surveyor observed Certified Nurse Assistant (CNA, E #3), as E#3 donned a mask, gown, and gloves and removed the soiled incontinent brief from Resident #4. E #3 continued to provide incontinence care with the same gloves on, E #3 then took the respiratory tubing on the wall that was attached to the humidifier while wearing the same gloves, attached the same tubing to Resident #4's [MEDICAL CONDITION] collar. E #3 removed her gloves, gown, and performed hand washing for 12 seconds, not 20 seconds according to facility policy. E #3 applied soap, turned on the faucet, rubbed her hands together under the running water for the aforementioned seconds, then dried her hands with the paper towel. 4. On 10/21/18 at 1:24 p.m., the surveyor observed Licensed Practical Nurse (LPN, E #4) donned a mask, gown, gloves, and administered medication to Resident #5 via the gastrostomy tube. After the medication administration E #4 removed her gloves and performed hand washing for 13 seconds, not 20 seconds according to the facility policy. E #4 applied soap and rubbed her hands together away from the stream of running water for the aforementioned seconds and then rinsed the soap off under running water then dried hands with a paper towel. 5. On 11/13/18 at 10:04 a.m., the surveyor observed Certified Nurse Aide (CNA #3) performed handwashing for 6 seconds, not the 20 seconds according to facility policy: CNA #3 was in the resident's room, removed her PPE, turned on the faucet, applied soap and rubbed her hands together, rinsed under the running water, then dried her hands with the paper towel. CNA #3 left the room and went to another resident's room. On 11/13/18 at 12:10 p.m., the surveyor did a follow-up observation on CNA #3 for handwashing: CNA #3 was inside the resident's room, turned on the faucet, wet her hands, applied soap, rubbed her hands together, then rinsed under the running water, turned off the faucet, dried her hands with the paper towel for 16 seconds, not the 20 seconds according to the facility policy. The surveyor asked CNA #3 how long should she wash her hands. The CNA stated 20-30 seconds. The surveyor requested CNA #3 to demonstrate her handwashing technique and when she did it was for 19 seconds, not the 20 seconds according to the facility policy. During an interview with the Assistant Director of Nursing (ADON) on 11/13/18 at 12:15 p.m., the surveyor informed her about the aforementioned handwashing observation for CNA #3. The surveyor requested the ADON to have the Facility Educator show CNA #3 the handwashing technique according to their policy. During the follow-up interview with the ADON on 11/13/18 at 12:55 p.m., the ADON stated that CNA #3 was evaluated for handwashing technique and failed the first evaluation. However, when she was reeducated the second time, CNA #3 did the handwashing technique for 22 seconds, according to their facility policy. A review of the undated facility's policy Infection Prevention and You, showed under the section Droplet precautions: Wear mask. Change when moist. Remove before leaving the room .wash hands! The same policy under the section Standard precautions include: 1. Hand hygiene 2. Use of personal protective equipments . A review of the facility policy titled, Hand Washing/ Hand Hygiene, dated 3/31/2011, showed: Hand hygiene is a basic requirement for infection prevention. It is the facility's policy that all staff is trained in proper technique and is monitored for proper hand hygiene practices. Procedure: 1. Employees will perform hand hygiene at appropriate times to reduce the risk of transmission and acquisition of health care associated infections. 2. Hand Hygiene can consist of hand washing with soap and water or use of an alcohol based hand rub . Under section titled Hand washing with soap and water: 4. Hands should be washed with soap and water at the following times: a. When hands are visibly soiled . 8. Turn the water on . 9. Wet your hands and wrists. 10. Apply soap (about 3 to 5 ml (millimeter)), spreading over the entire skin area adding water as needed to keep the lather from becoming dry. 11. Work lather over hands and wrists .l. Scrub for at least 20 seconds . Under section titled Use of Alcohol Based Hand Rubs: 1. Hands should be decontaminated with alcohol based rubs at the following times: a. Routine decontamination when hands are not visibly soiled .e. After contact with body fluids or excretions .h. After removing gloves . B. Based on observation, interview and review of documentation, the facility failed to review the infection control polices and procedures annually for the First Floor Pediatric Unit as evidenced by the following: On 11/13/2018 at 3 P.M., the surveyor asked the First Floor Unit Manager (UM) for the infection control procedures manual that is currently in use for the nursing staff. The UM handed the surveyor the large black binder labeled Policy and Procedure Pediatric. The UM stated that the infection control policies and procedures are included in this binder. A review of the binder revealed that the last review of THE POLICY and PR[NAME]EDURE MANUAL APPROVAL indicated it has been reviewed and approved for use by the Administrator, Director of Nursing, and Medical Director on 4/13/2015. Also, INFECTION CONTROL BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN policy was reviewed, updated, and signed on 1/19/2015 by Administrative staff. At 1:30 p.m., on 11/14/2018, the surveyor interviewed the Director of Respiratory care for the First Floor Pediatric Unit about the policies and procedure for infection care for the Respiratory Department. The Director stated that the respiratory department follows the same infection control practices as nursing that staff the first floor Pediatric Unit. At 2:00 p.m.,on 11/14/2018, an interview with Staff Development/Infection Control Nurse, confirmed that all policies and procedures for infection control of the Pediatric unit were included in the binder. However, she didn't know why the review was not done annually for that unit. At 2:30 p.m., on 11/14/2018, the surveyor asked the Administrator about the First Floor Pediatric Unit policies and procedures manual that was last reviewed and updated 4/13/2015 and 1/19/2015. The Administrator stated that she would look in to why the unit was missed for update and review. At 5 p.m., 11/14/2018, the Regional Director of Clinical Services stated to the surveyor that she could not provide documented evidence for the First Floor Pediatric Unit Infection Control Policies and Procedures being updated after (YEAR). She also stated that the Policy and Procedure for Infection Control should have been reviewed and updated annually. NJAC 8:39-19.4(a)

Based on observation, interview and record review, it was determined that the facility failed to follow care plan interventions to prevent falls and/or accidents and injury for Resident #2, who was 1 of 3 residents reviewed for falls. The resident sustained [REDACTED]. This deficient practice was evidenced by the following: On 3/16/16 at 12:30 p.m. during the initial tour of the facility, the Unit Manager informed the surveyor that Resident #2 was a high fall risk and had sustained a fall with a [MEDICAL CONDITION]. Resident #2 used a wheel chair for mobility, was unable to self-propel, was able to verbalize needs and was alert and oriented to person, place and time. On 3/17/16 at 12:55 p.m. the surveyor reviewed the medical record for Resident #2. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The nurse documented in the written Fall Risk assessment dated [DATE] that the resident was at high risk for falls due to functional limitations with range of motion to bilateral upper and lower extremities and was unable to stand independently. A second Fall Risk assessment dated [DATE] noted that the resident's risk for falls was due to the following factors: the resident received anti-[MEDICAL CONDITION] medication, had a history of [REDACTED]. The Interdisciplinary (IDC) team assessed the resident utilizing Quarterly Minimum Data Set (MDS), an assessment tool, dated 7/2/15, 9/24/15, 3/3/16 and the Annual MDS dated [DATE]. The IDC team assessed that the resident was alert and oriented to person, place and time; was dependent for transfer and required the help of two people; needed extensive assistance of one person for dressing, toilet use and personal hygiene; and was totally dependent on one person for assistance with bathing. On 3/18/16 at 10:10 a.m. the surveyor reviewed the plan of care developed by the IDC team to prevent the resident from falling as well as the facility's investigations of the falls sustained by the resident. The care plan was initiated 2/25/13 and identified that the resident's risk for falls and/or injury related to impaired balance, involuntary movements, a [DIAGNOSES REDACTED]. The care plan intervention to prevent falls dated 5/11/15, indicated that a mechanical lift to transfer the resident with the assistance of two staff members was to be utilized. On 3/18/16 the surveyor reviewed the following fall investigations: Resident #2 sustained a fall on 9/17/15 at 6:33 p.m. The nurse documented the resident slipped off the shower chair when two Certified Nurses Assistants (CNAs) were giving the resident a shower. On 9/17/15 the IDC team discontinued use of the shower chair and initiated the use of a shower bed for safety. This intervention was also added to the resident's care plan. Resident #2 sustained a 2nd fall on 1/4/16 at 7:15 p.m. when one CNA showered the resident in the shower room. The investigation revealed that the resident held onto the shower rail, the resident's legs gave way and the CNA eased the resident to the floor. The CNA asked another CNA to help and they assisted the resident to a chair without reporting the fall to the nurse or supervisor. The resident was not assessed by a nurse for potential injuries prior to the transfer to the chair. The CNA also did not use the shower bed for safety during showering as indicated on the care plan. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to provide a safe environment for Resident #2, 1 of 3 residents reviewed for falls. The resident sustained [REDACTED]. This deficient practice was evidenced by the following: On 3/16/16 at 12:30 p.m. during the initial tour of the facility, the Unit Manager informed the surveyor Resident #2 was a high fall risk and had sustained a fall with a hip fracture. Resident #2 used a wheel chair for mobility, was unable to self-propel, was able to verbalize needs, and was alert and oriented to person, place and time. On 3/17/16 at 12:40 p.m. the surveyor observed Resident #2 seated in a wheelchair at the lunch meal in the 4th floor dining room. A seat belt was fastened across the Resident's lap and a lift pad was under the resident. The surveyor talked with the resident about lunch and the resident was able to answer appropriately and converse with the surveyor. On 3/17/16 at 12:55 p.m. the surveyor reviewed the medical record for Resident #2. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The nurse documented in the written Fall Risk assessment dated [DATE] that the resident was at high risk for falls due to functional limitations with range of motion to bilateral upper and lower extremities. Resident #2 was unable to stand independently. A second Fall Risk assessment dated [DATE] noted that the resident's risk for falls was due to the following factors: the resident received anti-seizure medication; had a history of [REDACTED]. A numeric fall risk range from 0-3 indicated a minimal risk for falls, a range of 4-7 indicated a moderate risk for falls and 8 or more was considered a high risk for falls. Resident #2's total score on 7/27/15 was 13 and on 9/17/15 was 15. The Interdisciplinary (IDC) team assessed the resident utilizing Quarterly Minimum Data Set (MDS), an assessment tool, dated 7/2/15, 9/24/15, 3/3/16 and the Annual MDS dated [DATE]. The IDC team assessed that the resident was alert and oriented to person, place and time; was dependent for transfer and required the help of two people; needed extensive assistance of one person for dressing, toilet use and personal hygiene; and was totally dependent on 1 person for assistance with bathing. On 3/18/16 at 10:10 a.m. the surveyor reviewed the plan of care developed by the IDC team to prevent the resident from falling as well as the facility's investigations of the falls sustained by the resident. The care plan was initiated 2/25/13 and identified that the resident's risk for falls and/or injury was related to impaired balance, involuntary movements, a [DIAGNOSES REDACTED]. The care plan to prevent falls included an intervention dated 5/11/15 to use a mechanical lift to transfer the resident with the assistance of two staff members. On 3/18/16 the surveyor reviewed the following fall investigations: Resident #2 sustained a fall on 9/17/15 at 6:33 p.m. The nurse documented the resident slipped off the shower chair when two Certified Nurses Assistants (CNAs) were giving the resident a shower. The resident stated I slid. The resident did not sustain an injury. The facility noted in the fall investigation that a wet floor and the resident's gait imbalance, weakness and incontinence as predisposing factors that could have contributed to the fall. On 3/18/16 at 12:15 p.m. the surveyor interviewed the Administrator, Director of Nurses (DON), Assistant Director of Nurses (ADON) and the Staff Development Nurse. They stated that at the time of the fall on 9/17/15 there were two CNAs in the shower room with the resident. The resident was seated in a shower chair and moved very quickly. The CNA's were unable to stabilize the resident so the resident was eased to the floor and the situation was immediately reported to the charge nurse. On 9/17/15 the IDC team discontinued use of the shower chair and initiated the use of a shower bed for safety. This intervention was also added to the resident's care plan. The IDC team also requested a rehabilitation screen for safety awareness. Resident #2 sustained a 2nd fall on 1/4/16 at 7:15 p.m. when one CNA showered the resident in the shower room. The investigation revealed that the resident held onto the shower rail, the resident's legs gave way and the CNA eased the resident to the floor. The CNA asked another CNA to help her and they assisted the resident to a chair without reporting the fall to the nurse or supervisor. The resident was not assessed by a nurse for potential injuries prior to the transfer to the chair. The CNA also did not use the appropriate assistive device, a shower bed, to provide a safe environment for the resident. The shower bed was initiated on 9/17/15 following a prior fall which discontinued the use of a shower chair and initiated the use of a shower bed for safety during showering. On the 11 p.m. to 7 a.m. shift the resident told the staff that s/he had a fall during the 3 p.m.-11 p.m. shift. The nurse completed a body assessment and no apparent injury was noted. The physician ordered an x-ray of the right hip at 11:50 a.m. which revealed a fracture of the distal femoral shaft with lateral displacement and anterior angulation of the distal fragment. Pain medication was ordered and the Resident was sent to the hospital on [DATE] at 3 p.m. for evaluation. The hospital report of the resultant surgery dated 1/7/16 noted that the resident had open reduction internal fixation of the left distal femoral shaft. On 3/21/16 at 2 p.m. the surveyor asked Resident #2 if the fall in the shower room caused the resident pain. The resident stated that s/he did not have pain right away but later in the night it was painful and the nurse gave a pill for the pain. NJAC 8:39-27.1(a)