Every finding on record at Voorhees Pediatric Facility

Based on interviews, medical records and review of other pertinent facility documentation on 1/30/26, it was determined that the facility failed to ensure clinical records were complete and accurately documented. This failure had the potential to affect the facility's ability to monitor the resident's nutritional status. This deficient practice was identified for 1 of 3 residents reviewed for resident records (Resident #2), and was evidenced by the following:According to the admission Record (AR) face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a clinical condition where a patient with a pre-existing, long-term (chronic) respiratory impairment experiences a new, sudden (acute) worsening of their ability to exchange oxygen and carbon dioxide. This diagnosis, often referred to as acute on chronic respiratory failure, is used when documentation confirms both conditions coexist, but the specific type of blood gas abnormality-low oxygen (hypoxia) or high carbon dioxide (hypercapnia), gastrostomy status (a surgically created opening (stoma) into the stomach, usually with a feeding tube (G-tube) in place for nutrition, medication, or decompression), and anoxic brain damage (a serious, often life-threatening condition caused by a complete lack of oxygen reaching the brain, leading to cell death within minutes).A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/13/26, indicated that the resident could not be assessed for a Brief Interview for Mental Status (BIMS) as the resident is rarely/never understood.On 1/30/26 at 10:54 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that feeds are documented on the Medical Administration Record (MAR), Treatment Administration Record (TAR), and Enteral Nutrition Log (ENT). She further stated that if a feed is not given, the charge nurse is notified as well as the medical team. The LPN waits for further instructions from the medical team, documents the instructions and notifies family as per facility policy.On 1/30/26 at 11:07 AM, the surveyor interviewed the Registered Nurse (RN) who stated that documentation for resident care is completed in Point Click Care (PCC) and that the expectation is that PCC documentation is done within the shift and that information should be documented as soon as possible. She further stated that documentation allows nurses to keep track of what is happening with residents and that it is important to document because even the slightest change could set off another chain of events for the facility's residents. She stated that several of the residents at the facility are vulnerable as they are nonverbal.On 1/30/26 at 1:46 PM, the surveyor presented the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), and Director of Social Work (DSW) with Resident #2's January nutrition log. The surveyor circled and showed the facility's team the empty documentation for 1/7/26 for 5:00 AM.On 2/2/26 at 8:50 AM, the surveyor conducted a phone interview with the Director of Nursing (DON) who stated that the expectation for staff regarding documentation is that all the documentation for residents should be done.A review of the facility's policy titled EMR Documentation-PCC, with an effective date of 12/25, included the following information under Policy: to ensure timely, accurate, and complete clinical documentation in PointClickCare (PCC) in order to support safe resident care, regulatory compliance, and effective communication among the interdisciplinary team. Under, RN/LPN Documentation Responsibilities:-Nursing interventions and resident responses-Medication administration documentation and required monitoringA review of the facility's policy titled, Nutrition: Enteral (GT, JT, NJT, NGT), with a last revised date of 6/2025, included the following information under Purpose: to ensure residents safely and effectively receive appropriate nutrition via enteral tube. Under, Policy: Pump or bolus feedings via enteral tube will be used in accordance with a physician's order to supply partial or total nutritional support for the patient whose clinical condition demonstrates that nourishment via an enteral tube is necessary. Under, Procedure Guidelines:19. Record feeding on EMR.8:39-35.2(c)

Complaint: 2642805Based on interviews, review of the medical records, and review of other pertinent facility documents, it was determined that the facility failed to protect a severely cognitively impaired resident (Resident #1) from abuse a.) when the Certified Nursing Aide (CNA #1) alleged that she heard CNA #2 smacking Resident #1 and CNA #1 did not report the alleged abuse immediately and b.) when the Registered Nurse (RN #1) was made aware that Resident #1 was visibly upset from CNA #2 yelling at them and RN #1 left the resident in CNA #2's care and did not immediately report it. This deficient practice was identified for 1 of 3 residents reviewed for abuse.On 10/09/25 at approximately 1:45 PM, CNA #1 alleged while attending to Resident #2, she heard CNA #2, who was attending to Resident #1's bowel movement, smack Resident #1 who was touching their feces. CNA #1 stated that she was unable to report the incident at the time to the Unit Manager (UM), and reported the incident around 3:00 PM that day, to the Director of Nursing (DON). CNA #2 continued to care for Resident #1, and on 10/09/25, at approximately 2:00 PM, CNA #2 asked RN #1 to assist her in transferring Resident #1 onto the shower stretcher. At that time, RN #1 observed that Resident #1 looked sad and had a tear in [their] eye. RN #1 questioned CNA #2 why Resident #1 was sad, and CNA #2 reported that she had yelled at the resident. RN #1 did not report that allegation to her supervisor. During interviews on 10/20/25, with both RN #1 and CNA #2, they both confirmed Resident #1 was yelled at on 10/09/25, by CNA #2.The facility's failure to implement their abuse policy including protecting Resident #1 from abuse by CNA #1 not immediately reporting CNA #2 for the alleged physical abuse and for RN #1 not reporting CNA #2 after CNA #2 indicated that Resident #1 was visibly upset because she yelled at the resident, placed Resident #1 and all residents at risk for abuse. This posed the likelihood of serious physical harm and psychological, injury, impairment, or death which resulted in an Immediate Jeopardy (IJ) situation.The IJ began 10/09/25 at 1:45 PM, when CNA #1 alleged she heard CNA #2 smack Resident #1 and did not immediately report it. The facility was notified of the IJ on 10/20/25 at 3:22 PM. The facility submitted an acceptable Removal Plan (RP) on 10/20/25 at 7:38 PM. The surveyor verified the implementation of the RP on-site during the continuation of the survey on 10/21/25 at 12:21 PM.The evidence was as follows:A review of the facility's policy titled Safety: Abuse, Neglect and Exploitation updated 5/21/25, included Policy: [name redacted] has an obligation to protect the welfare of its residents and to fully investigate and correct any circumstances bearing upon that welfare. The approach should be as proactive as possible. As such, all new employees shall be in-serviced about abuse and neglect as part of orientation, and all current employees shall review this information at least annually thereafter [.] VI. Protection of the Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. If alone, do not leave the resident and pull the code bell for immediate help.A review of the Facility Reported Event (FRE) dated 10/09/25, submitted to the New Jersey Department of Health (NJDOH) revealed the following:On 10/09/25, at approximately 1:45 PM, a staff member (CNA #1) providing care to Resident #1's roommate heard a slapping sound. When she turned to investigate, she observed a nursing aide (CNA #2) raising her hand, appearing to slap Resident #1's hand. At the time, Resident #1 had a bowel movement and feces on their hands.The event was reported to the DON after the staff was unable to notify her immediate supervisor. The nursing aide [CNA #2] involved in the allegation was immediately removed from the unit and from all patient.The FRE included a summary of the investigation created by the DON, which indicated that Resident #1 is incontinent and fully dependent on staff for medical and clinical needs which results in CNA #2 being immediately removed from the unit and suspended.A further review of the FRE included a written statement from CNA #1, which indicated CNA #1, who was 3-4 feet away from Resident #1, heard a loud slapping sound, and when CNA #1 turned her head and saw CNA #2 repeatedly raising her hand and it appeared she was slapping [Resident #1] on the arm. CNA #1 asked CNA #2 what she was doing, and CNA #2 replied she was going to get Resident #1 in the shower. The written statement also included CNA #1 was unable to notify her immediate supervisor and waited around an hour before reporting the incident to the DON.According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: localization related (focal: seizures that originate in a specific area of the brain) (partial: seizures that cause a loss of awareness) symptomatic epilepsy (a chronic neurological condition characterized by recurrent, unprovoked seizures) and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus (chronic neurological condition characterized by recurrent, unprovoked seizures), spastic quadriplegic cerebral palsy (a group of disorders that affect movement, muscle tone, and posture that affects all four limbs (quadriplegia) and causes increased muscle tone),and other respiratory disorders.According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 7/29/25, Resident #1's Cognitive Patterns under Section C indicated that the resident was severely cognitively impaired.On 10/20/25 at 10:42 AM, the Director of Social Work (DSW) and DON were interviewed together. The DON stated he educated CNA #1 to reach out right away when abuse was suspected rather than waiting as CNA #1 did. The DON further stated that CNA #2 admitted in an interview with the Licensed Nursing Home Administrator (LNHA) and the police on 10/09/25, that she had called Resident #1 nasty. The DSW stated that CNA #2 had a history of unprofessional behavior and that those other allegations showed a pattern. The DON agreed, and stated CNA #2's prior incidents showed a pattern of behavior, and that this incident was just when she was caught. Both the DSW and DON agreed that regardless of whether Resident #1 was physically hit, CNA #2 was abusive towards Resident #1.On 10/20/25 at 11:04 AM, the surveyor conducted a telephone interview with CNA #1, who stated she was providing care for Resident #2 who was Resident #1's roommate, and she turned while providing care for Resident #2 because she thought she heard a hitting sound. CNA #1 stated that she did observe CNA #2's hand going up and down towards Resident #1. CNA #1 stated she was not sure what was happening, but after CNA #2 left the room, she went over to Resident #1 and saw that Resident #1 had not been changed and she requested to speak with the UM who was busy at that time. CNA #1 stated 45 minutes went by and because she knew CNA #2 was supposed to shower Resident #1, she left the unit to go find the DON and report CNA #2. CNA #1 further stated that she had worked with CNA #2 prior to this incident and that CNA #2 was easily agitated with the children she provided care for and complained about the children's conditions such as contractures, and she got very annoyed and frustrated and is vocal about it.On 10/20/25 at 11:29 AM, the surveyor conducted a telephone interview with CNA #2, who stated she had come back from her lunch break and saw that Resident #1 was covered in feces, which was a regular occurrence. CNA #2 stated she told Resident #1 that it was nasty and wiped Resident #1's hand and went to go get shower supplies to bathe Resident #1. CNA #2 then went on to state that she asked RN #1 to help assist her on putting Resident #1 on the shower stretcher. CNA #2 then stated that RN #1 asked why Resident #1 looked sad, and CNA #2 replied saying I yelled at [the resident].During an interview on 10/20/25 at 12:10 PM, RN #1 confirmed CNA #2 asked for her assistance in getting Resident #1 on the shower stretcher; that she had asked why Resident #1 looked sad; and that CNA #2 had responded by stating, I yelled at [the resident]; and that Resident #1 was left with CNA #2 to be bathed. When asked by the surveyor if that alarmed her, RN #1 stated that it did alarm her that CNA #2 yelled at the resident, which was why she asked what was wrong with the resident and comforted them. When asked if she would consider that staff to resident abuse, RN #1 stated abuse would by physical and verbal. RN #1 stated that she reported it to the UM after the UM pulled her aside to ask her about the incident.During an interview on 10/20/25 at 12:23 PM, the UM denied that RN #1 reported that CNA #2 had yelled at Resident #1 and had only reported to him that Resident #1 looked sad and had a tear in [their] eye when being transferred to the shower.During an interview on 10/20/25 at 12:25 PM, the DON confirmed that he knew that RN #1 had been told that CNA #2 had admitted to yelling at Resident #1 and stated that RN #1 could have stopped the shower from occurring or inquired further as to what was going on.During an interview on 10/20/25 at 1:38 PM, the LNHA stated that he was aware that CNA #2 had bathed Resident #1 during the time it took CNA #1 to report her allegation of abuse against CNA #2, but he was not aware that CNA #2 had told RN #1 that CNA #2 had yelled at Resident #1. The LNHA further stated that the facility policy for abuse was not followed, and that CNA #1 could have done a much better job in reporting the alleged abuse as there was a delay in timeliness. The LNHA stated that timeliness of reporting was important because the alleged abuser in this incident was left with the resident and if a staff member suspected abuse the facility's goal was to keep all residents safe and not leave the abuser with the residents.An acceptable Removal Plan was received on 10/20/25 at 7:38 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including on 10/09/25, when the DON was made aware, CNA #2 was immediately removed from resident care and suspended pending investigation and was terminated on 10/17/25. On 10/9/25, the local police were notified, the facility started investigating, and Resident #1 was assessed. On 10/17/25, the facility reported CNA #2 to the NJDOH on the FRIDAY form and the Health Care Professional Responsibility and Reporting Enhancement Act. On 10/20/25, RN #1 was individually counseled and provided with remedial training; the facility's Abuse Prevention Policy was updated and redistributed to all staff to include termination for failure to report in a timely manner; quick reference posters for abuse reporting were installed in staff lounges; and a daily abuse incident reporting audit was started and will be conducted by the DON or appointed designee daily for 30 days to verify timeliness of incident reporting, proper resident protection procedures, and staff compliance with facility policy.The surveyor verified the implementation of the Removal Plan on-site during the continuation of the survey and determined the IJ for F 600 was removed as of 10/21/25 at 12:21 PM.NJAC 8:39-4.1(a)(5)

Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure that there was sufficient competent staff to ensure a) all residents were provided with appropriate and timely incontinence care and were consistently available to provide appropriate care to maintain residents highest practicable physical, mental, and psychosocial well-being and b) the minimum staffing requirements per the New Jersey Department of Health based on acuity of the residents was maintained. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following: Refer to 677F, 688D A. On 05/18/25 at 7:17 PM, the Registered Nurse Nursing Supervisor for the B -Wing Unit, informed the survey team the B- Wing Unit had 60 residents. When the surveyor asked how many Certified Nurse Aides (CNAs) were assigned to the unit, a CNA at the nursing station stated she was the only CNA on the unit and she was assigned ten residents. The CNA explained that the nurses were responsible for providing all of the care required to their assigned residents, as she had her own assignment. On 05/18/25 at 7:30 PM, Surveyor #1 reviewed the B- Wing Unit, Assignment Sheet and confirmed 1 CNA was listed. On 5/18/25 at 7:45 PM, Surveyor #2 toured the B- Wing Unit and observed a strong feces and urine odor in the hallway. All the residents were observed in bed at that time. On 5/18/25 at 8:29 PM, Surveyor #2 observed Resident #82 in an enclosure bed (a complete bed system resembling a tent, designed to provide safety). The resident was facing the window. From a clear unobstructed view through the door, the surveyor observed the resident's incontinence brief was bulging from the back. The surveyor then observed the resident was asleep, and there was no sheet to cover the bed. The Surveyor then observed 3 incontinence pads on the mattress and underneath the resident. On 5/18/25 at 9:15 PM, Surveyor #2 and surveyor #3 returned to Resident #82's room and both observed the resident in the same position with the bulging incontinence brief, and the strong smell of urine and feces permeated into the hallway. On 05/19/25 at 10:00 AM, Surveyor #1 interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) in the presence of Surveyor #2 regarding the facility staffing pattern and use of CNAs. The LNHA stated there were nurses on medication carts and there were Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) to also provide care, it was a total care model. The surveyors informed the LNHA that the nurses had informed the surveyors that the CNAs were responsible for all of the Activities of Daily Living (ADLs- including washing, dressing, toileting) and the CNAs informed the surveyors that they were assigned to specific residents only. On 05/19/25 at 11:05 AM, Surveyor #2 reviewed the B- Wing Unit assignment sheet and located the CNA (CNA #2) assigned to care for Resident #82. CNA #2 informed the surveyor that she would need another staff to assist with Resident #82. An LPN (LPN #2) entered the room to assist with the incontinence care. The incontinence pads and the bed were observed saturated with urine. Resident #82 was wearing two incontinence briefs. The resident's genital area was also wrapped up in an infant brief which was also saturated with urine and feces. The large sized incontinent brief was saturated with urine and filled with feces. CNA #2 turned the resident to the right side to facilitate the care. Resident #82 was covered with feces from the waist to the buttocks. CNA #2 used one pack of wipes and consistently wiped the embedded feces from Resident #82's backside and buttocks as the feces appeared to be caked on. On 5/19/25 at 11:30 AM, Surveyor #2 inquired regarding the protocol for incontinence care. The Registered Nurse (RN #2) stated that the CNAs were responsible to provide incontinence care, and the nurses were to administer treatments and assist as needed. On 5/19/25 at 1:10 PM, Surveyor #2 interviewed CNA #2 who was assigned to Resident # 82 on her assignment. CNA #2 stated that the night shift was responsible to wash and dress Resident #82. CNA #2 stated checked the resident this morning and Resident #82 was sleeping and confirmed that she had not yet provided incontinence care to Resident #82. On 05/19/25 at 1:13 PM, Surveyor #1 and Surveyor #2 entered the Annex (6 single bed unit fully occupied). The medication cart was unlocked and there were no staff in attendance, the surveyor easily opened the bottom drawer of the medication cart to confirm it was unlocked. At that time Resident #66 was in the wheelchair in the room and was in full view upon entering the unit. A staff was observed at the bedside with Resident #84 (a few rooms away and out of view of Resident #66).Resident #66 disrobed and was fully exposed from the waist up. At 1:17 PM, the Registered Nurse (RN #3) assigned to the Annex, exited Resident #84's room and the surveyors showed RN #3 the opened medication cart drawer and asked if it was okay to leave the medication cart unlocked? RN #3 stated, I had to pass medication, so I leave it open. When we have enough staff, and it is not often that we do. I am all by myself and the nurse does everything. RN #3 then stated, when the Respiratory Therapist assigned to the Annex had to go on break, we have no one to cover. On 05/20/25 at 9:45 AM, Surveyor #2 observed Resident #82 in the enclosure bed and the resident was asleep. The surveyor interviewed the LPN (#2) who assisted the CNA (#2) with the incontinence care. The LPN informed the surveyor that Resident #82 was a heavy wetter. LPN #2 added that they have an order to wrap the resident's genital area in an infant brief. The surveyor inquired regarding the rationale to wrap the resident's genital area in an infant brief. LPN #2 could not provide the rationale. The surveyor then inquired regarding the facility protocol for incontinence care. On 05/20/25 at 9:46 AM, LPN #2 stated that the protocol was to provide incontinence care every two hours but it was unrealistic based on staffing and who was assigned to the resident. On 05/20/25 at 2:20 PM, the surveyor observed a strong feces odor in the B- Wing Unit hallway. The surveyor observed Resident #58 standing inside an enclosure bed. The Surveyor observed a CNA (#6) in the hallway and asked to assist to observe incontinence care. CNA #6 checked Resident #58 and the incontinence brief was heavily soiled with urine and feces. CNA #6 informed the surveyor that she had Resident #58 on her assignment but was not aware that the resident returned from school. Upon return from school the CNAs were supposed to be informed if the resident needed to be changed. On 05/21/25 at 9:09 AM, the surveyor interviewed the RN (#6) in charge of the B- Wing Unit. RN #6 stated that Resident #58 left for school at 8:30 AM and returned at 12:30 PM every day. RN #6 added, the staff at the school could also provide incontinence care but the CNAs were responsible to check on their residents upon return from school. On 05/21/25 at 9:23 AM, Surveyor #1 interviewed the Respiratory Therapy Director (RTD) regarding the care that the Respiratory Therapists (RT) provided in the Annex. The RTD stated that there were 6 residents on the Annex and maybe only 4 of 6 received RT care because the residents were ventilator dependent (machine used when unable to breathe on their own) and RTs managed ventilatory care, all alarms, and completed airway clearance. The RTs also helped with positioning which was considered lung therapy and when the residents needed to be transferred and the RTs transferred all of the respiratory equipment. Surveyor #1 then asked if the RTs completed any other resident care? The RTD stated the RTs did not complete activities of daily living ADLs or any type of CNA work. The RTD stated the RTs could help with some things, but that was not their role, and confirmed that when the RT was on lunch or any other break that there was no coverage for the RT on the Annex. On 05/21/25 at 9:42 AM, Surveyor #1 interviewed RT #2 on the Annex regarding her workload. RT #2 stated she was responsible for 4 of 6 resident's respiratory care on the Annex. On 05/21/25 at 9:54 AM, the surveyor entered the Annex and felt a noticeable chill in the air temperature. The surveyor observed Resident #103 was in the room, the curtain was pulled, and staff was talking to resident while the resident was heard crying. On 05/21/25 at 9:59 AM, the surveyor observed a sign posted outside of Resident #103's door that revealed Enhanced Barrier Precautions, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting . At that time, the surveyor observed the curtain open, and a pile of linen was on the floor, while the Registered Nurse (RN #1) was observed kneeling on the floor in front of resident #103 who was in a wheelchair, then RN #1 with her gloved hands, placed socks on the resident's feet. RN #1 was not wearing a gown, picked up the soiled linen from the floor with her gloved hands and placed the linen into a bin in the hallway. On 05/21/25 at 10:05 AM, the surveyor asked RN #1 if Resident #84 was wearing their handrolls. Both the surveyor and RN #1 observed Resident #84 in bed, and the signs behind the resident's bed regarding the directions for use of the right and left handroll. RN #1 stated, I don't see them, and the surveyor asked if they were supposed to be there? RN #1 responded yes. Surveyor #1 asked RN #1 if she had signed the Treatment Administration Record for the use of the handrolls. RN #1 stated she didn't sign, and I did not have a chance to look at that, I have to prioritize my meds [medications] and what I need to do, give meds and give care, have no idea about handrolls, maybe therapy has them? On 05/23/25 at 10:23 AM, the survey team interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) and presented the above concerns. The DON stated, RN #3 should not have left the med cart open. The survey team asked about the adequacy of the facility staffing and the LNHA stated, we meet the requirement and confirmed the facility met the acuity staffing hours requirement. When asked if the RTs were considered part of the staffing for providing resident care, the LNHA stated RTs were not nurses and confirmed that there was no process in place to cover the time the RTs were on break if there was only 1 nurse assigned and 1 RT for the Annex. The survey team asked if the facility reviewed the CNA staff available for ADL care, and the LNHA stated, the facility was going to get a waiver (for CNA staffing) because they replaced CNAs with nurses, but our plan moving forward was to get more CNAs to help with changing residents and doing weights. On 05/23/25 at 12:43 PM, the surveyor went to the B- Wing Unit, and again, four days after the initial observation that occurred on 5/19/25 at 11:05 AM, observed a strong urine odor in the hallway. The surveyor interviewed a random CNA (CNA #3) observed in the hallway regarding the odor. CNA #3 stated that she noticed the odor and was about to locate the CNA (CNA #4) assigned to that hallway. The surveyor entered Resident #82's room and noted that the urine odor was pervasive in the room. The surveyor met CNA #4 in the hallway and asked to check Resident #82 for incontinence. The surveyor observed that Resident #82's bed was saturated with urine, the incontinence brief was yellow stained and also saturated with urine. When inquired regarding the last time incontinence care was provided, CNA #4 stated, Not too sure, possibly around 9:00 AM or 10:00 AM. The surveyor then asked CNA #4 who assisted her with the resident's care and she stated, I checked the resident alone. I have ten residents to care for and [Resident #82] used to have an order for double briefs and it was discontinued. B. Based on review of the Nurse Staffing Reports for the weeks of 05/04/2025 to 05/17/2025, it was determined that the facility failed to provide at least minimum staffing levels for 2 of 14 days. The required staffing hours and actual staffing hours were as follows: For the week of 05/04/25 Required Staffing Hours: 562.75 -05/10/25 had 560 actual staffing hours, for a difference of -2.75 hours. For the week of 05/11/25 Required Staffing Hours: 567 -05/11/25 had 488 actual staffing hours, for a difference of -79 hours. The Administration: Staffing Plan, Effective 12/24 revealed: Purpose: To ensure adequate nurse staffing in order to provide care safely and effectively. Policy: Nursing services are provided 24-hours a day, seven days a week. Staffing plans are established based on daily census and patient acuity. Procedure: 6. Staffing shall include at least the minimum numbers of licensed and certified staff 24 hours a day, seven days a week, as defined in New Jersey Département of Health rules and regulations of total number of patients multiplied by 2.5 hours/day as well as the total number of patients receiving each service listed below, multiplied by the corresponding number of hours per day: a. Wound Care- .75 hours/day; b. Nasogastric or gastrostomy tube feedings- 1.0 hours per day; c. Oxygen therapy 0 .75 hours/day; d. Tracheostomy-1.25 hours/day; e. Intravenous Therapy-1.5 hours/day; f . Use of ventilator-1.25 hours/day; g. Head trauma stimulation/advanced neuromuscular/orthopedic care-1.5 hours/day. The LPN Job Description effective 2/09 revealed under essential duties: 4. Assists with ADLs based on patient ability. 10. Turns/repositions residents at least every two hours. 11. Performs range of motion during daily care. 18. Delegates appropriate duties to CNAs on team and 19. Assures CNA duties performed as directed. NJAC 8:39-27.1(a); 25.2(a)(b)(c)

Based on observation, interview and document review it was determined that the facility failed to a) ensure the formula preparation process and nourishment area was implemented in a clean and sanitary manner, b) food items were labeled with a use by date, and c) appropriate cleaning items were utilized to prevent potential contamination. The deficient practice had the potential for development of food borne illness and was evidenced by the following: On 5/19/25 at 8:43 AM, the surveyor conducted a tour of the kitchen with a Food Service Director (FSD) from another facility, the District Manager for the Food Service Management Company was present, and did not join the tour. Findings include: 1. A package of undated frozen pancakes was stored in the freezer and was not tightly wrapped. The surveyor asked about a use by date, and the FSD stated she could not tell when the package was opened and discarded it. 2. A metal table, with a sink and a shelf above the sink contained three plastic containers that were appeared stained and were stored with the opening directly on red cleaning type rag which was directly on the shelf. When asked what they were used for, the FSD stated they were used to prepare the tube-feeding (special feeding prepared that are inserted directly into a tube in the abdomen when unable to eat by mouth). The containers also had a sticky substance on them and one had a hair stuck to it. The surveyor asked if the containers should be stored directly on the wipes with the open area facing the wipes, the FSD stated, no, because fibers from the wipe could enter into the formula. 3. Eight additional plastic containers were stored on the top shelf of a black cart, on top of white bath towels and the cart appeared soiled. There were two containers stored on the middle shelf of the cart, with the opening directly on the frayed towels, and the two containers were toppled behind those containers on the middle shelf and the red container tops were stored on the towel and directly on top of the middle shelf facing down. The surveyor asked if the manner that the containers was stored was sanitary and the FSD stated, no, it was not. The surveyor requested a formula policy at that time. The FSD showed the surveyor a list of 12 residents who required special formula preparations. 4. A reach in freezer, contained 20 typical quart sized deli type containers of frozen puree food. One of the containers appeared to be sunken in. The surveyor asked for all the information and manufacturer specifications related to both containers. 5. There was a pile of white towels was stored by the tray line area, visibly shredded on the ends and asked what they were used for. The FSD stated the staff used them to clean and the surveyor asked if they were appropriate to use and the FSD stated, no, maybe because they shred. 6. A reach in refrigerator had a digital thermometer that registered 45 degrees Fahrenheit and the log had 29 degrees registered. The surveyor asked if the log was correct and the FSD stated, no. On 05/19/25 at 11:07 AM, the Registered Dietitian (RD) provided the surveyor with a computer picture of the containers from a small business and did not provide the manufactures specifications, or a policy for use for the containers. There was also no manufacturer specification provided for the larger tube-feeding/formula containers or a policy for use. The surveyor asked about the process for cleaning the tube-feeding/supplement containers. The RD stated if the containers should be air dried and they should be closed and placed in the formula station. The Formula Preparation and Noursihment Area Maintenance Policy, effective August 2018 revealed: Policy: The formal preparation area will be designated for preparing infant formal and enteral feeding by aseptic technique. The policy did not address the use of the large containers. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure all residents received the care and services needed to maintain residents highest practicable physical, mental, and psychosocial well-being by failing to ensure: a) a thorough investigation of an injury of unknown origin was completed, b) staffing was appropriate to meet resident needs to provide incontinence care in an appropriate and timely manner and according to the facility policy, c) staff followed the Center for Disease Control (CDC) guidelines and the facility's infection control policy to prevent the spread of potential infection, d) there was a process in place to ensure staff completed their annual competency evaluations. This deficient practice affected all facility residents and was evidenced by the following: Refer to F610, F677, F725, F730, F880 A review of the Administrator's job description provided by the facility revealed the following under position summary: Directs and guides the activities of clinical, administrative and service departments. Manages the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern long term care facilities to assure that the highest degree of quality care can be provided to residents at all times. Ensures all employees receive orientation and ongoing training to meet the quality goals of the organization. 1. A review of the progress notes dated 3/31/25 at 5:35 PM revealed that 2 circular bruises were noted on Resident #37's right exterior elbow. According to the progress notes, the resident was to be assessed and a follow up was to be done by the medical. The surveyor requested the full investigation for the bruises. An incident report was provided and there were no statements attached. On 5/23/25 at 12:45 PM, the surveyor again inquired regarding the investigation for the bruise documented as an injury of unknown origin, no additional information was provided and it was confirmed by the Director of Nursing (DON) that statements had not been completed. 2. The facility failed to have a system in place to ensure the facility had enough staff to meet resident needs. The facility failed to ensure incontinence care was provided in a timely manner and in accordance with the facility policy. a) On 5/18/25 at 8:29 PM, the surveyor observed Resident #82 in an enclosure bed. The resident was facing the window. From a clear unobstructed view through the open door, the surveyor observed the resident's incontinence brief was bulging from the back. The surveyor then observed the resident was asleep, and there was no sheet to cover the bed. The Surveyor then observed 3 incontinence pads on the mattress underneath the resident. On 5/18/25 at 9:15 PM, the surveyor escorted another surveyor to the room and we both observed Resident #82 in the same position with bulging incontinence brief, and the strong smell of urine and feces permeated into the hallway. On 05/19/25 at 8:30 AM, the surveyor returned to the B Wing Unit and observed the resident in the enclosure bed, was in the same position as observed on 5/18/25 at 8:29 PM, facing the window and the incontinence brief could be observed bulging from the back as observed on 05/18/25 at 9:15 PM. On 05/19/25 at 11:05 AM, the Certified Nurse Aide (CNA #2 ) assigned to care for Resident #82. CNA #2 informed the surveyor that she would need another staff to assist with Resident #82. A Licensed Practical Nurse (LPN #2) entered the room to assist with the incontinence care. The incontinence pads and the bed were observed saturated with urine. Resident #82 was wearing two incontinence briefs. The resident's genital area was wrapped up in an infant brief which was also saturated with urine and feces. The larger sized incontinence brief was also saturated with urine and filled with a large amount of feces. CNA #2 turned the resident to the right side to facilitate the care. Resident #82 was observed covered with feces from the waist to the buttocks. CNA #2 used one pack of wipes and consistently wiped the embedded feces from Resident #82's backside and buttocks as the feces appeared caked on. On 5/20/25 at 11:55 AM, the surveyor interviewed the DON who stated that he was not aware that Resident #82 had an infant brief wrapped around their genital area and he stated was not aware of the order related to using an infant brief wrapped around the genitals On 05/23/25 at 12:43 PM, the surveyor went to the B Wing Unit, and again observed a strong urine odor in the hallway. The surveyor interviewed a random CNA (CNA #3) observed in the hallway regarding the odor. CNA #3 stated that she also noticed the odor and was about to locate the CNA (CNA #4) assigned to that hallway. The surveyor entered Resident #82's room and noted that the urine odor was pervasive in the room. The surveyor met CNA #4 in the hallway and asked to check Resident #82 for incontinence. The surveyor then observed, four days after the initial observation that occurred on 5/19/25 at 11:05 AM, that Residnet #82's bed was saturated with urine, and the incontinence brief was yellow stained and also saturated with urine. When inquired regarding the last time incontinence care was provided, CNA #4 stated, Not too sure, possibly around 9:00 AM or 10:00 AM. The surveyor then asked CNA #4 who assisted her with the resident's care and she stated, I checked the resident alone. I have ten residents to care for and [Resident #82] used to have an order for double briefs and it was discontinued. b) On 05/20/25 at 2:20 PM, the surveyor returned to the B- Wing Unit and noted a strong feces odor in the B- Wing Unit hallway. The surveyor observed Resident #58 standing inside the enclosure bed. The Surveyor observed CNA #6 in the hallway and asked to assist to observe incontinence care. CNA #6 checked Resident #58 and the incontinence brief was heavily soiled with urine and feces. CNA #6 informed the surveyor that she had Resident #58 on her assignment but was not aware that the resident returned from school. Upon return from school the CNAs were supposed to be informed if the resident needed to be changed. On 5/19/25 at 11:30 AM, the surveyor inquired regarding the protocol for incontinence care. The Registered Nurse (RN #6) informed the surveyor that all CNAs were responsible to provide incontinence care, and the nurses were to administer treatments and assist as needed. The surveyor asked the CNA assigned to the resident to assist with incontinence check. Resident #58's brief was saturated with urine and feces. The CNA stated that she was not aware that Resident #58 had returned from school. On 5/21/25 at 9:05 AM, during an interview with the Registered Nurse in charge she informed the surveyor that Resident #58 left for school at 8:30 AM and returned every day at 12:30 PM. The RN further stated that incontinence care could be provided in school, but it was the CNA's responsibility to check their residents upon return from school for incontinence care. 3. The facility failed to ensure that staff adhere to infection control practices and follow the recommendations of the Center for Disease Control during hand hygiene. On 05/21/25 at 9:59 AM, the surveyor observed a sign posted outside of Resident #103's door that revealed Enhanced Barrier Precautions, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Ativities. Dressing, Bathing/Showereing, Transaferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting . At that time, the surveyor observed the curtain open, and a pile of linen was on the floor, while the Registered Nurse (RN #1) was observed kneeling on the floor in front of Resident #103 who was in a wheelchair, then RN #1 with her gloved hands, placed socks on the resident's feet. RN #1 was not wearing a gown and then picked up the soiled linen from the floor with her gloved hands and placed the linen into a bin in the hallway. RN #1 then re-entered Resident #103's room, removed the gloves, turned on the faucet, used the soap dispenser, and rubbed both hands under running water for 4 seconds. 05/21/25 10:00 AM, RN #1 exited the room and the surveyor interviewed her about what care she provided for Resident #103. RN #1 stated she washed the resident up every morning with care and the resident had a big poop and didn't like to be washed. The surveyor asked about putting linens on floor, and if what was observed was soiled? RN #1 stated Yes, they were soiled. The surveyor then asked if RN #1 wore a gown during care, and she stated No, I did not. The surveyor asked if Resident #103 required EBP and pointed to the sign next to the door. RN #1 looked at the sign and stated, no not for [Resident #103], the sign would have been on front of the door. RN #1 confirmed all the linens and soiled items were placed in the bin directly. The surveyor asked if was protocol to wash hands under running water and how should hands be washed. RN #1 stated, it was okay, to put the soap on the hands and put the hands under the water. On 05/21/25 at 10:38 AM, the surveyor informed the facility Infection Preventionist Registered Nurse (IPRN) regarding the above observations and asked is it okay to change a resident and not wear a gown. The IPRN stated, no, you should be wearing a gown. The surveyor then asked if a feces soiled diaper could be placed on the floor with linen. The IPRN stated, No, your feet are tracking it all over the floor, it is disgusting and you should bag it, it should not be placed directly into the bin due to infection control. The surveyor informed the IPRN of the hand washing observation and inquired regarding the protocol for hand hygiene as the staff was observed washing their hands under running water. The IPRN confirmed that the staff should have had a gown on during incontinence care and acknowledged that 100% of the facility population was on EBP and RN #1 should have been wearing a gown when Resident #103 received incontinence care. 4. The facility failed to ensure that their CNA's had their annual performance evaluation completed at least every 12 months according to facility policy. Review of the LNHA Job Description revealed the following: Direct and guide the activities of clinical administrative and service departments and manage the day-to-day functions of the facility .On 5/22/25 at 11:26 AM, the surveyor interviewed the LNHA regarding the facility Quality Assurance and Performance Improvement (QAPI) and his job description. The LNHA informed the surveyor that he was the abuse officer and was in charge of all investigations. The LNHA stated that his current responsibilities included: reviewing all reported incidents, conducting random audits throughout the facility, engaging directly with residents and staff regularly, and staff education on abuse at orientation, annually, and on an as-needed basis; however, the LNHA stated that he has not received formal, specialized training in abuse prevention or investigation. The LNHA stated that after the most recent abuse incident, no immediate retraining was conducted. The LNHA stated, that is where I messed up. On 05/23/25 at 1:53 PM, the survey team met the DON and the LNHA for an exit conference. The DON and the LNHA did not provide additional information. NJAC 8:39-4.1(a), 9.2(a), 13.4(c), 14.2, 27.1(a), 33.2(a)(b)(c)

Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care, and personal hygiene care for 2 of 4 residents (Resident #82 and #58) reviewed for Activities of Daily Living (ADLs) on 1 of 2 resident units, (B Wing Unit). The deficient practice was evidenced by the following: 1. On 5/18/25 at 7:45 PM, the surveyor toured the B Wing Unit, and observed a strong feces and urine odor in the hallway. All the residents were observed in bed at that time. On 5/18/25 at 8:29 PM, the surveyor observed Resident #82 in an enclosure bed (a complete bed system resembling a tent, designed to provide safety). The resident was facing the window. From a clear unobstructed view through the open door, the surveyor observed the resident's incontinence brief was bulging from the back. The surveyor then observed the resident was asleep, and there was no sheet to cover the bed. The Surveyor then observed 3 incontinence pads on the mattress underneath the resident. On 5/18/25 at 9:15 PM, the surveyor escorted another surveyor to the room and we both observed Resident #82 in the same position with bulging incontinence brief, and the strong smell of urine and feces penetrated into the hallway. On 05/19/25 at 8:30 AM, the surveyor returned to the B Wing Unit and observed the resident in the enclosure bed, was in the same position as observed on 5/18/25 at 8:29 PM, facing the window and the incontinence brief could be observed bulging from the back as observed on 05/18/25 at 9:15 PM. On 05/19/25 at 10:37 AM, the surveyor observed Resident #82 in the enclosure bed in the same position as observed on 5/19/25 at 8:30 AM, and the resident was still sleeping. On 05/19/25 at 11:05 AM, the surveyor reviewed the B Wing Unit's assignment sheet and located the Certified Nurse Aide (CNA #1 ) assigned to care for Resident #82. CNA #1 informed the surveyor that she would need another staff to assist with Resident #82. A Licensed Practical Nurse (LPN #1) entered the room to assist with the incontinence care. The incontinence pads and the bed were observed saturated with urine. Resident #82 was wearing two incontinence briefs. The resident's genital area was wrapped up in an infant brief which was also saturated with urine and feces. The larger sized incontinence brief was also saturated with urine and filled with a large amount of feces. CNA #1 turned the resident to the right side to facilitate the care. Resident #82 was observed covered with feces from the waist to the buttocks. CNA #1 used one pack of wipes and consistently wiped the embedded feces from Resident #82's backside and buttocks as the feces appeared caked on. On 5/19/25 at 11:30 AM, the surveyor inquired regarding the protocol for incontinence care. The Registered Nurse (RN #6) informed the surveyor that all CNAs were responsible to provide incontinence care, and the nurses were to administer treatments and assist as needed. On 5/19/25 at 1:10 PM, the surveyor interviewed Certified Nurse Aide (CNA #1) who was assigned to provide care to Resident #82. CNA #1 stated that the night shift was responsible to wash and dress Resident #82. CNA #1 stated she checked the resident this morning and Resident #82 was sleeping and confirmed that she had not yet provided incontinence care to Resident #82. On 05/20/25 at 9:45 AM, the surveyor observed Resident #82 in the enclosure bed and the resident was asleep. The surveyor interviewed LPN #1 who assisted CNA #1 with the incontinence care. LPN#2 informed the surveyor that Resident #82 was a heavy wetter. LPN #1 added that they have an order to wrap the resident's genital area in an infant brief. The surveyor inquired regarding the rationale to wrap the resident's genital area in an infant brief. LPN #1 could not provide the rationale. The surveyor then inquired regarding the facility protocol for incontinence care. On 05/20/25 at 9:46 AM, the surveyor interviewed LPN #2 regarding the protocol for incontinence care. LPN #2 stated, the protocol was to provide incontinence care every two hours but it was unrealistic based on staffing and who was assigned to the resident. On 5/20/25 at 10:30 AM, the surveyor interviewed the Registered Nurse Nursing Supervisor (RN #5) regarding the concerns with incontinence care. RN #5 informed the surveyor that the staff who wrote the order to wrap Resident #82's genital area in an infant brief was no longer employed by the facility. At that time the surveyor reviewed the medical record for Rsident #82 with RN #5 which revealed a Physician Order dated 3/11/24 for Resident #82 to have a condom catheter (a plastic sleeve over the genital area to collect urine) from 6:00 AM-6:00 PM. The Care Plan did not include the use of an infant brief. Further review of the medical record revealed: Resident #82's admission Record (AR) revealed, Resident #82 was admitted to the facility with diagnoses which included but were not limited to; Spastic Quadriplegic Cerebral Palsy, other disorders of thee lungs, Symptomatic Epilepsy and Epileptic syndromes with complex partial seizures. The quarterly Minimum Data Set (MDS), an assessment tool dated 03/20/25, revealed that Resident #82 had severe cognitive impairment. Section GG of the MDS, which referred to ADLs revealed that Resident #82 was totally dependent on staff for care. Review of the Care Plan for Resident #82, reflected there was no focus for ADLs. The care plan dated 3/11/24 and last revised 04/02/25 included a Focus Potential for skin breakdown, initiated 03/11/24. The goal was for Resident #82 to remain dry as much as possible to avoid skin breakdown. The intervention was for Resident #82 will use a [condom catheter] daily from 6:00 AM- 6:00 PM. Initiated 03/11/2024. The care plan did not indicate when staff were to provide incontinence care to the resident and the frequency for staff to turn and reposition the resident. On 5/20/25 at 11:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated that he was not aware that Resident #82 had an infant brief wrapped around their genital area and he stated was not aware of the order related to using an infant brief wrapped around the genitals. On 05/23/25 at 12:43 PM, the surveyor went to the B Wing Unit, and again observed a strong urine odor in the hallway. The surveyor interviewed a random CNA (CNA #4) observed in the hallway regarding the odor. CNA #4 stated that she also noticed the odor and was about to locate the CNA (CNA #5) assigned to that hallway. The surveyor entered Resident #82's room and noted that the urine odor was pervasive in the room. The surveyor met CNA #5 in the hallway and asked to check Resident #82 for incontinence. The surveyor then observed, four days after the initial observation that occurred on 5/19/25 at 11:05 AM, that Residnet #82's bed was saturated with urine, and the incontinence brief was yellow stained and also saturated with urine. When inquired regarding the last time incontinence care was provided, CNA #5 stated, Not too sure, possibly around 9:00 AM or 10:00 AM. The surveyor then asked CNA #5 who assisted her with the resident's care and she stated, I checked the resident alone. I have ten residents to care for and [Resident #82] used to have an order for double briefs and it was discontinued. 2. On 05/18/25 at 8:46 PM, the surveyor observed Resident #58 on the B- Wing Unit in an enclosure bed. Resident #58 was was yelling and screaming. A strong feces odor was observed in the room. An interview with CNA (CNA #6) the same day at 9:15 PM, revealed that Resident #58 expressed behaviors, the enclosure bed was to maintain the resident safety. On 05/20/25 at 2:20 PM, the surveyor returned to the B- Wing Unit and noted a strong feces odor in the B- Wing Unit hallway. The surveyor observed Resident #58 standing inside the enclosure bed. The Surveyor observed CNA #6 in the hallway and asked to assist to observe incontinence care. CNA #6 checked Resident #58 and the incontinence brief was heavily soiled with urine and feces. CNA #6 informed the surveyor that she had Resident #58 on her assignment but was not aware that the resident returned from school. Upon return from school the CNAs were supposed to be informed if the resident needed to be changed. On 05/21/25 at 9:09 AM, the surveyor interviewed the Registered Nurse in charge of the B- Wing Unit (RN #6). RN #6 stated that Resident #58 left for school at 8:30 AM, and returned at 12:30 PM every day. RN #6 added the staff at the school could also provide incontinence care but the CNAs were responsible to check on their residents upon return from school. On 5/21/25 at 12:30 PM, the surveyor reviewed Resident #58's medical record which revealed the following: Resident #58 was admitted to the facility with diagnoses which included but were to limited to: Pulmonary hypertension, paralysis of vocal cords, anxiety disorder and short stature (Child). According to the Quarterly Minimum Data Set, dated [DATE], Resident #58 had memory problems and was assessed by the facility as being severely cognitively impaired. The MDS also indicated that Resident #58 was totally dependent on staff for all ADLs, and was always incontinent of urine and stool. Review of the Care Plan for Resident #58 initiated on 01/16/25 and last revised 02/22/25, revealed the following: Focus: Resident #58 engages in noncompliance during nursing and ADLs. The goal was to: Limit reaction/attention to the behavior Do not give the resident access to preferred items/ activities. There was no Care Plan to address incontinence care or the frequency for Incontinence care should be provided. On 05/23/25 at 10:23 AM, the survey team interviewed the Director of Nursing and Licensed Nursing Home Administrator and presented the above concerns. The DON stated, RN #3 should not have left the med cart open. The survey team asked about the adequacy of the facility staffing and the LNHA stated, we meet the requirement and stated the acuity staffing hours requirement. When asked if the RTs were considered part of the staffing for resident care, the LNHA stated RTs were not nurses and confirmed that there was no process in place to cover the time the RTs were on break if there was only 1 nurse assigned and 1 RT for the Annex. The survey team asked if the facility looked at the CNA staff available for ADL care, and the LNHA stated, the facility was going to get a waiver (for CNA staffing) because they replaced CNAs with nurses, but our plan moving forward was to get more CNAs to help with changing residents and doing weights. A review of the facility's policy titled, Routine Care: Incontinence Care/ Diapers Care effective 12/1997 and last revised 6/16 revealed the following: Purpose: To assure the comfort and safety of the residents, prevent the transmission of infection. To assure an adequate supply of diapers if needed. General Information: Residents shall be checked every two hours for the presence of incontinence/wet or soiled diapers to facilitate immediate changing, thus decreasing the risk of skin breakdown. NJAC 8:39 - 27.1(a)

Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete a performance review of Certified Nurse Aides (CNA) at least every 12 months. The deficient practice was identified for 4 of 5 Certified Nurse Aides reviewed under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by: A review of the facility-provided CNA annual performance evaluations revealed that 4 of the 5 CNAs did not have an annual performance evaluation for 2024. On 05/22/25 09:41 AM during an interview with the surveyor, the Liscensed Nursing Home Administrator (LNHA) confirmed there were no performance evaluations for 2024 for 4 out of 5 CNA's. The LNHA stated, I know we should have them, but we don't, the place fell apart. The LNHA stated they have had two Director of Nursing's and an interim DON in the past year. The LNHA had no further information to provide. A review of an undated facility provided policy titled Employee Evaluation revealed: Each employee will have a written evaluation of their job performance within three months of employment and annually thereafter. NJAC 8:39-43.17(b)

Based on observation, interview and document review it was determined that the facility failed to ensure a) appropriate Personal Protective Equipment was utilized while providing care to a resident who required Enhanced Barrier Precautions (EBP), b) soiled linens were appropriately handled, and c) appropriate hand hygiene was performed per facility and Center for Disease Control Guidance. The deficient practice occurred on 1 of 3 resident units (The Annex) and was evidenced by the following: On 05/21/25 at 9:54 AM, the surveyor entered the Annex Unit and observed Resident #103 was in the room, the curtain was pulled, and staff were heard talking to resident while providing care. On 05/21/25 at 9:59 AM, the surveyor observed a sign posted outside of Resident #103's door that revealed Enhanced Barrier Precautions, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Ativities. Dressing, Bathing/Showereing, Transaferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting . At that time, the surveyor observed the curtain open, and a pile of linen was on the floor, while the Registered Nurse (RN #1) was observed kneeling on the floor in front of Resident #103 who was in a wheelchair, then RN #1 with her gloved hands, placed socks on the resident's feet. RN #1 was not wearing a gown and then picked up the soiled linen from the floor with her gloved hands and placed the linen into a bin in the hallway. RN #1 then re-entered Resident #103's room, removed the gloves, turned on the faucet, used the soap dispenser, and rubbed both hands under running water for 4 seconds. 05/21/25 10:00 AM, RN #1 exited the room and the surveyor interviewed her about what care she provided for Resident #103. RN #1 stated she washed the resident up every morning with care and the resident had a big poop and didn't like to be washed. The surveyor asked about putting linens on floor, and if what was observed was soiled? RN #1 stated Yes, they were soiled. The surveyor then asked if RN #1 wore a gown during care, and she stated No, I did not. The surveyor asked if Resident #103 required EBP and pointed to the sign next to the door. RN #1 looked at the sign and stated, no not for [Resident #103], the sign would have been on front of the door. RN #1 confirmed all the linens and soiled items were placed in the bin directly. The surveyor asked if was protocol to wash hands under running water and how should hands be washed. RN #1 stated, it was okay, to put the soap on the hands and put the hands under the water. On 05/21/25 at 10:38 AM, the surveyor informed the facility Infection Preventionist Registered Nurse (IPRN) regarding the above observations and asked is it okay to change a resident and not wear a gown. The IPRN stated, no, you should be wearing a gown. The surveyor then asked if a feces soiled diaper could be placed on the floor with linen. The IPRN stated, No, your feet are tracking it all over the floor, it is disgusting and you should bag it, it should not be placed directly into the bin due to infection control. The surveyor informed the IPRN of the hand washing observation and inquired regarding the protocol for hand hygiene as the staff was observed washing their hands under running water. The IPRN confirmed that the staff should have had a gown on during incontinence care and acknowledged that 100% of the facility population was on EBP and RN #1 should have been wearing a gown when Resident #103 received incontinence care. On 5/23/25 at 10:23 AM, the surveyor informed the Liscensed Nursing Home Administrator and Director of Nursing of the above findings. On 5/23/25 at 12:36 the IPRN provided the surveyor with Tips for Meeting the Linen Requirements in Skillled Nursing Facilities which revealed: Tips: Carefully roll up soiled linen to prevent contamination of the air, surfaces, staff, and/or residents. Do not shake linen; Moving or shaking linens can aerosolize pathogens causing spread to others and contamination of the environment; Make sure contaminated laundry is gagged or contained at the point of collection (e.g. location where it was used) not in the entry way or hallway; This will reduce the risk spreading pathogens elsewhere in the facility to others; Place soiled linen into a clearly labeled, leak-proof container (e.g. bag) in the resident care area. Do not transport soiled linen by hand outside of the specific resident care area from where it was removed. Make sure all containers and bags are leak proof. On 5/23/24 at 2:00 PM, during the facility exit, the facility provided no additional information. The Handling Soiled Linen Policy, Revied 11/24 revealed: Procedure: 3. Linen should not be allowed to touch the uniform or floor and should be handheld as little as possible with minimum agitation to avoid contamination of air, surfaces, and persons. 4. Used or soiled linen shall be collected at the bedside and placed in a lined bag or designated lined receptacle. Bags will be stored on the clean linen carts. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. The Enhanced Barrier Precautions Policy, effective 6/17/24 revealed: Purpose was in infection and control intervention to reduce the spread of multi-drug resistant organisms to residents. The Hand Hygiene Policy, Reviewed/Revised 2/25 revealed: Purpose: Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids or contaminated surfaces (even if gloves are worn); before invasive procedures; after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings). To reduce the incidence of Healthcare-acquired infections (Center for Disease Contol, 2014). Hand-Hygiene Technique: B: When washing hands with soap and water, we hands first with warm water, apply an amount of product recommended by the manufactured to hands, and rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use clean dry towel to turn off the faucet . NJAC 8:39-21.1(h)

Based on observation, interview it was determined that the facility failed to ensure a) the required ambient air temperature (between 71-81 degrees Farenheight) was maintained in all resident areas, and the shower room with an adjacent storage area was maintained in a clean and sanitary manner. The deficient practice was identified for 1 of 2 shower areas on the B-Wing Unit, for the 6 bed Annex Unit and was evidenced by the following: On 5/18/25 at 7:29 PM, during a tour of the B-Wing Unit shower room the surveyor observed what appeared to be a brown feces covered washcloth wrapped around the bath sprayer nozzle which was below the bath stretcher that was on top of the bath. The surveyor showed the Registered Nurse Supervisor (RNS) who stated, she was not sure what happened. The surveyor then entered the attached store room and a tub of urine cups was stored directly on the floor and what appeared to be a mop or broom handle was stored inside the tub. The RNS stated someone must have dropped them (urine cups) there. On 05/21/25 at 9:54 AM, the surveyor entered the Annex Unit and felt a noticeable chill in the air temperature. The surveyor interviewed a Respiritory Therapist (RT # 2) at that time regarding the air temperature in the Annex and RT #2 stated sometimes its colder in here. The surveyor observed that temperature reading on the thermostat behind the nursing desk was 73 degrees Farenheight (F). The six bed unit contained six residents (Resident # 41, #66, #84, #103, #108 and one Unsampled Resident (UR #1) at that time. The surveyor observed Resident #103 was in room and staff was talking to resident behind the curtain. On 05/21/25 at 10:30 AM, two surveyors registered an ambient (environmental) temperature at the nursing desk of 68.8 F, although the wall thermostat registered 73 F. The surveyors observed the temperature in Resident # 103's room registered an ambient temperature of 68.3 F while the resident was in bed, and the Packaged Terminal Air Conditioner (PTAC) unit in the room was set to 61 F and was not running at that time. At that time, the Maintenance Director (MD) was present and the surveyor asked why was the PTAC temperature set to 61 F. The MD stated, anyone can touch it, you can come in here and lower it to anything. When asked if the room temperature felt cold, the MD stated, it is cold in here, and it is cold outside. On 5/21/25 at 10:45, the surveyor reviewed the National Weather Service weather which revealed the outside temperature at the facility location was 55 F with rainy conditions, and 49 F forecasted for the evening. On 05/23/25 at 1:54 PM, the survey team reviewed responses to the above concerns from the Liscensced Nursing Home Administrator (LNHA) and Director of Nursing, the LNHA stated moving forward the MD will monitor the temperatures in the resident rooms. NJAC 8:39-5.1(a)

REPEAT DEFICIENCY Based on interview, medical record review and review of other facility documents, it was determined that the facility failed to complete a thorough investigation of an injury of unknown origin, and to rule out abuse. This deficient practice was identified for 1 of 4 residents reviewed for abuse, Resident #37 and was evidenced by the following: On 5/22/25 at 10:08 AM, the surveyor reviewed the electronic medical record for Resident #37. According to the admission Record, Resident #37 was admitted to the facility with diagnoses which included, but were not limited to; Spastic quadriplegic cerebral palsy (is a severe type that is characterized by paralysis of both arms and both legs, with muscle stiffness), Contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility) and Septo-optic dysplasia of brain (is a disorder of early brain and eye development). A review of Resident #37's Quarterly Minimum Data Set (an assessment tool used to facilitate the management of care) dated 03/27/25, reflected that the resident's Brief Interview for Mental Status (BIMS) interview was not conducted because resident was rarely/never understood. The MDS did not indicate that Resident #37 had physical behavioral symptoms directed towards others or self. Further review of the MDS indicated resident had functional limitation in range of motion/impairment on both sides in their both upper and lower extremities. A review of the Progress Notes (PN) revealed the following: The PN revealed a Communication - with family/NOK/POA [next of kin/power of attorney] note dated 3/31/25 at 4:51 PM, which revealed: Spoke with [family] regarding exam of left arm upon return from [name redacted] school. Assessed with Director of Nursing (DON) present, to be examined by medical. The PN revealed a [name redacted] General Note dated 3/31/25 at 5:35 PM, which revealed: On assessment with DON present, 2 circular bruises noted right exterior elbow, skin intact, no swelling, no discomfort when touched top bruise faded, second blue and purple in color. Will place on medical list to re-assessed. Further review of the PN revealed a communication - with family/NOK/POA note dated 3/31/25 at 4:32 PM which revealed: received call from [family], stated [name redacted] school called regarding bruise left upper leg. Nursing supervisor made aware. On 5/23/25 at 9:55 AM, the surveyor reviewed an incident report dated 3/31/25 at 4:51 completed by the Registered Nurse (RN) and checked off other for location of incident. Under section Procedure related incidents checked off other: Bruising related to blood draw 3/27/2025. Under Miscellaneous- Additional information: Report of bruising from [name redacted] school- per [family]- discussed bruise with [family]- verbalized understanding and acknowledged blood work- stated told school to call me first so they could inform them that they were aware of bruises. Signed off by Immediate supervisor, Nurse Manager, and the DON. There were no statements attached to the incident report. On 5/23/25 at 9:22 AM, during an interview with the surveyor, the day shift Nursing Supervisor (NS) stated if she observed a resident with bruises, she would fill out incident report and investigate how did the resident get bruises. The NS further stated she would go back 3 days to complete her investigations. The NS stated the process to complete an investigation was to get staff statements. On 5/23/25 at 10:23 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The surveyor presented above mentioned concerns regarding the investigation having no conclusion or and there were no statements. The DON stated Resident #37 had blood drawn and that was how Resident #37 got bruises on their arms. The surveyor requested for additional information including blood test report or any statements that were obtained. On 5/23/25 at 1:42 PM, In the presence of the survey team, the DON stated everything was in the Progress Notes, and confirmed that that there were no statements obtained regarding the investigation of Resident #37's bruises. The DON acknowledged that the facility wanted to ensure that injuries of unknown origin were investigated to rule out abuse. The DON could not provide any further information. A review of the facility's policy titled, Abuse and Neglect, last revised 11/23 revealed the following: The facility shall promptly report all suspected cases of abuse or neglect in compliance with New Jersey Law and Regulation. All reports of abuse, neglect or exploitation shall be considered allegations until the matter is substantiated. The facility has an obligation to protect the welfare and to fully investigate and correct any circumstances upon that welfare. The approach should be as proactive as possible. As such, all new employees shall review this information at least annually. Procedure: Any allegation of abuse from any source shall be investigated and every effort shall be made to prevent recurrence. The report shall be made to the administrator /DON or after business hours to the Supervisor on duty. The Supervisor shall in turn report the incident to the Administrator, designee and if an investigation is necessary, take immediate steps to address the situation including: Securing medical attention for the alleged victim . NJAC 8:39-4.1(a)(5)

Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure a system was in place to ensure devices used to prevent contractures were consistently applied per physician order. The deficient practice occurred for 1 of 6 residents reviewed for positioning (Resident #84) and was evidenced by the following: On 5/18/25 at 8:00 PM, the surveyor observed Resident #84 in bed sleeping with both hands visibly contracted and there was no device inside both hands. There were two posters on the wall above Resident #84's bed detailing the use of Resident #84's right and left hand roll (a device used to prevent the hands from closing into the palms). On 5/19/25 at 9:30 AM, the surveyor reviewed the medical record for Resident #84 which revealed the following: - The admission Record revealed the resident had diagnoses which included, but were not limited to; Localization-related (Focal)(Partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus, Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, Spastic quadriplegic cerebral palsy. - A Care Plan Focus for alteration in muscle tone and/or joint stability related to their diagnosis, initiated 6/7/24. A Goal, initiated 6/7/24 to remain free from complications related to the use of specialized positioning equipment, including but not limited to, skin integrity issues or progression of contratures. Interventions included: OT (Occupational Therapy) to monitor specialized equipment PRN [as needed] and quarterly for the IDT [Interdisciplinary Team], initiated 6/7/24. Another Intervention revealed will utilize L (orange) and R (blue) hand rolls for 3 hours, two times each 12 hour nursing shift with a minimum of 1 hour break between wearing periods, date initiated 6/7/24. -A physician order dated 6/7/24 at 1900 [7:00 PM] for Orthotics: R (Right) (blue) wrist roll, R blue hand roll, and L (Left) (orange) hand roll to be worn for 3 hours, two times each 12 hour nursing shift with a minimum of 1 hour break between wearing periods, every shift for Contracture. The Treatment Administration Record (TAR) revealed the above order with an area only to indicate Day/ Night and staff initials. There were no times specified to ensure that the hand rolls would be worn two times each 12 hour period for for 3 hours with the ordered 1 hour break between wearing. The Quarterly Minimum Data Set, dated [DATE] revealed the resident had impairment on both sides related to range of motion and was dependent on staff for all care. On 05/21/25 at 10:05 AM, the surveyor asked the Registered Nurse (RN #1) providing care to Resident #84 if the resident was wearing their handrolls. Both the surveyor and RN #1 observed Resident #84 in bed, and the signs behind the resident's bed regarding the directions for the right and left handroll. RN #1 stated, I don't see them, and the surveyor asked are they supposed to be there? RN #1 responded yes. On 05/21/25 at 12:34 PM, the surveyor interviewed the Occupational Therapy Supervisor (OTS), and asked what the handrolls were used for. The OTS stated they used orthotics to keep fingers open and help to prevent contractures. On 05/21/25 at 12:40 PM, both the OTS and the surveyor went to Resident #84's room, the sheets were now removed from the bed, and the blue and orange handrolls were on the nightstand. The surveyor asked how did they ensure the orders were carried out for the specific amount of time since it was not specific in the TAR. The OTS stated, they were not responsible for putting specific times into the TAR, and stated that was a nursing function. On 05/23/25 at 1:53 PM, during the exit conference held with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA). The DON stated, he would look into it and he acknowledged that there was no specific times documented in the TAR to ensure the handrolls were worn per physician order. The Hand Rolls policy, Dated, 11/00 revealed: Purpose: Patients who required preventive measure and/or positioning devices will be provided with these devices in order to prevent contractures or problems associated with contractures. These measure or devices will be provided in accordance with an order from a physician, nursing, occupational therapy, and/or physical therapy. NJAC 8:39-27.1(a)

REPEAT DEFICIENCY Based on observation, interview and record review, it was determined that the facility failed to ensure that nurses administer all prescribed medications according to the physician's order. This deficient practice occurred to 1 of 7 residents (Resident #85) observed during the medication pass observation and was evidenced by the following: On 5/21/25/25 at 9:45 AM, during the medication administration observation the Licensed Practical Nurse (LPN ) informed the surveyor that Resident #85's Propanolol dose was not available. The surveyor inquired regarding the facility's protocol to reorder medications. The LPN informed the surveyor that the medication should be reordered before reaching the remaining 8 doses on the Bingo cart or remaining 3 doses left in multidose bottle. The LPN stated that she had not been on the medication cart and could not comment when the medication was reordered. On 5/21/25 at 10:15 AM, the surveyor reviewed the medical record which revealed: Resident #85 had diagnoses which included, but were not limited to; Chronic respiratory failure, persistent vegetative state, essential hypertension and tachycardia. According to the Quarterly Minimum Data Set Assessment (MDS) dated [DATE] Resident #85 was severely cognitively impaired. Resident #85 was totally dependent on staff for care. On 05/22/25 at 1:45 PM, during the reconciliation of physicians orders in the medical record, it was noted that Resident #85 had an order for Propanolol Solution (heart medication and also used for anxiety) 20 milligrams (mg)/5 milliliter (ml). The order was to give 0.7 ml via Gastrostomy tube every 8 hours for dysautonomia, spasticity. The medication was to be held if Systolic blood pressure was less than 70 and heart rate less than 70. On 5/19/25 the blood pressure was not entered on the medication administration record. A review of the Medication Administration Record (MAR) for April 2025 reflected that five doses of Propanolol had not been administered on 4/25/25 at 10:00 PM; 4/26/25 at 6:00 AM and 2:00 PM; 5/19/25 at 10:00 PM, and 5/20/25 at 6:00 AM. There was no blood pressure and heart rate entered on the days the medication was missing. On 5/20/25 at 11:30 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN #7) who confirmed that the Propanolol was not administered because the pharmacy did not send the medication. A review of the Progress notes failed to indicate that the physician was made aware of the omission and that Resident #85 was being monitored for any adverse effects. On 5/23/25 at 10:15 AM the facility was made aware of the above concerns. No additional information was provided. A review of the facility's policy titled, Medication Ordering and receiving from pharmacy revealed the following: Medications and related products are received from pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. NJAC 8:39-29.3(a)(4)(5)

REPEAT DEFICIENCY Based on observation, interview and record review it was determined that the facility failed to properly label, dispose and store medication in 1 of 2 medication storage areas. The deficient practice was evidenced by the following: On 5/20/25 at 10:45 AM, the surveyor inspected the Unit 2 Medication Room in the presence of the Registered Nurse Unit Manager (RN #7) found a bottle of iron liquid with an expiration date of 2/2025. RN #7 informed the surveyor that the Nursing Supervisor checked the storage room daily and could not provide the rationale for the expired medication to be among other medications. On 5/20/25 at 11:00 AM, the surveyor inspected the Unit 2 Medication Cart #1 in the presence of the Licensed Practical Nurse (LPN#3) and noted a vial of Lantus Insulin that was opened and not dated. LPN #3 stated that all insulin vials and Pen should be dated upon opening. LPN #3 added that the 7:00 PM-7:00 AM used the Lantus Insulin and should have been dated. A review of the Manufacturer's Specifications for Lantus Insulin revealed the following: Lantus Insulin should be discarded 28 days of first use regardless of whether it's been refrigerated or stored at room temperature. On 5/23/25 at 10:15 AM the facility was made aware of the above concerns. No additional information was provided. A review of the facility's policy Delivery, Receipt and Storage, last revised 1/2025 revealed the following:Medication bottles are to be labeled with date and time opened. Medications are to be checked daily for expiration date. Any expired medications should be disposed of properly. NJAC 8:39-29.4 (a) 8

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation for seven of seven unsampled residents reviewed for misappropriation (Resident (R) 39, R36, R35, R94, R6, R87, and R70). Specifically, nursing staff borrowed medications from the residents and administered the medications to other residents. Findings include: 1. Review of R39's undated Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R39 was admitted to the facility on [DATE] with the diagnoses of epilepsy, and spastic quadriplegic cerebral palsy. Review of R39's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/23 and located in the resident's EMR under the MDS tab revealed R39 was in a persistent vegetative state with no discernible consciousness. Review of R39's Physician Orders located under the Orders tab in the EMR revealed an order dated 12/23/23 for R39 to receive lorazepam concentrate (a narcotic antianxiety medication) two mg/ml (milligram per milliliter) give two ml by G-tube (gastrostomy tube) every four hours as needed for myoclonus/storming. Review of R39's Controlled Drug Receipt/Record/Disposition Form provided by the facility revealed four doses of the resident's lorazepam concentrate medication were misappropriated and administered to R4 on 12/31/23, 01/03/24, 01/04/24, and 01/27/24. R4 had a physician order for lorazepam concentrate two mg/ml give 1.5 ml by G-tube at bedtime. Continued review of R39's Controlled Drug Receipt/Record/Disposition Form revealed 11 doses of lorazepam concentrate were misappropriated and administered to R57 on 01/28/24 through 01/29/24. R57 had a physician order for lorazepam concentrate two mg/ml give 0.9 ml by G-tube every four hours for muscle spasms. 2. Review of R36's undated Admission Record located under the Profile tab in the EMR revealed R36 was readmitted to the facility on [DATE] with the diagnoses of respiratory failure with hypoxia and autonomic dysreflexia. Review of R36's quarterly MDS with an ARD of 02/08/24 revealed R36 was in a persistent vegetative state with no discernible consciousness. Review of R36's Physician Orders located under the Orders tab in the EMR revealed an order dated 11/04/22 for R36 to receive diazepam oral concentrate (a narcotic antianxiety medication) five mg/ ml by G-tube every four hours as needed for sustained clonus and/or tachycardia. Review of R36's Controlled Drug Receipt/Record/Disposition Form provided by the facility revealed one dose of the resident's diazepam oral concentrate medication was borrowed for R11on 01/13/24. R11 had a physician order for diazepam oral solution five mg/ ml give five ml by G-tube every six hours as needed for anxiety causing respiratory distress prior to trach changes. Continued review of R36's Controlled Drug Receipt/Record/Disposition Form revealed one dose of diazepam was misappropriated and administered to R47 on 02/16/24. R47 had a physician order for diazepam oral concentrate 3.5 ml by G-tube. 3. Review of R35's undated Admission Record located under the Profile tab in the EMR revealed R35 was readmitted to the facility on [DATE] with the diagnoses of respiratory failure with hypoxia and epilepsy. Review of R35's quarterly MDS with an ARD of 11/21/23 revealed R35 had short term and long-term memory problems and was severely impaired in making daily decisions. Review of R35's Physician Orders located under the Orders tab in the EMR revealed an order dated 12/10/23 for R35 to receive diazepam solution five ml by G-tube every six hours as needed for pre-procedure agitation. Review of R35's Controlled Drug Receipt/Record/Disposition Form revealed six doses of the resident's diazepam solution medication was misappropriated to R49 on 12/11/23, 12/12/23, and 01/08/24. R49 had a physician order for diazepam oral solution five mg/ ml give 7.5 ml by G-tube every six hours for spasticity. Continued review of R35's Controlled Drug Receipt/Record/Disposition Form revealed seven doses of the resident's diazepam were misappropriated and administered to R105 on 12/29/23 12/30/23, 12/31/23, and 01/01/24. R105 had a physician order for diazepam oral solution five mg/five ml give five ml by G-tube three times a day for spasticity/storming. Further review of R35's Controlled Drug Receipt/Record/Disposition Form revealed 11 doses of the resident's diazepam were misappropriated and administered to R95 on 01/03/24, 01/04/24, 01/05/24, and 01/06/24. R95 had a physician order for diazepam solution one mg/ml give 1.2 ml by G-tube four times a day for spasticity. Additionally, R35 had 17 doses of diazepam medication misappropriated and administered to R55 on 01/06/24, 01/19/24, 01/21/24, 01/22/24, 01/23/24, 01/24/24, and 01/25/24. 4. Review of R94's undated Admission Record located under the Profile tab in the EMR revealed R94 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy. Review of R94's quarterly MDS with an ARD of 11/14/23 revealed R94 had short and long-term memory problems and was severely impaired in daily decision making. Review of R94's Physician Orders located under the Orders tab in the EMR revealed an order dated 12/08/23 for R94 to receive diazepam solution five mg/five ml give two ml by G-tube every six hours as needed for tachycardia, autonomic storming. Review of R94's Controlled Drug Receipt/Record/Disposition Form revealed one dose of diazepam solution was misappropriated and administered to R55 on 12/11/23. R55 had a physician order for diazepam 0.6 ml to be given on 12/11/23 at 12:01 AM. Continued review of R94's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the diazepam solution medication was misappropriated and administered to R49 on 12/11/23. R49 had a physician order for diazepam oral solution five mg/five ml give three times a day by G-tube for spasticity. Further review of R94's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the resident's diazepam was misappropriated and administered to R56 on 02/13/24. R56 had a physician order for diazepam solution five mg/five ml give 7.5 ml by G-tube as needed for 30 minutes prior to dental exam and procedures. 5. Review of R6's undated Admission Record located under the Profile tab in the EMR revealed R6 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy. Review of R6's quarterly MDS with an ARD of 02/06/24 revealed R6 had short term and long-term memory problems and was severely impaired in making daily decisions. Review of R6's Physician Orders located under the Orders tab in the EMR revealed an order dated 08/08/23 for R6 to receive nayzilam (a benzodiazepine medication) five mg nasal spray give 0.1 ml in one nostril every five minutes as needed for seizures greater than five. May repeat times one if still seizing. Review of R6's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the nayzilam medication was misappropriated and administered to R24 on 01/19/24. R24 had a physician order for nayzilam nasal solution five mg/0.1 ml give 0.1 alternating nostrils every 10 minutes as needed for seizure rescue medication. 6. Review of R87's undated Admission Record located under the Profile tab in the EMR revealed R87 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and respiratory failure hypoxia. Review of R87's quarterly MDS with an ARD of 12/28/23 revealed R87 was in a persistent vegetative state with no discernible consciousness. Review of R87's Physician Orders located under the Orders tab in the EMR revealed an order dated 04/14/22 for R87 to receive diazepam 10 mg rectal gel insert 10 mg rectally as needed for a seizure greater than five minutes. Review of 87's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the resident's diazepam medication was misappropriated and administered to R88 on 08/05/23. R88 had a physician order for Diastat (diazepam) rectal gel 10 mg insert 10 mg rectally every six hours as needed for seizure activity lasting greater than five minutes or clusters of seizures without returning to baseline within five minutes. 7. Review of R70's undated Admission Record located under the Profile tab in the EMR revealed R70 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy. Review of R70's quarterly MDS with an ARD of 11/03/23 revealed R70 had short term and long-term memory problems and was severely impaired in making daily decisions. Review of R70's Physician Orders located under the Orders tab in the EMR revealed an order dated 10/21/22 for R70 to receive diazepam 10 mg rectal gel insert 10 mg rectally as needed for a seizure greater than five minutes. Review of R70's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the resident's diazepam medication was misappropriated to R97 on 05/12/23. R97 had a physician order for diazepam 10 mg rectal gel insert 10 mg rectally as needed for a seizure greater than five minutes. Review of the facility's Quality Improvement Plan dated 02/16/24, provided by the facility revealed under the Problem stated, According to the Consultant's Unit Inspection Report - it was noted that there was discrepancy on the controlled drug log - borrowing resident medication. Under the area of Action revealed All medication nurses were educated on the protocols of not borrowing resident medication. In-servicing was arranged with Polaris connect portal of tracking medication and reorder. During an interview on 02/21/24 at 2:00 PM, Licensed Practical Nurse (LPN) 6 stated, When we need the medicine we borrow it. We know it's wrong but what else do we do when we have a child that needs it. During an interview on 02/22/24 at 3:18 PM, the Administrator stated, We did not even consider misappropriation . The DON stated, We felt it was more of a medication issue. An attempt to reach the medical director by phone on 02/22/24 at 3:40 PM was unsuccessful. A message was left asking for a return call. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation dated 06/2023 revealed, .Misappropriation means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . NJAC 8:39-4.1(a)15

Based on interview, record review, and facility policy review, the facility failed to identify and investigate misappropriation of residents' narcotic medications for seven of seven unsampled residents (Resident (R) 39, R36, R35, R94, R6, R87, and R70). This placed all residents at risk for further incidents of misappropriation. Findings include: 1. Review of R39's undated Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R39 was admitted to the facility on [DATE] with the diagnoses of epilepsy, and spastic quadriplegic cerebral palsy. Review of R39's Controlled Drug Receipt/Record/Disposition Form provided by the facility revealed 15 doses of the resident's lorazepam concentrate (a narcotic antianxiety medication) were misappropriated. 2. Review of R36's undated Admission Record located under the Profile tab in the EMR revealed R36 was readmitted to the facility on [DATE] with the diagnoses of respiratory failure with hypoxia and autonomic dysreflexia. Review of R36's Controlled Drug Receipt/Record/Disposition Form provided by the facility revealed two doses of the resident's diazepam oral concentrate (a narcotic antianxiety medication) were misappropriated. 3. Review of R35's undated Admission Record located under the Profile tab in the EMR revealed R35 was readmitted to the facility on [DATE] with the diagnoses of respiratory failure with hypoxia and epilepsy. Review of R35's Controlled Drug Receipt/Record/Disposition Form revealed 41 doses of the resident's diazepam solution medication were misappropriated. 4. Review of R94's undated Admission Record located under the Profile tab in the EMR revealed R94 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy. Review of R94's Controlled Drug Receipt/Record/Disposition Form revealed three doses of the resident's diazepam solution were misappropriated. 5. Review of R6's undated Admission Record located under the Profile tab in the EMR revealed R6 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy. Review of R6's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the nayzilam (a benzodiazepine) medication was misappropriated. 6. Review of R87's undated Admission Record located under the Profile tab in the EMR revealed R87 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and respiratory failure hypoxia. Review of 87's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the resident's diazepam medication was misappropriated. 7. Review of R70's undated Admission Record located under the Profile tab in the EMR revealed R70 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy. Review of R70's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the resident's diazepam medication was misappropriated. During an interview on 02/22/24 at 3:18 PM, the Administrator stated, We did not even consider misappropriation . The DON stated, We felt it was more of a medication issue. An attempt to reach the medical director by phone on 02/22/24 at 3:40 PM was unsuccessful. A message was left asking for a return call. During an interview on 02/22/24 at 3:18 PM, the Administrator stated, We did not even consider misappropriation . but if we had considered that, we would have reported it. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation dated 06/2023 revealed, .Misappropriation means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Any allegation of abuse, neglect, exploitation or misappropriation resident property from any source shall be investigated and every effort shall be made to prevent recurrence . The Administrator/designee shall complete an investigation report. The report shall be completed as soon as possible, and forwarded to the appropriate agencies/authorities as necessary . NJAC 8:39-9.4(f)

Based on observation, record review, interview, and policy review, the facility staff failed to: 1. have correct labels on medications and failed to obtain pharmacy labels to affix to the Controlled Drug Receipt/Record/Disposition Form for three of 19 residents (Resident (R)94, R55, and R15); 2. waste a narcotic medication after the physician's order end date for one of 19 residents (R6); and 3. failed to have a pharmacy label on an opened bottle of liquid lorazepam (antianxiety medication) stored in the medication refrigerator on one of three units (Annex unit). Findings include: 1.Review of R94's undated Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R94 was readmitted to the facility on [DATE] with the diagnosis of epilepsy and cerebral palsy. Review of R94's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R94 had short term and long-term memory problems and was severely impaired in daily decision making. Review of R94's Controlled Drug Receipt/Record/Disposition Form revealed the pharmacy label read, Diazepam [antianxiety medication] Sol [solution] 5mg/5ml [milligram per milliliter] Give 2 ml via [by] G-tube [gastrostomy tube] every 6 hours as needed for tachycardia [rapid heartbeat], autonomic storming 2 ml = 2 mg. Give Give (sic) 2 tablets (650 mg) by mouth every 4 hours . Review of the label on bottle of diazepam medication for R94 revealed the same information as documented above as being on the Controlled Drug Receipt/Record/Disposition Form. During an interview on [DATE] at 4:18 PM, Nursing Supervisor/Registered Nurse(NS)1 stated, That label is wrong, he [R94] doesn't get anything by mouth. During an interview, the Director of Nursing (DON) on [DATE] at 5:30 PM stated, The nurse [referring to NS1] told me about the label being wrong. The DON confirmed the label was wrong for R94. 2.Review of R55's undated Admission Record located under the Profile tab in the EMR revealed R55 was readmitted to the facility on [DATE] with the diagnosis of epilepsy, and respiratory failure with hypoxia (low oxygen levels). Review of R55's quarterly MDS with an ARD of [DATE] revealed R55 was in a persistent vegetative state with no discernible consciousness. Review of R55's Controlled Drug Record revealed there was no label from the pharmacy on this record however, it was noted a staff member had handwritten [R94's name] and Diazepam Solution 5mg/5ml on this form. Interview on [DATE] at 10:45 AM NS1 stated, The nurse should have called the pharmacy and requested a new form with a label that comes from the pharmacy. They should not write this information in on this form. Interview on [DATE] at 5:30 PM, the DON confirmed the Controlled Drug Record should have the label on it from the pharmacy. 3.Review of R15's undated Admission Record located under the Profile tab in the EMR revealed R15 was readmitted to the facility on [DATE] with the diagnosis of epilepsy, spastic quadriplegic cerebral palsy, and anoxic (lack of oxygen) brain damage. Review of R15's annual MDS with an ARD of [DATE] revealed R15 had short term and long-term memory problems and was severely impaired in making daily decisions. Review of R15's Controlled Drug Receipt/Record/Disposition Form revealed the pharmacy label stated, Diazepam Tab [tablet] 5 mg Give ,d+[DATE] tablet by mouth (2.5 mg) via [by] G-tube [gastrostomy tube] four times a daily for Epilepsy. Give with 10 mg tablet to equal a total dose of 12.5 mg. Interview n [DATE] at 10:50 AM, NS1 stated, He [R15] doesn't get medications by mouth, they are given in his G-tube. NS1 confirmed the directions were wrong for R15. On [DATE] at 5:30 PM the DON confirmed the directions on the route to use to give this medication was wrong. 4.Review of R6's undated Admission Record located under the Profile tab in the EMR revealed R6 was readmitted to the facility on [DATE] with the diagnosis of epilepsy and cerebral palsy. Review of R6's quarterly MDS with an ARD of [DATE] revealed R6 had short term and long-term memory problems and was severely impaired in making daily decisions. Review of R6's Controlled Drug Receipt/Record/Disposition Form revealed Diazepam Sol [solution] Give 2 ml (milliliter) via [by] G-tube [gastrostomy tube] every 6 hours as needed for anxiety, trach [tracheostomy] pulling for 14 days. The date of this order was [DATE]. An observation of this medication being stored in the narcotic drawer of the medication cart in the Annex unit was made on [DATE] at 4:30 PM. NS1 stated, This should had been taken out of the narcotic drawer and wasted [destroyed] because this order ran out. Interview on [DATE] at 5:30 PM, the DON confirmed the medication found in the narcotic drawer for R6 should have been wasted because the order was no longer in effect. On [DATE] at 4:45 PM, an opened bottle of lorazepam was stored in the medication refrigerator on the Annex unit. This bottle of lorazepam did not have a pharmacy label on it, nor did it have the box the medication came in from pharmacy. NS1 was notified of this documented finding and NS1 stated, The nurse will waste this medication since it doesn't have a label on it. On [DATE] at 5:30 PM, the DON stated NS1 had made her aware and confirmed the bottle of lorazepam should have a label on it or have the box with a pharmacy label attached. Review of the facility's policy Medication Ordering and Receiving From Pharmacy, dated [DATE], revealed .An individual resident's controlled substance record is prepared by the pharmacy or the facility for each controlled substance prescribed for a resident. The following information is completed upon dispensing or upon receipt of the controlled substance: 1) Name of the resident, 2) Prescription number, 3) Drug name, strength (if designated), and dosage form of medication, 4) Date received, 5) quantity received, and 6) Name of the person receiving the medication supply. Review of the facility's policy Medication: Documentation of Controlled Substances, dated ,d+[DATE], revealed .Each controlled substance will have a Controlled Medication Utilization Record issues with the medication from the pharmacy .Scheduled narcotics that are discontinued or expired are to be wasted in the presence of an RN and another licensed nurse . NJAC 8:,d+[DATE].4 NJAC 8:,d+[DATE].7(c)

Based on observation, interview, and record review the facility failed to develop a care plan for intermittent urinary catheterization for one of three residents (Resident (R) 24) reviewed for a urinary catheter. Findings include: Observation of R24 on 02/19/24 at 12:47 PM revealed the resident was in bed on his back with tubing from a urinary catheter coming from under his clothes, going off the side of his bed to a urine collection bag. Review of R24's Physician Order, dated 01/09/24, located in the resident's electronic medical record (EMR) under the Orders tab revealed Texas Cath (catheter) a condom style catheter, apply at 0600 [6:00 AM]), remove at 1800 [6:00 PM]. Review of R24's Care Plan dated 04/21/17, revealed a problem related to .episodes of retaining urine. The goal was for R24 to empty his bladder every eight hours and the interventions included documenting the amount, color, and clarity of the urine. The care plan did not include the use of a catheter. During an interview on 02/22/24 at 3:24 PM, the Director of Nursing (DON) revealed her it was her expectation a care plan would have been developed in January 2024 when the catheter was ordered. NJAC 8:39-11.2(b) NJAC 8:39-27.1(a)

Based on staff interview, record review, and facility document review, the facility staff failed to follow professional standards of practice regarding the signing of the on coming and off going nurse when narcotics were counted for each shift. This occurred on two of three units in the facility (B wing medication cart 1 and 2, and A wing high side medication cart). Findings include: During observation of the Medication Storage and Labeling Task, performed on 02/21/24 and 02/22/24, revealed the narcotic count sheets were missing two licensed nurses' signatures for the following dates and areas: 1.For January 2024 on the B wing medication cart 1, the narcotic and barbiturate count log were missing two nurses' signatures on 01/04/24 7:00 PM, 01/06/24 7:00 AM, 01/09/24 at 7:00 PM, 01/10/24 at 7:00 AM, 01/15/24 at 7:00 PM, and 01/26/24 at 7:00 AM. 2.For February 2024 on the B wing medication cart 1, the narcotic and barbiturate count log were missing two nurses' signatures on 02/20/24 at 7:00 PM. 3.For November 2023 on the B wing medication cart 2, the narcotic and barbiturate count log were missing two nurses' signatures on 11/10/23 at 7:00 AM and 7:00 PM, 11/14/23 at 7:00 AM and 7:00 PM, 11/18/23 at 7:00 AM and 7:00 PM, 11/19/23 at 7:00 AM and 7:00 PM, 11/26/23 at 7:00 PM, and 11/30/23 at 7:00 PM. 4.For November 2023 on the A wing high side medication cart, the narcotic and barbiturate count log were missing two nurses' signatures on 11/17/23 at 7:00 AM. 5.For December 2023 on the A wing high side medication cart, the narcotic and barbiturate count log were missing two nurses' signatures on 12/21/23 at 7:00 PM. 6.For February 2024 on the A wing high side medication cart, the narcotic and barbiturate count log were missing two nurses' signatures on 02/02/24 at 7:00 AM. On 02/22/24 at 1:00 PM, the Director of Nursing (DON) was asked if the facility had a standard of practice they followed in regard to counting narcotics and the DON stated, We have our own resource from the pharmacy that is on the internet. During an interview on 02/22/24 at 6:30 PM, the DON stated, The on coming and off going nurses are to count the narcotics for each shift change and they are to sign the narcotic log before leaving their shift. Reviewed the facility policy Medication: Documentation of Controlled Substances, dated 12/23, revealed .At the change of shift, the Controlled Medication Utilization Record will be verified with the actual inventory on hand. Having accounted for all doses, verifying patient name, medication .and all routes of administration .The count must be completed by two licensed nurses. NJAC 8:39-11.2(b) NJAC 8:39-27.1(a) NJAC 8:39-29.7(c)

Based on record review and interview, the facility failed to ensure appropriate techniques were used for a residents who were dependent on respirators during for one of three residents reviewed for respiratory care (Resident (R) 20). R20 had an episode of apnea when a respirator therapist performed a sternal rub on the resident even though the resident was conscious. R20 sustained a bruised area to the chest. Findings include: Review of R20's Admission Record, located in the resident's electronic medical record (EMR) under the Profile revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute and chronic respiratory failure, tracheostomy status, dependence on respiratory (ventilator) status, and dysphasia. Review of R20's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/16/23, located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS), was unable to be completed since R20 was rarely understood. Review of R20's Care Plan, dated 02/10/16 and located in the resident's EMR under the Care Plan tab revealed the resident required mechanical ventilation for altered breathing related to lung disease, muscle weakness and depressed central nervous system. Interventions in place were to initiate ventilator and tracheotomy management protocol, multiple layers of monitoring as needed using tight ventilator and pulse oximeter alarms and monitor oxygen and dioxide levels. Review of R20's Nurse's Note, dated 12/17/23 at 7:40 PM and located in the resident's EMR under the Progress Notes tab and indicated, the nursing supervisor notified R20's family that the resident was going to receive Tylenol for discomfort. Family verbalized understanding. Will continue to monitor. The note was written by Nursing Supervisor/Registered Nurse (NS) 2. Review of R20's Nurse's Note, dated 12/18/23 and located in the resident's EMR under the Progress Notes tab indicated the resident had a bruise on their anterior chest, due to sternal rub. The note indicated R20's family was made aware, and Tylenol was given for comfort due to resident crying. Review of Pediatric Facility Incident Report, dated 12/17/23 and provided by the facility revealed an incident involving R20 and a staff member in the resident's room when a sternal rub was given for apnea (when one stops breathing or has little airflow while sleeping) causing soft tissue damage and bruising. Review of facility's undated and untitled Investigation into a resident bruise sustained during staff intervention on 02/17/23 R20 experienced a breath-holding incident with oxyhemoglobin (the normal, oxygen-carrying form of hemoglobin in which iron is in the reduced state) desaturation. The investigation revealed RT1 intervened using sternal rub, gentle limb restraint. Following the incident, a bruise was discovered on R20's center chest. The facility's conclusion was that while R20 sustained a bruise during the incident, the investigation determined that it was an unintended consequence of an intervention and not the result of staff negligence or misconduct. During an interview on 02/21/24 at 10:28 AM. Registered Nurse (RN) 2 stated she was the RN on duty on 12/17/23 during the 7:00 AM to 7:00 PM shift. RN2 stated she did not remember seeing any marks or bruises on R20; however, she was not specifically looking for them. RN2 also stated staff at the facility did not typically need to do sternal rubs because if a child was unresponsive, they would call a code; however, if a sternal rub was performed, it was to be reported to the charge nurse along with the family and documented in the resident's progress notes. During an interview on 02/21/24 at 10:54 PM, Nursing Supervisor/Registered Nurse (NS) 2 stated on 12/17/23, R20 was crying, and staff went into the room along with RN 3 who told her there was a raised red mark or bruise on R20's chest that looked like it was from a sternal rub. She said the bruise was right on the sternum and appeared fresh. NS2 stated a sternal rub was not general practice, and she has never seen one done or the need for one during the year she has worked at the facility. An attempted call was placed on 02/21/24 at 11:17 AM to Registered Nurse (RN) 3 but was unsuccessful. A voice message was left requesting a call back. A return call was not received by the end of the survey. An attempted call was placed on 02/21/24 at 11:42 AM to Charge Nurse (CN) 2 but was unsuccessful. A voice message was left requesting a call back. A return call was not received by the end of the survey. During an interview on 02/22/24 at 3:35 PM, Respiratory Therapist (RT) 1 stated on 12/17/23 he was assigned to R20 during the 7:00 PM to the 7:00 AM shift. RT1 stated at approximately 8:30 PM he responded to R20's room for a desaturation (decrease in blood oxygen level) alarm sounding when he observed R20 on his ventilator, and he hyper oxygenated him, and suctioned the resident's tracheostomy (removes mucus from the windpipe so that the windpipe stays clear) him out and R20's oxygen saturation returned to above 92%. RT1 stated about two minutes later R20 desaturated again, and he knew the resident did not need suctioned again in such a short period of time. RT1 also stated R20 was grimacing, clinching his teeth, and his monitor was alarming which indicated the resident was not reaching a certain volume of air. Continued interview revealed he determined R20 was holding his breath, but he was unsure if it was intentional, so he performed a light sternum rub on R20 that lasted no longer than four to five seconds to get the resident to release his breath. RT1 stated when he returned to work the next day, he was made aware that a bruise was discovered on R20's chest. RT1 further stated he did not use the sternal rub as it was intended and should not have performed the sternal rub. During an interview on 02/22/24 at 4:09 PM RT2 stated if there was a situation with a resident when there was a cessation of breathing, staff should try some type of gentle stimulation such as gently shaking them by holding onto their shoulders, or verbal stimulation by calling them by their name. RT2 stated sternal rubs were not used on residents of the facility. Continued interview revealed he had never been told sternal rubs were not appropriate in the facility as a technique. During an interview on 02/22/24 at 5:07 PM, the Director of Nursing (DON) stated she was informed by the Respiratory Therapy Director that it was poor clinical judgment on RT 1's behalf to perform a sternal rub on R20because R20 was not unresponsive. During an interview on 02/22/24 at 5:12 PM, the Medical Director stated she was new as the Medical Director and could not speak specifically to the incident that occurred on 12/17/23 with R20. The Medical Director stated when a resident was not breathing or holding their breath, there were other means of interventions such as tapping the resident or asking the resident their name. During an interview on 02/22/24 at 5:40 PM, the Respiratory Therapy Director stated she spoke with RT1 about using a sternal run for an episode of apnea. Continued interview revealed a sternal rub was a painful stimulus and to check for a resident's actual level of responsiveness, they would not use sternal rubs. She said a formal flick of the foot would have been sufficient or the use an ambu bag. Review of the facility's protocol for assessing level of conscience (LOC), What is a sternal Rub. Sternal rubs are a painful stimulus. They are used to assess a person's level of consciousness and response to pain. Performing a sternal rub on someone who is conscious could cause unnecessary pain and distress. There is a risk of injury. Even when performed correctly, sternal rubs can cause bruising or other skin injuries. This risk is even greater if the rub is performed incorrectly. It can be misinterpreted. A lack of response to a sternal rub does not necessarily mean that the person is unconscious. There are other factors that can affect a person's response to pain, such as medication, injury, or medical conditions. There are several alternatives to a sternal rub for assessing consciousness, each with its own advantages and limitations: Verbal Stimuli: Simple questions: Start with basic questions like What is your name? or where are you? This assesses orientation and ability to understand and respond. Commands: Give simple commands like Open your eyes or squeeze my hand. This assesses motor response and ability to follow instructions. Visual Stimuli: Bright light: Shine a bright light in the person's eyes and observe their reaction. This assesses pupillary response and basic awareness. Object movement: Wave an object in front of the person's face and watch for eye tracking. This assesses visual awareness and ability to follow movement. Tactile Stimuli: Gentle touch: Gently touch the person's shoulder or arm and observe their response. This assesses basic awareness and responsiveness to touch. Other Methods AVPU scale: This scale assesses alertness. verbal response, pain response and unresponsiveness. It's a quick and easy way to assess overall level of consciousness. Glasgow Coma Scale (GCS): This more detailed scale assesses eye opening, verbal response, and motor response. It's used by medical professionals for a more comprehensive evaluation. Important Considerations: Choose methods appropriate for the situation and your training level. Prioritize gentle and non-painful methods whenever possible. Remember, these methods are not diagnostic tools and should not be used to replace professional medical evaluation. If the person is unresponsive or shows signs of distress, call emergency services immediately. NJAC 8:39-27.1

Based on record review, interview and policy review, the facility failed to ensure medications were acquired and dispensed for one of three residents reviewed for medication administration (Resident (R) 58). The facility failed to notify the resident's family timely to ensure the medication was ordered and delivered to the facility. Findings include: Review of R58's undated Admission Record, located in the resident's EMR under the Profile tab revealed to the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Lennox-Gastaut syndrome no intractable without status epilepticus. Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/24, located in the resident's ERM under the MDS tab revealed a Brief Interview for Mental Status (BIMS), was unable to be completed since R58 was rarely understood. Review of R58's Care Plan, dated 08/28/16, and located in the resident's EMR under the Care Plan tab revealed, The resident was at risk for seizure activity .Interventions .administer anti-epileptic and emergency medications as ordered . Review of R58's Physician Orders, located in the resident's EMR under the Orders tab revealed an order dated 11/17/22, for Sabril (anticonvulsant medication) give 100 milligrams via g-tube two times a day for epileptic spasms. Review of R58's January 2024 Medication Administration Record (MAR), located in the resident's EMR under the Orders tab revealed the Sabril medication was scheduled to be administered twice a day at 2:00 AM and 2:00 PM. Continued review of the MAR revealed the no doses of the medication were administered on 01/24/24 or 01/25/24; and on 01/26/24 the 2:00 AM dose was not administered. Review of R58's Nurse's Note, dated 01/25/24 and located in the resident's EMR under the Progress Notes tab indicated Family Member (F58) called the facility and asked about R58's Sabril medication being ordered. F58 was informed the facility did not have the medication on hand and it needed to be ordered. F58 stated she would call the pharmacy. During an interview on 02/21//24 at 1:48 PM, Licensed Practical Nurse (LPN) 3 stated nursing staff were responsible for contacting F58 about R58's prescription for the Sabril medication because F58 ordered the medication and had it sent to the facility in the mail. She was unsure how far in advance the facility was supposed to notify F58. During an interview on 02/21/24 at 2:32 PM, LPN1 stated nursing staff dated all medications when they were opened to track when they were getting low. LPN1 stated she went to administer R58's Sabril medication on 01/23/24 and noticed it was the last dose. LPN1 also stated she locked the medication cart and told Nursing Supervisor/Registered Nurse (NS) 1 there was only one dose left and the system was not allowing her to reorder it. NS1 informed her it was a medication the family member needed to reorder, and he would contact them to get it refilled. During an interview on 02/21/24 at 2:48 PM, LPN4 stated R58's family was responsible for ensuring the resident's Sabril medication was refilled. LPN4 stated she became aware that R58's Sabril prescription was out during shift report, and she reported that to NS1, but she could not remember what day that was. LPN4 stated she told NS1 she would contact F58; however, she instead asked LPN3 to call F58. During an interview on 02/21/24 at 2:57 PM, F58 stated the facility's nursing staff never called her until R58 was completely out of the Sabril medication. F58 stated she needed the facility to give her a week's notice to ensure the resident does not go without the medication. During an interview on 02/22/24 at 11:31 AM, NS1 stated he called F58 on 01/23/24 when the last dose of Sabril was about to be administered. NS1 also stated he relied on the medication nurses to notify him when the prescription was low, and it was unacceptable. F58 was not notified until the last dose was about to be administered. Continued interview revealed the facility did not have a process in place to track the medication to ensure F58 was notified in time to have the medication refilled before it ran low. NS1 stated it was the facility's fault that R58 ran out of her medication and went without it for 2 1/2 days. By not having her medication, it put R58 at risk of seizure activity, or a potential change in mental status which would make her more combative and put her health and wellbeing at risk. During an interview on 02/22/24 at 5:32 PM, the Director of Nursing (DON) stated nursing staff should have notified F58 when there was at least a minimum of two days of medication left. NJAC 8:39-29.2 NJAC 8:39-29.7

Complaint # NJ00110496 Based on interviews, review of records, and review of facility policy, the facility failed to ensure for all 101 of 101 residents utilizing wheelchairs that their care plans addressed wheelchair safety (securing on wheelchair). The facility's deficient practice resulted in R5 suffering accidental asphyxiation [deprivation of oxygen supply to body tissues] by a chest harness when the resident was not properly secured in the wheelchair. On [DATE] at 9:07 PM, the Administrator and the Quality Safety Coordinator (QSC) were notified of an Immediate Jeopardy (IJ) at F656: Develop/Implement Comprehensive Care Plan. The Immediate Jeopardy began on [DATE] when R5 suffered accidental asphyxiation after being improperly secured by staff in R5's wheelchair. Individualized wheelchair safety interventions were not included on the care plans of all 101 residents, including R5, who utilized wheelchairs in the facility. The Administrator and QSC were informed that immediate jeopardy was still present and ongoing at the time of exit from the survey on [DATE] at 8:15 PM. The facility submitted an acceptable removal plan on [DATE]. The removal plan was verified as implemented on site by surveyors on [DATE]. Findings include: 1. The facility's policy for comprehensive care plans was requested but was not provided for review. Review of R5's undated electronic medical record (EMR) ADMISSION RECORD revealed R5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses to include epileptic spasms, and functional quadriplegic [complete inability to move due to severe disability], and used a wheelchair for mobility. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not completed and R5 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility. Review of R5's Care Plan under the EMR Care Plan tab revealed R5's care plan lacked interventions for wheelchair safety/straps/harness. Review of R5's Progress Note, [DATE] at 2:30 PM, under the EMR Progress Notes tab . was sent out to . ED [emergency department] for evaluation after having a respiratory arrest and requiring bagging with oxygen. Spontaneous respirations returned with bagging . Review of R5's ED Provider Notes, provided by QSC and dated [DATE] at 2:57 PM, revealed . presents to the ED via EMS [emergency medical services] for evaluation of asphyxiation . found belted into wheel chair slumped over into top half of the belt, cutting off circulation to . head . cyanotic [bluish hue to the skin indicative of low oxygen] and had petechiae to neck and face . EMS reports on their examination pt had tenderness to back of neck . Physical Exam . tachycardia [rapid heart rate] present . Skin . Diffused petechiae [pinpoint, round spots that appear on the skin as a result of bleeding] to neck up including face . Medical Decision Making/Plan . Likely asphyxia event . Transfer to [hospital] for observation . Review of R5's PEDIATRIC HISTORY AND PHYSICIAL, [DATE], provided by the Director of Nursing (DON) revealed . presenting as a direct admission . for concerns of accidental asphyxia injury . per report . patient was left in wheelchair estimated to be unattended ,d+[DATE] minutes, found to have wheelchair seatbelt wrapped around neck. Patient found to be not breathing and was subsequently bagged with return of spontaneous respirations. Reported that no CPR [cardiopulmonary resuscitation] initiated and pulses intact . was cyanotic and had petechiae on . neck and face. Per report, facility staff was sternal rubbing patient when EMS arrived . Review of Systems . Petechiae on face . Skin . Diffuse facial petechiae . accidental seatbelt strangulation. Dry skin and scattered rashes to neck, dry skin with scratches to back . Intermittently having breath holding spells with desaturations but resolves saponaceous. Review of R5's REPORTABLE EVENT RECORD/REPORT, [DATE], provided by QSC revealed Type of incident: Resident Care . Child was up in wheel chair [sic] awaiting therapy. Child was found to be apneic and unresponsive. [R5] had slid down in the chair with [R5's] legs hanging, and neck at the level of the chest harness straps. [R5] was placed in the bed, code was called, and bagged immediately with rescue breaths. [R5] responded to bagging and began breathing [independently]. [R5] did not require any chest compressions . Prior to the event was plan of care developed that addressed this issue . Custom wheelchair with chest harness for support and lap belt, heart rate and pulse oximetry monitoring . During an interview on [DATE] at 2:22 PM, Licensed Practical Nurse (LPN) 1 recalled entering R5's room on [DATE] because Certified Nursing Assistant (CNA) 1 was heard frantically yelling for help. LPN 1 recalled witnessing R5's lifeless body hanging from R5's wheelchair by the neck from the chest harness on [DATE]. LPN1 stated R5's butt was not on the seat of the wheelchair but was dangling along with R5's legs and feet. LPN1 stated R5 was unconscious, not breathing and R5's lips were blue. LPN1 stated R5's lap belt was not buckled or secured around R5. LPN1 stated Registered Nurse Charge (RNC) 3 entered R5's room and transferred R5 to the bed and began manual respirations. LPN1 verified R5's care plan did not include an intervention to secure the resident in the wheelchair with chest harness, lap belt, or footrest. During an interview on [DATE] at 11:48 AM, the Director of Nursing (DON) stated she went to R5's room on [DATE] because R5's code bell was alarming, and staff were providing R5 with manual respiratory resuscitation via and ambu bag [A self-refilling bag used for artificial respiration] when she arrived. The DON stated R5 developed petechiae around both temples and mouth. The DON stated R5's petechiae was possibly related to the harness strap around R5's neck and asphyxiation. The DON stated the facility investigated R5's room accident/incident and determined the cause was due to human error. The DON stated the staff failed to ensure R5's seat belt was strapped/closed to ensure R5 could not slip out of the wheelchair. The DON stated the facility did not identify that R5's care plan did not include care or safety for the use of the wheelchair including the seat belt, chest harness or footrest and should have. The DON stated the nurse manager was responsible for ensuring R5's care plan included those interventions and did not. The DON stated the facility's omission of the resident's care plan interventions for safety of wheelchairs or physician's orders did not occur to the leadership while investigating R5's incident accident. During an interview on [DATE] at 1:30 PM, Registered Nurse (RN) 1 stated she was providing care for R5 on [DATE], the date of the incident, and was taking lunch break at the time. RN1 stated she transferred R5 from the bed to the wheelchair prior to the lunch break and had secured and buckled R5's chest harness, lap belt; and had placed R5's feet on R5's footrest and buckled R5's feet. RN1 stated R5's care plan did not include wheelchair safety or information about seat belt, footrest, or chest harness. RN1 stated she was informed of what and how to strap R5 into the wheelchair via another staff member. RN1 stated she was a new employee at the facility and gained employment in [DATE]. During an interview on [DATE] at 4:53 PM, Registered Nurse Charge at (RNC) 3 recalled going to R5's room on [DATE] because CNA1 was yelling and on the way the code bell was heard alarming. RNC3 recalled when entering R5's room, R5's lap belt was not secured around R5's waist, and R5's chest harness was around R5's neck. RNC3 stated R5 was dangling from the wheelchair. RNC3 stated R5 was breathless, face was blue, and mouth was open. RNC3 recalled unclasping R5's chest harness and scooping R5's body from the wheelchair, transferring R5 to the bed and providing artificial respirations. RNC3 recalled R5 had developed petechiae on the temporal area and on the head. RNC3 stated R5 was required to have the wheelchair lap belt secured but did not and RNC3 was unsure why. RNC3 stated the staff just know the residents should be secured while in their wheelchairs. During an interview on [DATE] at 2:22 PM, Nurse Practitioner (NP) 1 stated she went to R5's room on [DATE] because the code bell was alarming, and the staff were providing manual respiratory resuscitation to R5. NP1 stated R5 developed petechiae around both temples and mouth. NP1 stated R5's petechiae was possibly related to the harness strap around R5's neck and caused asphyxiation. NP1 stated she discussed R5's incident/accident with the facility's Medical Director but did not discuss care plan interventions for wheelchair safety for the residents. NP1 stated R5's incident was a preventable accident, and the facility should have ensured the nursing staff were competent to secure the child in the wheelchair. NP1 stated the residents' wheelchair safety belts and harness were a safety hazard. During an interview on [DATE] at 4:41 PM, the Social Services Director (SSD) stated the facility did not conduct a care conference after R5's accident/incident. The SSD stated R5's care plan was not revised to include interventions to secure R5 on the wheelchair after the accident. The SSD stated wheelchair safety was not an intervention that needed to be included on the residents' care plan because the staff just knew about securing the residents to their wheelchairs. During an interview on [DATE] at 5:54 PM, the Medical Director stated she was one of the first staff in R5's room on [DATE] because R5's code bell was alarming. The Medical Director stated R5 began breathing independently and had a pulse but became [NAME] and developed petechiae on the face. The Medical Directors stated petechiae was not something related to seizure activity but developed from obstruction of the upper airway. The Medical Director stated petechiae was something seen during an autopsy of a deceased body due to strangulation. The Medical Director stated she examined R5 and talked to the staff. The Medical Director stated R5 was not on the wheelchair properly and that caused airway obstruction. The Medical Director stated she absolutely thought the incident could have been prevented. The Medical Director stated she thought R5's accident was a result of a human error by the nurse that put R5 in the wheelchair. The Medical Director stated they looked at R5's wheelchair and determined the wheelchair was adequate and decided the incident was caused because the lap belt was not clasped correctly. The Medical Director stated she expected the residents' care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated the only explanation that they had was the lap belt was not secured properly or not secured at all and they put R5 in the annex to have closer supervision but did not put any interventions or plans in place for R5. 2. Review of R18's undated EMR ADMISSION RECORD revealed R18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegia cerebral palsy, and ileostomy. Review of R18's quarterly MDS with an ARD of [DATE], located in the EMR MDS tab, revealed a BIMS was not assessed and R18 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility. Review of R18's Care Plan, target date [DATE] and located under the EMR Care Plan tab, revealed no interventions for wheelchair safety. 3. Review of R15's undated EMR ADMISSION RECORD revealed R15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegic cerebral palsy, and Crohn's disease. Review of R15's quarterly MDS with an ARD of [DATE], located in the EMR MDS tab, revealed a BIMS was not assessed and R15 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility. Review of R15's Care Plan, located under the EMR Care Plan tab with a target date of [DATE], revealed no interventions for wheelchair safety. 4. Review of R23's undated EMR ADMISSION RECORD revealed R23 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome and spastic quadriplegic cerebral palsy. Review of R23's quarterly MDS with an ARD of [DATE] and located in the EMR MDS tab, revealed a BIMS was not assessed and R23 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility. Review of R23's Care Plan, located under the EMR Care Plan tab with a target date of [DATE], revealed no interventions for wheelchair safety. During an interview on [DATE] at 11:48 AM, the DON stated the facility's omission of the resident's care plan interventions for safety of wheelchairs or physician's orders did not occur to the leadership while investigating R5's incident accident. The DON confirmed residents were not care planned for wheelchair safety. During an interview on [DATE] at 4:35 PM, Registered Nurse Charge (RNC) 3 stated the staff just know the residents should be secured while in their wheelchairs. RNC3 stated all the residents' wheelchairs were different. RNC3 stated the facility's residents with wheelchairs did not have interventions on their care plans to secure them on their wheelchairs with their safety straps which increased their risk for accidents. RNC3 stated the facility provided some wheelchair training upon hire, but it was not resident individualized care. During a brief interview on [DATE] at 6:40 PM, the QSC reported 101 resided at the facility utilizing wheelchairs with safety harness/straps. During an interview on [DATE] at 2:22 PM, NP1 stated the residents' care plan interventions guided all the facility's staff directives for providing care for the residents and should contain interventions for wheelchair safety and harness. NP1 stated she discussed R5's incident/accident with the facility's Medical Director but did not discuss care plan interventions for wheelchair safety for the residents. NP1 stated she was unsure why she did not think about all the rest of the residents utilizing wheelchair safety and entering orders for the other resident, but she should have. NP1 stated the residents' wheelchair safety belts and harness were a safety hazard. During an interview on [DATE] at 4:41 PM, the SSD stated residents' care plan interventions were the drivers of the care the facility provided for the residents. The SSD stated the facility did not include every little thing on the residents' care plans that utilized wheelchairs. The SSD stated wheelchair safety was not an intervention that needed to be included on the residents' care plan because the staff just knew about securing the residents to their wheelchairs and it was not something that needed to be on the residents' care plan or interventions. During an interview on [DATE] at 5:54 PM, the Medical Director stated she expected the residents' care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated the facility did not put any interventions or plans in place for R5 or the other 100 residents with safety straps/harness on their wheelchairs. N.J.A.C.: 8:,d+[DATE].1 (a)

Complaint # NJ00110496 Based on interviews, review of records, and the facility policy, the facility neglected to ensure one resident out of 101 residents (Resident (R) 5) residing at the facility who utilized wheelchairs was safely secured in the wheelchair to prevent accident hazards. On [DATE], the facility's failure resulted in actual harm to R5 due to accidental asphyxiation [deprivation of oxygen supply to body tissues] by the wheelchair chest harness. The facility failed to have care planned interventions or physician's orders for wheelchair safety in place for four of four residents (R5, R18, R23, and R15) reviewed for wheelchair safety, and 97 other residents utilizing wheelchairs in the facility, increasing the risk of accident hazards for all 101 residents. On [DATE] at 9:07 PM, the Administrator and the Quality Safety Coordinator (QSC) were notified of an Immediate Jeopardy (IJ) for F689: Accident Hazards. The Immediate Jeopardy began on [DATE] when staff failed to safely secure R5 in the wheelchair which resulted in R5 suffering asphyxiation by R5's chest harness. R5 and the other 100 residents who utilized wheelchairs did not have care plan interventions or physician's orders for wheelchair safety. The Administrator and QSC were informed that immediate jeopardy was still present and ongoing at the time of exit from the survey on [DATE] at 8:15 PM. The facility submitted an acceptable removal plan on [DATE]. The removal plan was verified as implemented on site by surveyors on [DATE]. Findings include: Review of the facility's policy titled Wheelchair Positioning, dated ,d+[DATE], revealed To position resident in a therapeutic and safe adaptive seating device, in order to provide increased mobility and to insure proper positioning . once resident is positioned in the wheelchair secure the seat belt to prevent any unexpected movement or fall . Align the resident's trunk support and secure all straps on chair . Place feet on the foot rests and secure with foot straps if present . Ensure that any type of head or neck support system is properly in place and supporting the resident properly . Place lap tray on wheelchair if present . 1. Review of R5's undated electronic medical record (EMR) ADMISSION RECORD revealed R5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses to include epileptic spasms, and functional quadriplegic [complete inability to move due to severe disability], and used a wheelchair for mobility. Review of R5's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of [DATE], located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not completed and R5 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility. Review of R5's Physician's Orders, dated ,d+[DATE], under the EMR Orders tab revealed there were no orders for wheelchair safety/straps/harness. Review of R5's Medication Administration Record [MAR] and Treatment Administration Record [TAR], dated ,d+[DATE], under the EMR Orders tab revealed there were no orders for wheelchair safety/straps/harness. Review of R5's Care Plan under EMR Care Plan tab revealed the care plan lacked interventions for wheelchair safety/straps/harness. Review of R5's CODE BLUE RESUSCITATION SHEET [DATE] revealed . Time Ventilation Initiated . 2:08 PM. Review of R5's Progress Note, [DATE] at 2:30 PM. under the EMR Progress Notes tab revealed . was sent out to . ED [emergency department] for evaluation after having a respiratory arrest and requiring bagging with oxygen. Spontaneous respirations returned with bagging. Review of R5's ED Provider Notes, provided by QSC and dated [DATE] at 2:57 PM, revealed . presents to the ED via EMS [emergency medical services] for evaluation of asphyxiation . found belted into wheel chair slumped over into top half of the belt, cutting off circulation to . head . cyanotic [bluish who to the skin indicative of loss of oxygen] and had petechiae to neck and face . EMS reports on their examination pt [patient] had tenderness to back of neck . Physical Exam . tachycardia [rapid heart rate] present . Skin . Diffused petechiae [pinpoint, round spots that appear on the skin as a result of bleeding] to neck up including face . Medical Decision Making/Plan . Likely asphyxia event . Transfer to [hospital] for observation . Review of R5's hospital PEDIATRIC HISTORY AND PHYSICIAL, dated [DATE] and provided by the Director of Nursing (DON), revealed . presenting as a direct admission . for concerns of accidental asphyxia injury . per report . patient was left in wheelchair estimated to be unattended ,d+[DATE] minutes, found to have wheelchair seatbelt wrapped around neck. Patient found to be not breathing and was subsequently bagged with return of spontaneous respirations. Reported that no CPR [cardiopulmonary resuscitation] initiated and pulses intact . was cyanotic and had petechiae on . neck and face. Per report, facility staff was sternal rubbing patient when EMS arrived . Review of Systems . Petechiae on face . Skin . Diffuse facial petechiae . accidental seatbelt strangulation. Dry skin and scattered rashes to neck, dry skin with scratches to back . Intermittently having breath holding spells with desaturations but resolves saponaceous . Review of R5's REPORTABLE EVENT RECORD/REPORT [DATE] provided by QSC revealed Type of incident: Resident Care . Child was up in wheel chair [sic] awaiting therapy. Child was found to be apneic and unresponsive. [R5] had slid down in the chair with [R5's] legs hanging, and neck at the level of the chest harness straps. [R5] was placed in the bed, code was called, and bagged immediately with rescue breaths. [R5] responded to bagging and began breathing [independently]. [R5] did not require any chest compressions . Prior to the event was plan of care developed that addressed this issue .Custom wheelchair with chest harness for support and lap belt, heart rate and pulse oximetry monitoring . During an interview on [DATE] at 2:22 PM, Licensed Practical Nurse (LPN) 1 recalled entering R5's room on [DATE] because Certified Nursing Assistant (CNA) 1 was heard frantically yelling for help. LPN 1 recalled witnessing R5's lifeless body hanging from R5's wheelchair by the neck from the chest harness on [DATE]. LPN1 stated R5's butt was not on the seat of the wheelchair but was dangling along with R5's legs and feet. LPN1 stated R5 was unconscious, not breathing and R5's lips were blue. LPN1 stated R5's lap belt was not buckled or secured around R5. LPN1 stated Registered Nurse Charge (RNC) 3 entered R5's room and transferred R5 to the bed and began manual respirations. LPN1 verified R5's care plan did not include an intervention to secure the resident in the wheelchair with chest harness, lap belt, or footrest. During an interview on [DATE] at 3:22 PM, LPN2 stated the facility did not require her to demonstrate her knowledge or skills of buckling the resident's safety belts or harness on their wheelchairs during their yearly training. LPN2 stated R5 required a chest harness, lap rest, and footrest to secure R5 in the wheelchair. During a brief interview on [DATE] at 3:45 PM the QSC reported CNA1 was not available for interview. During an interview on [DATE] at 11:48 AM, the DON stated she went to R5's room on [DATE] because R5's code bell was alarming, and staff were providing R5 with manual respiratory resuscitation via an ambu bag [A self-refilling bag used for artificial respiration] when she arrived. The DON stated R5 developed petechiae around both temples and mouth. The DON stated R5's petechiae was possibly related to the harness strap around R5's neck and asphyxiation. The DON stated the facility investigated R5's room accident/incident and determined the cause was due to human error. The DON stated the staff failed to ensure R5's seat belt was strapped/closed to ensure R5 could not slip out of the wheelchair. The DON stated the facility did not identify R5's physician's orders, care plan, or TAR did not include care or safety for the use of the wheelchair including the seat belt, chest harness, or footrest and should have. The DON stated the nurse manager was responsible for ensuring R5's care plan included those interventions and did not. The DON stated the facility's omission of the residents' care plan interventions for safety of wheelchairs or physician's orders did not occur to the leadership while investigating R5's incident accident. During an interview on [DATE] at 1:30 PM, Registered Nurse (RN) 1 stated she was providing care for R5 on [DATE] and was taking lunch break at the time of the incident. RN1 stated she transferred R5 from the bed to the wheelchair prior to the lunch break and had secured and buckled R5's chest harness, lap belt; and had placed R5's feet on R5's footrest and buckled R5's feet. RN1 stated R5's physician's orders, TAR, or care plan did not include wheelchair safety or information about seat belt, footrest, or chest harness. RN1 stated she was informed of what and how to strap R5 into the wheelchair via another staff member. RN1 stated she was a new employee at the facility and gained employment in [DATE]. During an interview on [DATE] at 4:53 PM, Registered Nurse Charge (RNC) 3 stated she went to R5's room because she heard CNA1 yelling and, on the way, she heard the code bell alarming. RNC3 stated when she entered R5's room she found R5's lap belt was not secured around R5's waist, and the chest harness was around R5's neck. RNC3 stated R5 was dangling from the wheelchair. RNC3 stated R5 was breathless, face was blue, and mouth was open. RNC3 stated she unclasped R5's chest harness and scooped R5's body from the wheelchair, transferred R5 to the bed and began providing artificial respirations. RNC3 stated she noted R5 developed petechiae on the temporal area and head. RNC3 stated R5 was required to have the wheelchair lap belt secured but did not and she was unsure why. During an interview on [DATE] at 2:22 PM, Nurse Practitioner (NP) 1 stated she went to R5's room on [DATE] because the code bell was alarming, and the staff were providing manual respiratory resuscitation to R5. NP1 stated R5 developed petechiae around both temples and mouth. NP1 stated R5's petechiae was possibly related to the harness strap around R5's neck and caused asphyxiation. NP1 stated she discussed R5's incident/accident with the facility's Medical Director but did not discuss care plan interventions or physician orders for wheelchair safety for the residents. NP1 stated she was unsure why she did not think about all the rest of the children utilizing wheelchair safety and entering orders for the other resident, but she should have. NP1 stated R5's incident was a preventable accident, and the facility should have ensured the nursing staff were competent to secure the child in the wheelchairs. NP1 stated the residents' wheelchair safety belts and harness were a safety hazard. During an interview on [DATE] at 4:41 PM, the Social Services Director (SSD) stated the facility did not conduct a care conference after R5's accident/incident. The SSD stated R5's care plan was not revised to include interventions to secure her on her wheelchair after her accident. The SSD stated wheelchair safety was not an intervention that needed to be included on the resident's care plan because the staff just knew about securing the residents to their wheelchairs and it was not something that needed to be on the resident's care plan or interventions. During an interview on [DATE] at 5:54 PM, the Medical Director stated she was one of the first staff in R5's room on [DATE] because R5's code bell was alarming. The Medical Director stated R5 began breathing independently and had a pulse but became [NAME] and developed petechiae on the face. The Medical Director stated petechiae developed from obstruction of the upper airway. The Medical Director stated petechiae was something seen during an autopsy of a deceased body due to strangulation. The Medical Director stated she examined R5 and talked to the staff. The Medical Director stated R5 was not on the wheelchair properly and caused airway obstruction. The Medical Director stated she absolutely thought the incident could have been prevented. The Medical Director stated she thought R5's accident was a result of a human error by the nurse that put R5 in the wheelchair. The Medical Director stated they looked at R5's wheelchair and determined the wheelchair was adequate and decided the incident was caused because her lap belt was not clasped correctly. The Medical Director stated she expected the residents' care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated she expected the resident's physician's orders to have wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated the only explanation that they had was the lap belt was not secured properly or not secured at all and they put R5 in the annex to have closer supervision but did not put any interventions or plans in place for R5. 2. Review of R18's undated EMR ADMISSION RECORD revealed R18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegia cerebral palsy, and ileostomy. Review of R18's quarterly MDS with an ARD of [DATE], located in the EMR MDS tab, revealed a BIMS was not assessed and R18 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility. Review of R18's Physician's Orders ,d+[DATE] under the Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness. Review of R18's MAR and TAR ,d+[DATE] under Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness. Review of R18's Care Plan, target date [DATE] and located under the EMR Care Plan tab, revealed no interventions for wheelchair safety. 3. Review of R15's undated EMR ADMISSION RECORD revealed R15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegic cerebral palsy, and Crohn's disease. Review of R15's quarterly MDS with an ARD of [DATE], located in the EMR MDS tab, revealed a BIMS was not assessed and R15 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility. Review of R15's Physician's Orders ,d+[DATE] under the Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness. Review of R15's MAR and TAR ,d+[DATE] under Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness. Review of R15's Care Plan, located under the EMR Care Plan tab with a target date of [DATE], revealed no interventions for wheelchair safety. 4. Review of R23's undated EMR ADMISSION RECORD revealed R23 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome and spastic quadriplegic cerebral palsy. Review of R23's quarterly MDS with an ARD of [DATE] and located in the EMR MDS tab, revealed a BIMS was not assessed and R23 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility. Review of R23's Physician's Orders ,d+[DATE] under the Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness. Review of R23's MAR and TAR ,d+[DATE] under Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness. Review of R23's Care Plan, located under the EMR Care Plan tab with a target date of [DATE], revealed no interventions for wheelchair safety. During an interview on [DATE] at 3:22 PM, LPN2 stated the facility did not require her to demonstrate her knowledge or skills of buckling the residents' safety belts or harness on their wheelchairs during their yearly training. During an interview on [DATE] at 11:48 AM, the DON stated the facility's omission of the residents' care plan interventions for safety of wheelchairs or physician's orders did not occur to the leadership while investigating R5's incident accident. During an interview on [DATE], RNC3 stated the staff just know the residents should be secured while in their wheelchair. RNC3 stated all the residents' wheelchairs were different. RNC3 stated the facility's residents with wheelchairs did not have interventions on their care plans to secure them on their wheelchairs with their safety straps which increased their risk for accidents. RNC3 stated the facility provided some wheelchair training upon hire, but it was not resident individualized care. During a brief interview on [DATE] at 6:40 PM, the QSC reported 101 resided at the facility utilizing wheelchairs with safety harness/straps. During an interview on [DATE] at 2:22 PM, NP1 stated she discussed R5's incident/accident with the facility's Medical Director but did not discuss care plan interventions or physician orders for wheelchair safety for the residents. NP1 stated she was unsure why she did not think about all the rest of the residents utilizing wheelchair safety and entering orders for the other residents, but she should have. NP1 stated the facility did not provide her with wheelchair safety education at the start of her employment in [DATE]. NP1 stated the residents' wheelchair safety belts and harness were a safety hazard. During an interview on [DATE] at 4:41 PM, the Social Services Director (SSD) stated residents' care plan interventions were the drivers of the care the facility provided for the residents. The SSD stated the facility did not include every little thing on the residents' care plans that utilized wheelchairs. The SSD stated wheelchair safety was not an intervention that needed to be included on the residents' care plan because the staff just knew about securing the residents to their wheelchairs and it was not something that needed to be on the residents' care plan or interventions. During an interview on [DATE] at 5:54 PM, the Medical Director stated she expected the residents' care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated she expected the residents' physician's orders to have wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated she had been at the facility for years, and it had never been on their radar to include residents' physician's orders for wheelchair safety and different devices like chest straps and such even though the staff utilized the residents' TAR to provide care. The Medical Director stated the facility did not put any interventions or plans in place for R5 or the other 100 residents with safety straps/harness on their wheelchairs. N.J.A.C. 8:,d+[DATE].1 (a)

Complaint # NJ00110496 Based on interviews, review of records, and the facility policy, the facility neglected to ensure one resident out of four residents (Resident (R) 5) reviewed for wheelchair safety was safely secured in the wheelchair to prevent accident hazards. On [DATE], the facility's failure resulted in actual harm of R5 due to accidental asphyxiation [deprivation of oxygen supply to body tissues] caused by the wheelchair chest harness. Following the incident, the facility determined human error as the cause and neglected to take measures to prevent future accidents. On [DATE] at 9:07 PM, the Administrator and the Quality Safety Coordinator (QSC) were notified of an Immediate Jeopardy (IJ) for F600 Neglect. The Immediate Jeopardy began on [DATE] when the facility neglected to ensure staff safely secured R5 in the wheelchair which resulted in R5 suffering asphyxiation by R5's chest harness; and subsequently failed to take actions to prevent future accidents caused by human error. The Administrator and QSC were informed that immediate jeopardy was still present and ongoing at the time of exit from the survey on [DATE] at 8:15 PM. The facility submitted an acceptable removal plan on [DATE]. The removal plan was verified as implemented on site by surveyors on [DATE]. Findings include: Review of the facility's policy titled Safety: Abuse & Neglect, dated [DATE], revealed The facility has an obligation to protect the welfare of its residents. Review of the facility's policy titled Wheelchair Positioning, dated [DATE], revealed To position resident in a therapeutic and safe adaptive seating device, in order to provide increased mobility and to insure proper positioning . once resident is positioned in the wheelchair secure the seat belt to prevent any unexpected movement or fall . Align the resident's trunk support and secure all straps on chair . Place feet on the foot rests and secure with foot straps if present . Ensure that any type of head or neck support system is properly in place and supporting the resident properly . Place lap tray on wheelchair if present . Review of R5's undated ADMISSION RECORD located on the electronic medical record (EMR) revealed R5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses to include epileptic spasms, and functional quadriplegic [complete inability to move due to severe disability], and used a wheelchair for mobility. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not completed and R5 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility. Review of R5's Physician's Orders, dated [DATE], under the Orders tab located on the EMR lacked an order for wheelchair safety/straps/harness. Review of R5's Medication Administration Record [MAR] and Treatment Administration Record [TAR], [DATE], under Orders tab located on the EMR revealed there were no orders for wheelchair safety/straps/harness. Review of R5's Care Plan under Care Plan tab located on the EMR revealed no interventions for wheelchair safety/straps/harness. Review of R5's CODE BLUE RESUSCITATION SHEET, [DATE], revealed . Time Ventilation Initiated . 2:08 PM. Review of R5's Progress Note, [DATE] at 2:30 PM, under Progress Notes tab located on R5's EMR revealed . was sent out to . ED [emergency department] for evaluation after having a respiratory arrest and requiring bagging with oxygen. Spontaneous respirations returned with bagging . Review of R5's ED Provider Notes, provided by the QSC, [DATE] at 2:57 PM revealed . presents to the ED via EMS [Emergency Medical Services] for evaluation of asphyxiation . found belted into wheel chair [sic] slumped over into top half of the belt, cutting off circulation to . head . cyanotic [bluish hue to the skin indicative of low oxygen] and had petechiae [pinpoint, round spots that appear on the skin as a result of bleeding] to neck and face . EMS reports on their examination pt [patient] had tenderness to back of neck . Physical Exam . tachycardia [rapid heart rate] present . Skin . Diffused petechiae to neck up including face . Medical Decision Making/Plan . Likely asphyxia event . Transfer to [hospital] for observation . Review of R5's PEDIATRIC HISTORY AND PHYSICIAL, [DATE], provided by the Director of Nursing (DON) revealed . presenting as a direct admission . for concerns of accidental asphyxia injury . per report . patient was left in wheelchair estimated to be unattended ,d+[DATE] minutes, found to have wheelchair seatbelt wrapped around neck. Patient found to be not breathing and was subsequently bagged with return of spontaneous respirations. Reported that no CPR [cardiopulmonary resuscitation] initiated and pulses intact . was cyanotic and had petechiae on . neck and face. Per report, facility staff was sternal rubbing patient when EMS arrived . Review of Systems . Petechiae on face . Skin . Diffuse facial petechiae . accidental seatbelt strangulation. Dry skin and scattered rashes to neck, dry skin with scratches to back . Intermittently having breath holding spells with desaturations but resolves saponaceous . Review of R5's REPORTABLE EVENT RECORD/REPORT, [DATE], provided by QSC revealed Type of incident: Resident Care . Child was up in wheel chair [sic] awaiting therapy. Child was found to be apneic and unresponsive. [R5] had slid down in the chair with [R5's] legs hanging, and neck at the level of the chest harness straps. [R5] was placed in the bed, code was called, and bagged immediately with rescue breaths. [R5] responded to bagging and began breathing [independently]. [R5] did not require any chest compressions . Prior to the event was plan of care developed that addressed this issue . Custom wheelchair with chest harness for support and lap belt, heart rate and pulse oximetry monitoring . During an interview on [DATE] at 2:22 PM, Licensed Practical Nurse (LPN) 1 recalled entering R5's room on [DATE] because Certified Nursing Assistant (CNA) 1 was heard frantically yelling for help. LPN 1 recalled witnessing R5's lifeless body hanging from R5's wheelchair by the neck from the chest harness on [DATE]. LPN1 stated R5's butt was not on the seat of the wheelchair but was dangling along with R5's legs and feet. LPN1 stated R5 was unconscious, not breathing and R5's lips were blue. LPN1 stated R5's lap belt was not buckled or secured around R5. LPN1 stated Registered Nurse Charge (RNC) 3 entered R5's room and transferred R5 to the bed and began manual respirations. LPN1 verified R5's care plan did not include an intervention to secure the resident in the wheelchair with chest harness, lap belt, or footrest. During an interview on [DATE] at 3:22 PM, LPN2 stated the facility did not require staff to demonstrate knowledge or skills of buckling the resident's safety belts or harness on their wheelchairs during their yearly training. LPN2 stated R5 required a chest harness, lap rest, and footrest to secure R5 in the wheelchair. During a brief interview on [DATE] at 3:45 PM, the QSC reported CNA1 was not available for interview. During an interview on [DATE] at 11:48 AM, the DON stated she went to R5's room on [DATE] because R5's code bell was alarming, and staff were providing R5 with manual respiratory resuscitation via and ambu bag [A self-refilling bag used for artificial respiration] when she arrived. The DON stated R5 developed petechiae around both temples and mouth. The DON stated R5's petechiae was possibly related to the harness strap around R5's neck and asphyxiation. The DON stated the facility investigated R5's room accident/incident and determined the cause was due to human error. The DON stated the staff failed to ensure R5's seat belt was strapped/closed to ensure R5 could not slip out of the wheelchair. The DON stated the facility did not identify R5's physician's orders, care plan, or TAR did not include care or safety for the use of the wheelchair including the seat belt, chest harness or footrest and should have. The DON stated the nurse manager was responsible for ensuring R5's care plan included those interventions and did not. The DON stated the facility's omission of the resident's care plan interventions for safety of wheelchairs or physician's orders did not occur to the leadership while investigating R5's incident accident. The DON stated no training or education was provided for staff on wheelchair safety following R5's incident. During an interview on [DATE] at 1:30 PM, Registered Nurse (RN) 1 stated she was providing care for R5 on [DATE], the date of the incident, and was taking lunch break at the time. RN1 stated she transferred R5 from the bed to the wheelchair prior to the lunch break and had secured and buckled R5's chest harness, lap belt, and had placed R5's feet on R5's footrest and buckled R5's feet. RN1 stated R5's physician's orders, TAR, or care plan did not include wheelchair safety or information about seat belt, footrest, or chest harness. RN1 stated she was informed of what and how to strap R5 into the wheelchair via another staff member. RN1 stated she was a new employee at the facility and gained employment in [DATE]. During an interview on [DATE] at 4:53 PM, Registered Nurse Charge (RNC) 3 recalled going to R5's room on [DATE] because CNA1 was yelling and on the way the code bell was heard alarming. RNC3 recalled when entering R5's room, R5's lap belt was not secured around R5's waist, and R5's chest harness was around R5's neck. RNC3 stated R5 was dangling from the wheelchair. RNC3 stated R5 was breathless, face was blue, and mouth was open. RNC3 recalled unclasping R5's chest harness and scooping R5's body from the wheelchair, transferring R5 to the bed and providing artificial respirations. RNC3 recalled R5 had developed petechiae on the temporal area and on the head. RNC3 stated R5 was required to have the wheelchair lap belt secured but did not and RNC3 was unsure why. RNC3 stated the staff just know the residents should be secured while in their wheelchairs. RNC3 stated all the residents' wheelchairs were different. RNC3 stated the facility's residents with wheelchairs did not have interventions on their care plans to secure them on their wheelchairs with their safety straps which increased their risk for accidents. RNC3 stated the facility provided some wheelchair training upon hire, but it was not resident individualized care. During a brief interview on [DATE] at 6:40 PM, the QSC reported 101 residents at the facility utilized wheelchairs with safety harness/straps. During an interview on [DATE] at 2:22 PM, Nurse Practitioner (NP) 1 recalled going to R5's room on [DATE] because the code bell was alarming, and the staff were providing manual respiratory resuscitation to R5. NP1 stated R5 developed petechiae around both temples and mouth. NP1 stated R5's petechiae was possibly related to the harness strap around R5's neck and caused asphyxiation. NP1 stated the residents' care plan interventions guided all the facility's staff directives for providing care for the residents and should contain interventions for wheelchair safety and harness. NP1 stated R5's incident/accident was discussed with the facility's Medical Director but they did not discuss care plan interventions or physician orders for wheelchair safety for the residents. NP1 was unsure why they did not think about all the rest of the children utilizing wheelchair safety and entering orders for the other resident but should have. NP1 stated the facility did not provide her with wheelchair safety education at the start of employment in [DATE]. NP1 stated R5's incident was a preventable accident, and the facility should have ensured the nursing staff were competent to secure the child in the wheelchair. NP1 stated the residents' wheelchair safety belts and harness were a safety hazard. During an interview on [DATE] at 4:41 PM, the Social Services Director (SSD) stated residents' care plan interventions were the drivers of the care the facility provided for the residents. The SSD stated the facility did not include every little thing on the residents' care plans that utilized wheelchairs. The SSD stated the facility did not conduct a care conference after R5's accident/incident. The SSD stated R5's care plan was not revised to include interventions to secure R5 on the wheelchair after the accident. The SSD stated wheelchair safety was not an intervention that needed to be included on the resident's care plan because the staff just knew about securing the residents to their wheelchairs and it was not something that needed to be on the resident's care plan or interventions. During an interview on [DATE] at 5:54 PM, the Medical Director stated she was one of the first staff in R5's room on [DATE] because R5's code bell was alarming. The Medical Director stated R5 began breathing independently and had a pulse but became [NAME] and developed petechiae on the face. The Medical Director stated petechiae was not something related to seizure activity but developed from obstruction of the upper airway. The Medical Director stated petechiae was something seen during an autopsy of a deceased body due to strangulation. The Medical Director stated she examined R5 and talked to the staff. The Medical Director stated R5 was not on the wheelchair properly which caused airway obstruction. The Medical Director stated she absolutely thought the incident could have been prevented. The Medical Director stated she thought R5's accident was a result of a human error by the nurse that put R5 in the wheelchair. The Medical Director stated they looked at R5's wheelchair and determined the wheelchair was adequate and decided the incident was caused because the lap belt was not clasped correctly. The Medical Director stated she expected the resident's care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated she expected the resident's physician's orders to have wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated she had been at the facility for years, and it had never been on their radar to include resident's physician's orders for wheelchair safety and different devices like chest straps and such even though the staff utilized the resident's TAR to provide care. The Medical Director stated the only explanation that they had was the lap belt was not secured properly or not secured at all and they put R5 in the annex to have closer supervision but did not put any interventions or other actions in place for R5 or the other 100 residents with safety straps/harness on their wheelchairs. NJAC:8:,d+[DATE].1 (a) 5

Complaint # NJ00110496, NJ00107644 Based on record review, interviews, and policy review, the facility failed to ensure 101 of 101 residents utilizing wheelchairs at the facility had physician orders for wheelchair safety. This resulted in actual harm when Resident (R) 5 was not appropriately secured in the wheelchair and suffered asphyxiation. The facility failed to ensure two residents out of three residents (R23, R18) reviewed for physician services had physician's orders included for Remicade (Generic name infliximab, infusion therapy used to decrease inflammation and treat Crohn's disease, ulcerative colitis, and rheumatoid arthritis.) The facility's deficient practice increased R23 and R18's resident's risk of treatment (medication administration) overlooked and not administered. Findings include: Review of the facility's policy titled Physician Services [DATE] revealed .The resident's attending physician has oversight in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultant or treatment when called by the facility, and overseeing a relevant plan of care for the resident . prescribe an appropriately regimen . Physician orders . shall be maintained in accordance . 1. Review of R5's undated ADMISSION RECORD located on her electronic medical record (EMR) revealed R5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses to include epileptic spasms, and functional quadriplegic and used a wheelchair for mobility. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) with a score of was not assessed and R5 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility. Review of R5's Physician's Orders, dated [DATE] and located under the EMR Orders tab, lacked orders for wheelchair safety/straps/harness. Review of R5's Medication Administration Record [MAR] and Treatment Administration Record [TAR] [DATE] under EMR Orders tab lacked orders for wheelchair safety/straps/harness. Review of R5's hospital PEDIATRIC HISTORY AND PHYSICIAL, dated [DATE] and provided by the Director of Nursing (DON), revealed . presenting as a direct admission . for concerns of accidental asphyxia injury . per report . patient was left in wheelchair estimated to be unattended ,d+[DATE] minutes, found to have wheelchair seatbelt wrapped around neck. Patient found to be not breathing and was subsequently bagged with return of spontaneous respirations. Reported that no CPR [cardiopulmonary resuscitation] initiated and pulses intact . was cyanotic [bluish hue to the skin indicative of low oxygen] and had petechiae [pinpoint, round spots that appear on the skin as a result of bleeding] on . neck and face. Per report, facility staff was sternal rubbing patient when EMS [emergency medical services] arrived . Review of Systems . Petechiae on face . Skin . Diffuse facial petechiae . accidental seatbelt strangulation. Dry skin and scattered rashes to neck, dry skin with scratches to back . Intermittently having breath holding spells with desaturations but resolves saponaceous. Review of R5's REPORTABLE EVENT RECORD/REPORT, dated [DATE] and provided by the Quality Safety Coordinator (QSC), revealed Type of incident: Resident Care . Child was up in wheel chair [sic] awaiting therapy. Child was found to be apneic and unresponsive. [R5] had slid down in the chair with [R5's] legs hanging, and neck at the level of the chest harness straps. [R5] was placed in the bed, code was called, and bagged immediately with rescue breaths. [R5] responded to bagging and began breathing [independently]. [R5] did not require any chest compressions . Prior to the event was plan of care developed that addressed this issue . Custom wheelchair with chest harness for support and lap belt, heart rate and pulse oximetry monitoring . During an interview on [DATE] at 2:22 PM, Licensed Practical Nurse (LPN) 1 stated she entered R5's room because Certified Nursing Assistant (CNA)1 was heard frantically yelling for help. LPN 1 recalled witnessing R5's lifeless body hanging from R5's wheelchair by the neck from the chest harness on [DATE]. LPN1 stated R5's butt was not on the seat of the wheelchair but was dangling along with R5's legs and feet. LPN1 stated R5's was unconscious, not breathing, and R5's lips were blue. LPN1 stated R5's lap belt was not buckled or secured around R5. LPN1 stated Registered Nurse Charge (RNC) 3 entered R3's room and transferred R3 to the bed and began manual respirations. LPN1 verified R5's care plan did not include an intervention to secure R5 in the wheelchair with chest harness, lap belt or footrest. During an interview on [DATE] at 11:48 AM, the DON stated she went to R5's room on [DATE] because R5's code bell was alarming, and staff were providing R5 with manual respiratory resuscitation via and ambu bag [A self-refilling bag used for artificial respiration] when she arrived. The DON stated R5 developed petechiae around both temples and mouth. The DON stated R5's petechiae was possibly related to the harness strap around R5's neck and asphyxiation. The DON stated the facility investigated R5's room accident/incident and determined the cause was due to human error. The DON stated the staff failed to ensure R5's seat belt was strapped/closed to ensure R5 could not slip out of the wheelchair. The DON stated the facility did not identify R5's physician's orders, care plan or TAR did not include care or safety for the use of the wheelchair including the seat belt, chest harness or footrest and should have. The DON stated the facility's omission of the resident's physician's orders for safety of wheelchairs did not occur to the leadership while investigating R5's incident accident. During an interview on [DATE] at 1:30 PM, RN1 stated she was providing care for R5 on [DATE] and was taking lunch break at the time of the incident. RN1 stated she transferred R5 from the bed to the wheelchair prior to the lunch break and had secured and buckled R5's chest harness, lap belt and had placed R5's feet on R5's footrest and buckled. RN1 stated R5's physician's orders, TAR, or care plan did not include wheelchair safety or information about seat belt, footrest, or chest harness. RN1 stated she was informed of what and how to strap R5 into the wheelchair via another staff member. RN1 stated she was a new employee at the facility and gained employment in [DATE]. During an interview on [DATE] at 4:53 PM, Registered Nurse Charge (RNC)3 stated she went to R5's room because she heard CNA1 yelling and, on the way, she heard the code bell alarming. RNC3 stated when she entered R5's room she found R5's lap belt was not secured around R5's waist, and the chest harness was around R5's neck. RNC3 stated R5 was dangling from the wheelchair. RNC3 stated R5 was breathless, face was blue, and mouth was open. RNC3 stated she unclasped R5's chest harness and scooped R5's body from the wheelchair, transferred R5 to the bed and began providing artificial respirations. RNC3 stated she noted R5 developed petechiae on the temporal area and head. RNC3 stated R5 was required to have the wheelchair lap belt secured but did not and she was unsure why. RNC3 stated the staff just know the residents should be secured while in their wheelchair. RNC3 stated all the resident's wheelchairs were different. RNC3 stated the facility's residents with wheelchairs did not have interventions on their care plans to secure them on their wheelchairs with their safety straps which increased their risk for accidents. RNC3 stated the facility provided some wheelchair training upon hire, but it was not resident individualized care. During a brief interview on [DATE] at 6:40 PM, the QSC reported 101 resided at the facility utilizing wheelchairs with safety harness/straps. During an interview on [DATE] at 2:22 PM, Nurse Practitioner (NP) 1 stated she went to R5's room on [DATE] because the code bell was alarming, and the staff were providing manual respiratory resuscitation to R5. NP1 stated R5 developed petechiae around both temples and mouth. The NP stated R5's petechiae was possibly related to the harness strap around R5's neck and caused asphyxiation. NP1 stated the residents' care plan interventions guided all the facility's staff directives for providing care for the residents and should contain interventions for wheelchair safety and harness. The NP1 stated she discussed R5's incident/accident with the facility's Medical Director but did not discuss care plan interventions or physician orders for wheelchair safety for the residents. The NP1 stated she was unsure why she did not think about all the rest of the children utilizing wheelchair safety and entering orders for the other resident, but she should have. The NP1 stated the facility did not provide her with wheelchair safety education at the start of her employment in [DATE]. The NP1 stated R5's incident was a preventable accident, and the facility should have ensured the nursing staff were competent to secure the child in the wheelchairs. The NP1 stated the residents' wheelchair safety belts and harness were a safety hazard. During an interview on [DATE], the Medical Director stated she was one of the first staff in R5's room on [DATE] because R5's code bell was alarming. The Medical Director stated R5 began breathing independently and had a pulse but became [NAME] and developed petechiae on the face. The Medical Director stated petechiae was not something related to seizure activity but developed from obstruction of the upper airway. The Medical Director stated petechiae was something seen during an autopsy of a decreased body due to strangulation. The Medical Director stated she examined R5 and talked to the staff. The Medical Director stated R5 was not on the wheelchair properly and caused R5's airway obstruction. The Medical Director stated she absolutely thought the incident could have been prevented. The Medical Director stated she thought R5's accident was a result of a human error by the nurse that put R5 in the wheelchair. The Medical Director stated they looked at R5's wheelchair and determined the wheelchair was adequate and decided the incident was caused because the lap belt was not clasped correctly. The Medical Director stated she expected the residents' care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated she expected the resident's physician's orders to have wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated she had been at the facility for years, and it had never been on their radar to include resident's physician's orders for wheelchair safety and different devices like chest straps and such even though the staff utilized the resident's TAR to provide care. The Medical Director stated, the only explanation that we had was the lap belt was not secured properly or not secured at all and we put [R5] in the annex to have closer supervision but did not put any interventions or plans in place for R5 or the other 100 residents with safety straps/harness on their wheelchairs. 2. Review of R23's undated EMR ADMISSION RECORD revealed R23 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegic cerebral palsy, constipation unspecified and ulcerative colitis. Review of R23's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score was not completed and R23 was assessed by staff to be severely impaired cognitively and used a wheelchair for mobility. Review of R23's Physician's Orders, from [DATE] through [DATE] under the EMR Orders tab, lacked orders for Remicade medication. Review of R23's MAR and TAR, from [DATE] through [DATE] under EMR Orders tab, lacked orders for Remicade. Review of R23's Care Plan under the EMR Care Plan tab revealed .colitis. normal bowel movements . Remicade as ordered. date initiated [DATE] and did not indicate the frequency. Review of R23's History & Physical under the EMR MISC tab revealed: a. [DATE] Chief Complaint: bloody diarrhea for 4 weeks . bloody diarrhea likely UC [ulcerative colitis] flare (likely due to delays of the last two infliximab infusions and set off by the recent C diff [Clostridioides difficile, bacteria that causes diarrhea] infection) .C diff. Screen negative today . PLAN start steroids . by Physician. b. [DATE] Patient with improving diarrhea and resolution of bloody BM [bowel movements]. Symptoms improving on steroids . Likely has UC flare triggered by her recent C Diff infection . by Medical Doctor Gastrointestinal. c. [DATE] .Hospitalist Daily Progress Note . Patient presented with bloody diarrhea likely due to ulcerative colitis flare due to delays of the last two infliximab infusion and complicated by recent C diff infection. by the Hospitalist. During an interview on [DATE] at 12:07 PM, the Nurse Manager (NM, a Registered Nurse) stated R23 had a diagnosis of colitis and was treated with Remicade infusions. The NM stated he was unsure of R23's schedule for receiving infusions. The NM verified R23 did not have orders for Remicade on the EMR. The NM verified R23's care plan intervention did not have Remicade schedule and should. The NM stated R23's Remicade dose was administered late but he was unsure of the exact date or why it occurred other than a nurse did not order the supplies. During an interview on [DATE] at 3:03 PM, NP1 stated R23 had a diagnosis of colitis and required Infliximab infusions every six weeks. NP1 verified R23's did not have a physician's order on the EMR for Infliximab infusions and should have. NP1 stated R23 missed doses of Infliximab infusions at the facility and it caused R23 to flare up with ulcerative colitis and R23 was sent to the hospital by the facility. During an interview on [DATE] at 6:37 PM, the Medical Director stated she expected residents to have physician's orders for their Remicade medication infusions along with the frequency of administration. The Medical Director stated it was a terrible thing that R23's Remicade administration late and R23 suffered the consequences. The Medical Director stated R23 was provided with boluses of fluids for dehydration. The Medical Director stated R23 was sent to the hospital emergency room for treatment and evaluation. 3. Review of R18's undated EMR ADMISSION RECORD revealed R18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegia cerebral palsy, and ileostomy. Review of R18's quarterly MDS with an ARD of [DATE] and located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not completed at R18 was assessed by staff as severely impaired cognitively. Review of R18's Physician's Orders, dated [DATE] and located in EMR Orders tab included: a. follow up . on [DATE] . Crohn's Disease . dated [DATE]. b. There was no order for Remicade. Review of R18's MAR and TAR, dated [DATE] and located under the EMR Orders tab did not include orders for Remicade. Review of R18's Care Plan under the EMR Care Plan tab .Cronh's [sic] disease. initiated [DATE] revised on [DATE] and did not have an intervention for Remicade medication administration. During an interview on [DATE] at 3:03 PM, NP1 stated R18 had a diagnosis of Chron's disease and required Remicade infusions every four weeks. NP1 confirmed R18 did not have a physician's order on the EMR for Remicade. NP1 stated R18's physician's order on R18's EMR should include the Remicade intravenous administration. NP1 verified R18's care plan did not have interventions for Remicade medication or specify the frequency of his doses or to monitor for side effects and should. N.J.A.C. : 8:,d+[DATE].1 (a)

Complaint #: NJ 1 Based on observation, interviews, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to provide a safe environment and adequate supervision for 2 of 6 sampled residents (Resident #1, Resident #2). In addition the facility failed to follow the plan of care which resulted in an unwitnessed altercation between the two residents consequently resulting with Resident #1 sustaining a fracture to the Right eye orbital area. This deficient practice was evidenced by: 1. In the Medical Record, on the admission record, Resident #1 was admitted to the facility in June 2011 with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool, dated 6/20/17 indicated Resident #1 had impaired cognition. According to the MDS, Resident #1 required extensive staff assistance with Activities of Daily Living (ADL's). 2. In the Medical Record, on the admission record, Resident #2 was admitted to the facility in May 2009 with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool, dated 6/6/17 indicated Resident #2 had impaired cognition. According to the MDS, Resident #2 required limited staff assistance with Activities of Daily Living (ADL's). A review of the care plan revealed under the Focus section indicated Impulsive and Aggressive behaviors directed at other residents, staff and equipment was initiated on 8/28/17. In the Goal section, (Resident #2) will remain calm and interact with others appropriately. In the Interventions section, 1:1 staffing with CNA (Certified Nursing Assistant), nurse, respiratory therapist or recreation staff at all times. (Resident #2) will remain isolated from other residents until changes in behaviors have been noted. (Resident #2) may go out into the play ground with approved staff only after recreation and therapy have been notified to prevent other children from using the playground with (Resident #2). Monitor and document all incidences of aggression/agitation/perseveration in the EMR (Electronic Medical Record). Also note techniques which may work to keep (Resident #2) calm. According to the care plan under Focus section, PO (by mouth) feedings/ Mealtime with an initiated date of 2/16/16. In the Goal section, (resident #2) will have meals in safe environment. In the Interventions section, with a initiated date of 8/29/17 (Resident #2) is to be brought to breakfast at 6:45 AM and dinner at 5 PM Monday to Friday with 1:1 staff member in the cafeteria. (resident #2) will have breakfast, lunch and dinner Sat (Saturday) and Sunday and days off from school with 1:1 staff in the cafeteria. Review of the facility Feeding Group Guidelines dated 8/30/17, indicated the following: The following is what is expected when attending to the residents in the feeding group. These guidelines are in place for resident safety and should be followed accordingly. - Separated in to 2 groups. 1 in the cafeteria (Resident #2 and Unsampled Resident A) and 1 in the ADL room (Activity day Room), (Resident #1 and Resident #3). - At no time are (Resident #1) and (resident #2) to be in the same room for feeding group. - There should be a staff member, usually CNA, in both rooms. If you find yourself in a situation where you are the only available staff member to attend to feeding group you need to speak to your charge nurse or the nursing supervisor. - If you need immediate help do not hesitate to use the CODE BELL, that is what it is for. The Walkie - Talkies can also be utilized to ask for assistance. - Do not leave residents unattended in either room. If you need to leave, then you must radio the nurses station for relief; if your residents are not completed eating. As per DON documentation, the above care plan was physician directed, implemented and communicated to all staff on 3/6/17. A review of the Incident Report dated 8/25/17 at 5:30 PM indicated, Resident #1 was hit in the face by Resident #2 breaking Resident #1's eye glasses. Nurse's assessment revealed right eye bruise with bleeding noted from the lower eyelid and corner of the right eyelid. Resident #1 was sent to the hospital via 911. A review of the facility investigation indicated that CNA #1 in a written statement indicated, On 8/25/17 at 5:30 PM, (CNA #1) was alone in feeding group feeding (Resident #1, Unsampled Resident A, and Resident #2). I was under the impression that someone would be in to assist with (Resident #2). (Resident #2) began to ask can I take (him/her) to rec (recreation) because he/she had finished his/her dinner. I replied not right now, that he/she had to wait because I was feeding (Unsampled resident A) and assisting (Resident #1) with his/her dinner. He/she became upset and started to push the table that (Unsampled Resident A and Resident #1) sat at. Because of all that was occurring, I really did not have a chance to get help with feeding. Then (Resident #2) started to grab and move (Unsampled Resident A's) chair. I asked him/her to stop and have a seat and I will take you to rec when they're finished. He/she laughed sat down and repeated to push the table and move (Unsampled Resident A's) chair again. I continued to feed (Unsampled Resident A) hoping that someone from the Annex would come and help with (Resident #2). He/she started to play in the bathroom with (Resident #1) by closing the door to the bathroom. I told them to have a seat and that we were about to leave. They both sat down. I started to clean up the trays, when I heard (Resident #1) cry and saw (Resident #2) standing by the bathroom door laughing. I went over to (Resident #1) and noticed his eye. Immediately I went to the hallway and called the first nurse I saw. During an interview with the surveyor on 9/8/17 at 9:10 AM, CNA #1 stated, The protocol is that the two residents (Resident #1 and Resident #2) are not supposed to be in the same room while eating. The care plan was in place prior to the incident, however I did not call for anyone to assist. I was under the impression that someone would come in to help because usually someone will come by and get (Resident #2). I did not see Resident #2 hit Resident #1 or if he/she pushed him/her. When I turned around to put the trays away, I saw resident #1 laying on the floor in the bathroom and Resident #2 was outside the bathroom near the the door laughing. CNA #1, then stated that Resident #1's eye was bleeding and his/her eye glass lenses had popped out of the frame, but frame was not broken. At that time, CNA #1 immediately contacted another nurse for help. During an interview with the surveyor on 9/8/17 at 9:25 AM, Supervisor #1 stated, A nurse came in and said that (Resident #2) hit (Resident #1) in the eye and it was bleeding. I came and saw (Resident #1) with an ice pack and that 911 was called. (Resident #1) was not able to say what happened. I asked the CNA what happened, if she was by herself and to write a statement. The CNA (#1) stated she was by herself (in the small dining room). The DON and the Administrator were called. I did teaching with the CNA (CNA #1) informing her that 2 CNA's had to be there at all times. CNA (#1) said she was waiting for someone to come. I told CNA (#1) she should have called for help. The surveyor interviewed the Director of Nursing (DON) on 9/1/17 at 11:25 AM. The DON indicated that on 8/25/17, (CNA #1) brought (Resident #2) along with (Resident #1) and an (Unsampled Resident A) into the small dinning room for dinner. A Registered Nurse, (RN #1) entered the room with (Resident #3) and assisted with the feeding. RN (#1) then took (Resident #3) back to (his/her) wing. (Resident #2) eats separately in the general cafeteria by (him/her) self with a one to one (1:1). The staff try to keep (him/her) away from other children. (Resident #2) has history of pushing kids but not to cause serious injury. (Resident #2) never harmed any child previously. The CNA (#1) met with the Unit Manager (UM) (#1) regarding expectation and rules in the dining room and to call for help. She (CNA #1) should have rang the call bell to get help. The DON agreed that CNA#1 didn't follow the plan of care for Resident #2. During an interview with the surveyor on 9/1/17 at 12:20 PM, UM #1 stated, the plan of care indicated that 1 CNA from the Annex and 1 CNA from the B hall are to be in the feeding room. Then UM stated RN #1 did come to the dining room and assisted with feeding (Resident #3). They (Resident #1 and Resident #2) were place at 2 separate tables. RN (#1) took one child and left to go back to her unit. Being from a different unit, she was not aware that 2 staff were to be in that room. CNA (#1) did not inform the RN (#1) of the care plan. She should have told the RN not to leave or should have used the call bell for help. I spoke with CNA (#1), that guidelines are not to have (Resident #2) in the same group with another ambulatory child. (CNA #1) was told, she must call the charge nurse. {Resident #1) and (Resident #2) should not be in the same feeding group. They should be in separate rooms. During an interview with the surveyor on 9/1/17 at 1:15 PM, CNA #2 stated, (Resident #1 and Resident #2) are not supposed to be in the same room. The plan of care was put into place to separate (Resident #2) from other kids. Protocol is strictly enforced. reminders are given constantly. A nurse will check protocol is enforced and the UM sends weekly e-mails with teaching. During an interview with the surveyor on 9/1/17 at 1:30 PM, CNA #3 stated, We need to make sure (Resident #2) eats in the cafeteria with one CNA separate from the rest of the feeders. Whoever is with (Resident #2) brings him/her to the feeding room. We cannot leave him/her in his/her unit by him/herself so we take him/her with us until another aide (CNA) comes to take him/her to the cafeteria. (Resident #2's) behavior is he/she pushes. I never saw him/her hit before. After the incident we were re-instructed that (Resident #2) is not to be in the room with (Resident #1) or any other children. Also (Resident #2) is on 1:1 and is to eat in the cafeteria, not the small dining room. During an interview with the surveyor on 9/1/17 at 2:35 PM, RN #1 stated, I was not aware of the protocol for (Resident #2). I do not work on that unit. I would have stayed or would have asked someone to go in there. (Resident#2) had spilled some food on the floor and I instructed him/her to clean up his/her mess. He/she got up, got the broom and dust pan and swept up the floor. He/she followed directions, put it all back in place. He/she did not display any aggression. Normally he/she would escalate but no outbursts and no aggressive behavior from him/her. We were inserviced on the protocol after the incident. During an interview with the surveyor on 9/1/17 at 3:40 PM, Supervisor #2 stated, I and (Supervisor #1) started the investigation after we were informed of the incident on 8/25/17. When I saw (Resident #1), he/she was at the nursing station and his/her right eye, below the eye in the outer corner, was bleeding. (Supervisor #1) spoke with CNA (#1) and got her statement. I put ice over the eye and started the paperwork for the transfer. Review of the DON's Summary of Event August 25, 2017 is as follows: Resident (#1) was in feeding group at 17:00 where (he/she) suffered an injury to (his/her) left (sic. right) eye by another resident resulting in transfer to (Hospital). (He/she) was diagnosed with [REDACTED]. According to the CNA, (Resident #2) was finished (his/her) dinner and wanted to immediately go to the Rec Area. (CNA #1) was busy feeding (Unsampled Resident A) and she told (him/her) to wait. (He/she) started to push the table where the other children were sitting at. (He/she) then started to move (Unsampled Resident A's) chair as well and was essentially told to stop. At that point, (Resident #1) was up from the table and went into the resident bathroom, which is right next to the table and chairs. (Resident #2) proceeded to follow (him/her) there. According to (CNA #1), she told them both to have a seat and briefly turned her back to both of them while she was cleaning up. She turned around and (Resident #1) was on the floor crying and she saw (Resident #2) standing next to (him/her) laughing. It was at that time she noticed that (Resident #1) was on the floor, (his/her) glasses off and (he/she) had a bruised right eye. (Resident #1) stated that (Resident #2) hit him. According to (CNA #1), she did not see the mechanism of injury. Findings/Plan of Action. 1) According to (CNA #1) she was aware of the Feeding Group guidelines but felt she was able to handle by placing them at two separate tables. (CNA #1) was reminded by the Nurse Manager and expectations set. 2) Resident (#2) was immediately placed on a continual 1:1 until such time the medical staff feels it can be removed. 3) The Behavioral Team had reviewed and discussed (Resident #2's) behavior prior to the event and there was an increase in his psychotropic drugs. The Behavioral Team will continue to monitor (his/her) behaviors. (His/her) care plan and orders were reviewed and adjusted accordingly. NJAC 8:39 - 4.1 (a) 5

C# NJ Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statues 45:11-23. Definitions b. 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 well being, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem. 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 of licensed or otherwise legally authorized physician or dentist. Based on observation, interviews and medical record review, it was determined that the facility failed to administer medications according to physician orders, facility policy, and acceptable nursing standards of practice for 1 of 2 nurses observed during the medication pass. At 8:30 a.m. on 6/22/2016, the Licensed Practical Nurse (LPN #1) did not provide proper positioning or check for tube placement for a resident receiving feeding, flushes and medications via gastrostomy tube (GT) for Resident #1. The Immediate Jeopardy (IJ) was identified by the surveyor on 6/22/16 at 8:30 a.m., when during the medication pass the surveyor observed LPN #1 administering medications via (GT) while Resident #1 was lying completely flat and failing to check for placement of the GT, which placed the resident at immediate risk for aspiration. The Administrator and the Director of Nursing (DON) were notified on 6/22/2016 at 9:00 a.m. The IJ was corrected on 6/22/16 at 3:00 p.m. based on an acceptable plan of correction which was implemented by the facility. This deficient practice was evidenced by the following: On 6/22/16 at 8:15 a.m., LPN #1 prepared and administered the following liquid medications: [REDACTED]. LPN #1 mixed all of these medication together and poured them into an 8-ounce (oz) cup. Then, using another cup, LPN #1 prepared and administered 1 crushed Vitamin D-3 tablet in 4 oz. of water. When two surveyors and LPN #1 entered Resident #1's room, the feeding was not running. The resident was observed lying completely flat in bed. LPN #1 removed the bedding away and lifted the resident shirt to access the GT. The LPN used a 60 cc piston syringe to draw up the medications from each cup. LPN #1, then pushed the medications into the resident's GT. At this time, the surveyor observed that LPN #1 neither elevated Resident #1's head of the bed nor checked for placement of the GT prior to administering the medications. LPN #1 did not enter the room with a stethoscope nor was one available for her to use inside the room to check for tube placement. When interviewed by the surveyor at this time, LPN #1 stated, Resident #1 did not have any restrictions with regards to elevating the head of the bed. LPN #1 stated she should have elevated the head of Resident #1's bed to a 30-45-degree angle to prevent the resident from aspirating. Upon further surveyor inquiry about the resident's position, LPN #1 elevated the head of the resident's bed to a 45-degree angle. At 9:00 a.m. the surveyor informed the Administrator and the Director of Nursing (DON) of the aforementioned incident. During an interview conducted on 6/22/16 at 9:05 a.m., the DON confirmed Resident #1 should not have been lying in a flat position in bed, while the LPN was administering medications via GT. The DON stated that he believed that this was a standard of practice to elevate the head of the bed during the administration of medication via GT. The DON also stated that he was not sure about it being a facility policy and would have to get back to the surveyor later with additional information. During a follow-up interview on 6/22/16 at 10:00 a.m., the DON stated, leaving Resident #1 in a flat position could cause the resident to aspirate the medications and/or flushes. In addition, the DON stated the LPN should have elevated Resident #1's head of the bed and checked for proper placement of the tube prior to administering any medications. When interviewed 06/22/16 at 11:00 a.m., the Registered Nurse/Educator (RNE) said that it was the facility's policy to elevate the head of the bed and to check for the tube placement prior, between and after feedings, flushes and medications. A review of the LPN's medication pass worksheet dated 4/25/16 lacked documentation that the LPN had been observed by the nursing supervisor while administering medication via GT. The RNE said a nursing supervisor had performed the medication pass and she could not provide any additional information. The RNE said that the supervisor was not available for interview because she had worked the previous night and was home sleeping. The immediate jeopardy was corrected on 6/22/16 at 3:00 p.m. based on an acceptable plan of correction, which was verified by the survey team. The plan included the following: 1. (Resident #1's), head of the bed was elevated and was evaluated by the medical staff for any signs or symptoms of aspiration. The resident will be evaluated for 48 hours for any signs or symptoms of aspiration. Upon examination, findings were normal. In addition, the family was notified regarding the incident. The medication nurse was removed from continuing her medication pass and all other children who received medications from her were evaluated with no medical findings. All nursing staff in the building, were in-serviced regarding the deficiency to insure full compliance. Immediate repositioning of the resident was done. Vital signs and assessment were conducted with on-going monitoring every shift over the next three days for adverse reaction. 2. All residents have the potential to be affected by this practice. 3. Medications Administration Policy NO. 805 has been updated. Elevating the head of the bed is the standard of practice during the administration of medications, flushes and feeding for all residents whereas not contraindicated. All nursing staff will be in-service on the policy update on all shifts until completed. More specifically, the medication nurse found to be deficient will be remove from further medication administration & re-educated. She will shadow a medication nurse for two days and then observed administering medications for two additional days by the nurse educator/designee to evaluate her competency to administer medications. Once deemed competent by the nurse manager, she will be allowed to administer medications. 4. Further clarification, Medications Administration Policy NO. 805A, requires that an aspirate (J-Tube auscultation only) be obtained to confirm placement of a tube when a feeding is not running. If no residual, confirmation must be by auscultation. The policy was amended to add actual volume for aspirate as a minimum of 5 milliliters (ml) for gastric tubes only. All tubes (feeding attached or not) must be flushed with 10-30 ml before and after medication administration is completed, or otherwise volumes stated by physician. The policy was amended to define push slowly as 5-15 seconds, depending on the volume. 5. All nurses who administer medications will be monitored by the Nurse Managers/Designee to ensure 100% compliance during a Med-Pass. In addition, random spot checks will also be conducted on all shifts. These results will be reported weekly to the Director of Nursing who subsequently will report these to the Performance Committee monthly. This monitoring will be ongoing. Completion date 6/22/2016 & ongoing. NJAC: 8:39-27.1(a) Refer to F-322

C# NJ Based on observation, interviews and record review, it was determined that the facility failed to: provide proper positioning for a resident receiving feedings, flushes and medications via gastrostomy tube (GT) during a medication administration, and ensured that a Licensed Practical Nurse (LPN #1) had received proper training in the area of administering medications via GT tube. This resulted in an immediate jeopardy situation for 1 of 3 residents (Resident #1), receiving medications and/or flushes via (GT) to a resident who was dependent on staff for all care needs, had severe cognitive impairments, a history of poor swallowing capability and was at high risk for aspiration. The immediate jeopardy was identified on 6/22/16 at 8:30 a.m., when during the medication pass the surveyor observed LPN #1 administering medications via GT while Resident #1 was lying completely flat and failing to check for placement of the GT, which placed the resident at immediate risk for aspiration. It was corrected at 8:35 a.m. after inquiry by the surveyor and elevating the head of the bed by LPN #1. The immediate jeopardy was identified on 6/22/16 at 8:30 a.m. and the immediacy was corrected at that time. A plan of correction was submitted to the team at 3:00 p.m. and was reviewed, accepted and verified by the team. The deficient practice for the immediate jeopardy situation was evidenced by: During the medication pass conducted by the surveyor on 6/22/16 at 8:15 a.m., the surveyor observed LPN #1 prepare and administer the following liquid medications to Resident #1 via GT. LPN #1 poured a Multi-Vitamin 15 milliliters (ml), [MEDICATION NAME] (a stool softener) 12.5 ml, [MEDICATION NAME] (an anti-convulsant) 12 ml, [MEDICATION NAME] (a Barbiturate) 5 ml and an Iron Supplement (5 ml). LPN #1 mixed all of these medication together and poured them into an 8-ounce (oz) cup. Then, using another cup, LPN #1 prepared and administered 1 crushed Vitamin D-3 tablet in 4 oz. of water. When two surveyors and LPN #1 entered Resident # 1's room, the feeding was not running. The resident was observed lying completely flat in bed. LPN #1 removed Resident #1's bedding away and lifted the resident's shirt to access the resident's GT. The LPN used a 60 cc piston syringe to draw up the medications from each cup. The LPN pushed the medications into the Resident #1's GT. At this time, the surveyor observed that LPN #1 neither elevated the head of Resident #1's bed nor checked for placement of the tube prior to administering the medications. LPN#1 failed to flush the tube prior to administering and/or in between medications. In addition, the surveyor observed that LPN #1 entered the room without a stethoscope nor was one available for her inside the room to check for placement of the tube. When interviewed by the surveyor at this time, LPN #1 stated, Resident #1's did not have any restrictions with regards to elevating the head of the bed. LPN #1 stated she should have elevated Resident #1's bed to a 30-45-degree angle to prevent the resident from aspirating and checked the tube for placement prior to administering the medications. Upon further surveyor inquiry about the resident's position, LPN #1 elevated the head of the resident's bed to a 45-degree angle. At 9:00 a.m. the surveyor informed the Administrator and the Director of Nursing (DON) of the aforementioned incident. During an interview conducted on 6/22/16 at 9:05 a.m., the DON confirmed Resident #1 should not have been lying in a flat position in bed, while the LPN was administering medications via GT. The DON stated that he believed that this was a standard of practice to elevate the bed during the administration of medications via GT. The DON also stated that he was not sure about it being a facility policy and would have to get back to the surveyor later with additional information. During a follow-up interview on 6/22/16 at 10:00 a.m., the DON stated leaving Resident #1 in a flat position could cause the resident to aspirate the liquid medications and/or flushes. In addition, the DON stated, the LPN should have elevated Resident #1's head of the bed and checked for proper placement of the tube prior to administering any medications. When interviewed 06/22/16 at 11:00 a.m., the Registered Nurse/Educator (RNE) said that it was the facility's policy to elevate the head of the bed and to check for the tube placement prior, between and after feedings, flushes and medications. On 6/22/16, the surveyor reviewed Resident #1's medical record. According to the Transfer/Discharge Report Sheet, Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS) an assessment tool dated 5/13/16, indicated Resident #1 had severe cognitive impairment, required extensive assistance from staff for turning from side to side while in bed and transferring from the bed and into a chair. The MDS also identified the resident required nutrition via a feeding tube. Resident #5's care plan dated 6/08/16 indicated Resident #1 was unable to consume any food by mouth and was at risk for aspiration. The interventions listed on the resident's care plan required for staff to administer Enteral Feedings and water bolus via GT by gravity slowly. A review of the facility's policy for Medication Administration dated 1/01 and revised 7/15 instructed the nurses during the instillation of medication into a nasogastric tube (NG), gastrostomy tube (GT), gastrojejunal tube (GJ) or jejunal tube (JT), placement must be confirmed prior to instillation. Residuals should be checked for NGs, GTs, or GT ports of GJs. If no residual is obtained, then placement must be checked by abdominal auscultation. A review of the facility's policy for Medication Administration Via [DEVICE]/N[DEVICE]/J-Tube dated 12/2/97 and revised 11/2015 instructed the nurses to check for placement as per policy prior to administering medications. If feeding is running, you do not have to check placement. Flush tube with 10-30 ml of water pre and post medication if tube feeding is not infusing, or as per physician order. The immediate jeopardy was corrected on 6/22/16 at 3:00 p.m. based on an acceptable plan of correction which was verified by the survey team. The plan included the following: 1. (Resident #1's), head of the bed was elevated and was evaluated by the medical staff for any signs or symptoms of aspiration. The resident will be evaluated for 48 hours for any signs or symptoms of aspiration. Upon examination, findings were normal. In addition, the family was notified regarding the incident. The medication nurse was removed from continuing her medication pass and all other children who received medications from her were evaluated with no medical findings. All nursing staff in the building, were in-serviced regarding the deficiency to insure full compliance. Immediate repositioning of the resident was done. Vital signs and assessment were conducted with on-going monitoring every shift over the next three days for adverse reaction. 2. All residents have the potential to be affected by this practice. 3. Medications Administration Policy NO. 805 has been updated. Elevating the head of the bed is the standard of practice during the administration of medications, flushes and feeding for all residents whereas not contraindicated. All nursing staff will be in-service on the policy update on all shifts until completed. More specifically, the medication nurse found to be deficient will be remove from further medication administration & re-educated. She will shadow a medication nurse for two days and then observed administering medications for two additional days by the nurse educator/designee to evaluate her competency to administer medications. Once deemed competent by the nurse manager, she will be allowed to administer medications. 4. Further clarification, Medications Administration Policy NO. 805A, requires that an aspirate (J-Tube auscultation only) be obtained to confirm placement of a tube when a feeding is not running. If no residual, confirmation must be by auscultation. The policy was amended to add actual volume for aspirate as a minimum of 5 milliliters (ml) for gastric tubes only. All tubes (feeding attached or not) must be flushed with 10-30 ml before and after medication administration is completed, or otherwise volumes stated by physician. The policy was amended to define push slowly as 5-15 seconds, depending on the volume. 5. All nurses who administer medications will be monitored by the Nurse Managers/Designee to ensure 100% compliance during a Med-Pass. In addition, random spot checks will also be conducted on all shifts. These results will be reported weekly to the Director of Nursing who subsequently will report these to the Performance Committee monthly. This monitoring will be ongoing. Completion date 6/22/2016 & ongoing. NJAC 8:39-27.1 (a)