**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** PART A: NJ Complaint #: 163766 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to (a) ensure there was emergency tracheostomy equipment for a resident with a tracheostomy (a surgical opening in the neck to provide an airway and remove secretions from the lungs), and (b) ensure staff were trained to use the emergency equipment in case of displacement of the tracheostomy tube for one (1) of 1 resident (Resident #313) reviewed with a tracheostomy. Resident #313 was admitted to the facility with a tracheostomy (trach). A review of the Progress Notes revealed that the resident was sent to the hospital on two occasions, on 03/30/23 for not having tracheostomy supplies, and on 04/6/23 for decannulation (removal) of the trach. During an interview with the surveyor, the pulmonologist stated that the resident was admitted to the facility without the proper tracheostomy supplies (inner cannula, ambu bag, and an extra trach) and if the tracheostomy came out, there was no replacement, and that the facility did not know when the supplies would arrive. The pulmonologist sent the resident to the hospital twice on 03/30/23 and on 04/6/23 because there were no supplies for the resident. The surveyor interviewed LPN #1 who stated she cared for Resident # 313 but did not have education for taking care of a resident with a trach. She further stated that there were no tracheostomy supplies at the bedside or at the facility. The facility's failure to ensure there was emergency equipment in the resident's room and failure to ensure staff were trained to use the emergency equipment in case of the displacement of the tracheostomy tube placed the resident at risk for serious harm, serious impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 03/23/23 when the resident was admitted to the facility and was transferred to the hospital on [DATE] and 04/6/23 because there were no tracheostomy supplies at the bedside or in the facility in addition to ensuring that all staff caring for Resident #313 were trained. The Licensed Nursing Home Administrator (LNHA), the [NAME] President of Operations (VPO), the Director of Nursing (DON), the Regional DON (RDON), and the [NAME] President of Clinicals Services (VPCS) were informed of the IJ on 09/30/24 at 4:58 PM. The facility submitted an acceptable Removal Plan (RP) on 10/1/24 at 1:00 PM. The survey team verified the implementation of the (RP) during the continuation of the on-site survey on 10/1/24. The evidence was as follows: A review of the facility's undated Tracheostomy Care policy revealed Tracheostomy care and suctioning shall be performed as necessary to maintain a clear airway and to prevent infection. The purpose of tracheostomy care is to maintain a patent airway; to keep the tracheostomy area clean and free of irritation and infection; and to prevent the tracheostomy tube from being coughed or pulled out. Equipment needed included but not limited to a. oxygen set up including oxygen concentrator, oxygen humidifier bottle, oxygen flow meter, oxygen tubing/trach collar, b. Suctioning set up including portable suction machine, sterile tracheostomy care tray, suction gauge, sterile Sodium Chloride irrigation and c. Other: stethoscope, sterile disposable suction catheter kits for PRN (as needed) suctioning and replacement inner cannulas. The policy further indicated under SPECIAL NOTE: 1. Never remove outer cannula: this is changed only by a Physician and 2. Be careful not to dislodge the Tracheostomy Tube. On 09/30/24, the surveyor reviewed the closed record of Resident #313. A review of the admission Record documented that Resident #313 had diagnoses which included, but were not limited to, acute respiratory failure with hypoxia (low levels of oxygen in your body tissues), tracheostomy (trach), asthma, cocaine abuse, alcohol dependence, and homelessness. The admission Minimum Data Set (MDS), an assessment tool, dated 03/29/23, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. The MDS further indicated that the resident had a tracheostomy and received oxygen and suctioning. A review of Resident #313's Care Plan, initiated on 03/24/23 and revised on 04/06/24, included a focus for a tracheostomy related to acute respiratory failure with interventions that included to ensure trach ties were secured at all times, monitor/document for restlessness, agitation, confusion, increased heartbeat and bradycardia (decreased heart rate), good oral care and suction as necessary. The surveyor reviewed Resident #313's physicians orders (PO) dated 03/24/23 with a discontinued date of 04/18/23, which included the following: Give oxygen @(specify) via trach, mask continuous with (specify)% humidified air every shift for trach care. Suction tracheostomy tube as needed for patency or to keep the airway open. Suction tracheostomies tube every shift for patency or to keep the airway open AND as needed for patency or to keep the airway open. Tracheostomy Care every shift every shift for Trach Care. Tracheostomy care every shift as needed. Tracheostomy Size: 7.5 every shift for Tracheostomy Monitoring. A review of the Admit/Readmit Evaluation Assessment, dated 03/23/23 at 22:20 (10:20 PM), revealed that Resident #313 had an occasional cough and a tracheostomy size 7.5 cuffed. The nurse did not document if the resident was on oxygen, or if the resident had a trach collar (a soft plastic mask that fits over the trach to deliver humified air or oxygen directly to the trach) or humidification. A review of the admitting nurse (LPN #6) admission summary dated [DATE] at 22:40 (10:40 PM), revealed that Resident #313 was admitted to the facility with a 7.5 sized trach .able to make needs known by writing on the dry erase board, and call bell within reach and uses it frequently. A review of the Pulmonary Advanced Practice Nurse (APN #2) PN, dated 03/30/23 at 14:00 (2:00 PM), revealed that the resident was sent to the emergency room (ER) as the facility did not have equipment available for the resident's trach care and was unsure when they would get it [no ambu bag (a device used to provide respiratory support to patients in emergency and non-emergency situations), no inner cannula (a tube within the outer tube which can be removed and cleaned easily, without having to change the whole, outer tracheostomy tube), and no replacement trachs]. The progress notes also revealed that the case was discussed with nursing, and the primary care team were aware of the plan. A review of a nurse's note, dated 03/30/23 at 14:00 (2:00 PM), revealed that the resident was sent to the emergency room (ER) to replace the resident ' s trach inner cannula with a size 7.5. APN #2 saw the resident at the bedside and agreed for the resident to be sent to the ER. A review of the APN #2's Physicians Order, dated 03/31/23, revealed the following: Tracheostomy Type: [Name redacted] trach Size:8UN85H Routine trach care daily and as needed, change fastener weekly, and please order 3 appropriately sized tracheostomies to keep at the bedside, I will change the trach at my next visit. Please also order a box of appropriately sized inner cannulas to keep at the bedside. A review of a nurses note dated, 04/05/23 at 21:31(9:31 PM), revealed that the resident was sent to the ER for decannulation (removing) of the trach. A review of a PN that was written by the APN #2, dated 04/06/23 (late entry), reflected that a call was placed to the nursing supervisor at the acute hospital and supplies were obtained for the bedside by that provider. The progress notes also revealed that the case was discussed with nursing and primary care team aware of plan. On 09/30/24 at 12:55 PM, the surveyor interviewed LPN #4 who stated she had been employed at the facility for about a year and had not had a resident with a tracheostomy. LPN #4 stated that a resident admitted with a tracheostomy would need supplies kept at the bedside that would include oxygen set up, suction machine, extra tracheostomies, trach ties, and drain sponge pads. LPN#4 further stated that the Unit Manager (UM), Director of Nursing (DON) or admitting nurse would be responsible to make sure all equipment and supplies were in the resident's room before the resident was admitted . On 09/30/24 at 12;43 PM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) who had been employed with the facility since July 2024 who stated she had not had an admission with a tracheostomy. The LPN/UM further stated that a resident who had a tracheostomy should have the following supplies and equipment at the bedside: a compressor, oxygen set up, suction machine, ambu bag, trach supplies including trach collars, suction catheters, drain sponges, and extra trachs and inner cannulas in case of an emergency and that the Unit Manager would be responsible to ensure all trach supplies and equipment were in the resident's room prior to admission. The LPN/UM further stated that if they needed any supplies, they would notify Central Supply (CS). On 09/30/24 at 1:17 PM, the surveyor interviewed the Admissions Coordinator (AC) who stated she was previously an external liaison, but for the past two weeks has been employed as the AC. The AC stated that when a resident was admitted to the facility with a tracheostomy, the external liaison would provide the admissions director with the size of the trach and any oxygen requirements, then admissions would notify the unit and make sure the facility had all the necessary equipment needed prior to admission which would include; trach size, suction machine, oxygen tubing, and an ambu bag at the bedside. The AC added, I am not sure if respiratory or nursing would set up the room. On 09/30/24 at 1:33 PM, the surveyor conducted a telephone interview with the attending physician (MD) who reviewed the progress notes written by APN #1. The MD then reviewed the APN #2's note from 03/30/24 and stated he was not aware that APN #2 documented that the trachs, inner cannulas, or ambu bag were not at the bedside. The MD further stated that the facility usually would have supplies and equipment at the bedside for emergencies. The MD stated he would further review the medical records and call the surveyor back with any further information. The surveyor did not receive a return call from the MD. On 09/30/24 at 2:08 PM, the surveyor conducted a telephone interview with APN#2 who stated that Resident #313 was admitted to the facility without the proper trach supplies (inner cannula, ambu bag and extra trachs) and if the trach came out there would be no replacement at the bedside and at the facility. APN#2 stated the reason she sent Resident #313 to the ER on [DATE] was because the facility did not have the supplies at the facility and did not know when they would get the supplies. APN #2 stated she saw the resident again on 04/06/23 and the trach supplies were still not at the bedside (extra trachs and inner cannulas). APN #2 further stated she had notified the nurse at the desk but did not remember their name and notified the nursing supervisor. APN #2 stated that she spoke with the nursing supervisor at the acute hospital and told them that the resident was sent back from the ER without a spare trach or inner cannulas and either they provide the supplies, or she was sending the resident back to the ER. APN #2 stated she obtained the extra trachs and inner cannulas from the acute hospital and placed them at the resident's bedside. APN #2 further stated that it was important for a resident with a trach to have extra trachs and inner cannulas at the bedside because if the trach got plugged you need to take out the inner cannula and replace it or if the trach comes out you need another trach to put in for airway protection. On 09/30/24 at 2:47 PM, the surveyor interviewed the DON who stated she has been employed at the facility since May 2023 and confirmed that the facility had not admitted a resident with a tracheostomy since Resident # 313. The DON further stated that a resident admitted with a trach should have all supplies and equipment at the bedside prior to admission which includes: oxygen, suction machine, trach sizes (one up and one down sized trach) ambu-bag, inner cannulas, and drain sponges. The resident should have what they need prior to admission, or we shouldn't admit them. The DON further stated, The importance of having all supplies at the bedside is to prevent respiratory distress. On 09/30/24 at 3:06 PM, the surveyor conducted a telephone interviewed with LPN # 1 who stated that she was an agency nurse who worked the 11 PM to 7 AM shift when Resident #313 was admitted to the facility. LPN #1 further stated that she had not received education for tracheostomy care through her agency or the facility. LPN #1 stated, I remember that situation, because it was crazy. LPN #1 stated that when the resident was admitted to the facility, the room was not set up with supplies for a resident with a trach. LPN #1 stated the first night the resident came in we did not have anything, and I did not have a key to get anything. LPN #1 stated that the resident needed a suction canister, the cleaning thing for the resident ' s trach but there wasn't anything. LPN #1 stated that she was scrambling for supplies. LPN #1 stated, I remember [the resident ' s] trach was a 7.5, but I did not have any extra trachs or inner cannulas. LPN #1 stated that she had to set up the oxygen and use an oxygen mask over the trach because we did not have a trach collar mask. LPN #1 stated, This was my first trach patient ever, and we did not have the inner cannulas. LPN #1 further stated the next morning she stayed and told Central Supply (CS) that the supplies were needed. LPN #1 further stated that the second night on the 11 PM to 7 AM shift, she called a nurse from the second floor (LPN #2) who came to the unit and helped her to get all the supplies that were needed and set up the resident's room. LPN #1 stated, We had everything except the extra trachs and inner cannulas. She further stated, We needed the inner cannulas to take them in and out and we never got them. I remember the resident was having trouble breathing and I took out the inner cannula and it was dry. I had to clean it and put the same one back in. We had to keep cleaning the one (same) inner cannula we had when [the resident] came from the hospital. On 10/01/23 at 9:01 AM, the surveyor interviewed the CS staff who stated he had worked in central supply for about 5 years. The CS staff stated that admissions, the DON, or the UM were supposed to notify him prior to admission if a trach resident was to be admitted . The CS stated, Yes, I remember Resident #313. I was notified by admissions on the day [the resident] was admitted but I had already left for the day. He explained admissions notified him through [name redacted - a free, cross-platform messaging service application], the facility used when he was already at home. The CS stated, I had all the supplies in central supply including suction machine, tubing, concentrator, water, trach size #4 or #6. If I'm not here to set up the room with the supplies, it's up to the nurses to get the supplies. I may not have had the inner cannula tubes, but I had all the other supplies. I remember what I had in stock at that time trach #4, #5 and #6 and I think the resident had a #4 trach. I came in the next morning and brought all the trach supplies to the resident's room. On 10/01/24 at 1:53 PM, the surveyor conducted a telephone interview with LPN #6 who stated she was an agency nurse who had admitted Resident #313 on the 3 PM to 11 PM shift. LPN #6 stated yes, I remember that resident. The facility had trach sizes in house but not his size and that was an issue. The inner cannula was the wrong size. We did not have [the resident's] size inner cannula in the facility, we had smaller trachs but not the resident's size. LPN #6 further stated the facility was not prepared to take care of a trach patient; no one knew what to do with the resident. LPN #6 stated she did not receive education regarding trach care at the facility but had worked previously with trachs and ventilators at other facilities. LPN #6 concluded I feel the staff were afraid to take care of a trach. On 10/01/24 at 2:23 PM, the surveyor conducted a telephone interview with Resident #313's family representative (FR). The FR stated that when the resident was admitted to the facility, the facility had very little supplies and they were trying to get all the supplies that was needed. The FR further stated the facility did not have any inner cannulas and that they did not have the staff to do what needed to be done. The facility provided copies of Tracheotomy Care Competency skills list for LPN #1 and LPN #2. LPN #1 Tracheostomy Care Competency Skills Checklist was signed and dated as completed on 12/6/22. LPN #2's Tracheostomy Care Competency Skills Checklist was signed as completed on 11/09/23, after the resident was discharged . The surveyor requested to review the original, not copies, of the competencies for both LPNs but the facility was unable to provide the original checklists. An acceptable RP was received on 10/01/24 at 11:31 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: 1.) The DON conducted a house wide audit on 09/30/24 to resident physician orders and identified no additional residents with a trach were at the facility; 2.) The Assistant DON (ADON) completed education and in-servicing for all licensed staff on the location of trach supplies at the bedside and in the facility and to communicate the need for additional supplies on trach care and on trach care emergencies; 3.) the Pulmonologist was re-educated to inform the DON for trach supply related concerns should they arise in the future. The survey team verified the implementation of the removal plan during the continuation of the on-site survey on 10/01/24. The surveyor had requested the following information from 9/27/24 through 10/3/24: Staffing and assignments for the dates of 03/23/023 through 04/06/23; tracheostomy education or competencies for all staff who worked with Resident #313 from 03/23/23 through 04/06/23; timeclock/time sheets for the dates of 03/25/23 through 04/06/23; paper medical records that were not scanned into the electronic medical record, including after visit summaries from Resident #313's ER visits. On 10/03/24 at 10:45 AM, and the facility confirmed they were unable to provide the requested information. F695 remains a deficiency at a scope and severity of a D based on the following: PART B The facility further failed to (c) consistently document in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) that oxygen and respiratory related treatments were administered as ordered, (d) clarify physician orders for a resident with a tracheostomy, and (e) ensure that physician orders were accurately transcribed and followed for 1 of 4 residents (Resident #313) reviewed for respiratory care. A review of the March 2023 and April 2023 Order Summary Report and the March 2023 and April 2023 MARs and TARs for Resident #313 revealed that there was no documentation to indicate that the medications and treatments were administered as ordered on the following dates and times: 1.Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 3 ml inhale orally via nebulizer two times a day for SOB (shortness of breath)-Ordered 3/24/2023 0900 3/24/23, 04/9/23 2100 - 03/26/23, 04/6/23, 04/11/23, 04/12/23, 04/14/23 2. Acetylcysteine Solution 20 % 2 milliliter inhale orally every 12 hours for mucous secretions- Ordered 03/23/2023 0900- 03/24/23 2100-03/23/23 04/3/23, 04/06/23, 04/11/23, 04/12/23, 04/14/23 3. Give O2 @ (specify)via trach. mask continuous with (specify) % humidified air every shift for Trach Care-Ordered 03/24/23. Day shift- 03/28/23,03/29/23, 03/30/23 04/01/23, 04/05/23, 04/07/23, 04/12/23, 04/13/23, 04/14/23 Evening shift- 3/26/24, 3/27/24,3/30/24, 04/06/23, 04/10/23, 04/11/23, 0412/23, 04/13/23, 04/14/23, 04/17/23 Night shift 03/28/23, 04/08/23 4. Suction tracheostomy tube every shift for patency or to keep the airway open-Ordered 03/24/2023 Day shift-3/29/23, 03/30/23, 04/07/23. 04/12/23, 04/13/23, 04/14/23, 04/17/23 Evening shift-3/26/23, 03/27/23, 03/30/23, 04/06/23,04/10/23. 04/11/23, 04/12/23, 04/13/23, 04.14/23, 04/16/23 Night shift-3/28/24, 04/11/23 5.Tracheostomy Care every shift. every shift for Trach Care-Ordered 03/24/2023. Day shift-3/29/23, 03/03/30, 04/1/23, 04/07/23, 04/13/23, 04/14/23, 04/17/23 Evening shift-03/26/2, 03/27/23. 03/30/23, 04/6/23, 04/10/23, 04/11/23, 04/12/23, 04/13/23. 04/14/23, 04/16/23 Night shift-3/28/24, 04/10/23 A review of the Advanced Practice Nurse (APN #1) Progress Note (PN), dated 03/27/23 at 12:35 PM, revealed documentation of shortness of breath and to continue supplemental oxygen. There was no documentation of the trach size, oxygen liters and delivery method, or amount of oxygen humidification. This note was signed by the attending Medical Doctor (MD) on 04/01/23 at 11:19 PM. A review of the Pulmonary Advanced Practice Nurse (APN #2) PN, dated 03/30/23 at 14:00 (2:00 PM), revealed under the assessment and plan section, APN #2 documented to continue oxygen; monitor SpO2 (oxygen saturation); avoid hyperoxia (high oxygen levels); tracheostomy present *8UN85H (trach tube flexible cuffless 8.5 millimeter); tracheostomy care BID (twice a day), change tracheostomy every 8 weeks-next due on 05/01/23 and Humidified oxygen via TC (trach collar) at 38%. The progress notes also revealed that the case was discussed with nursing, and the primary care team were aware of the plan. A review of the March 2023 active physician's orders did not reflect a change in the PO to a Trach size of #8UN85H or the recommended oxygen and humidification. A PN that was written by the APN #2, dated 04/06/23 (late entry), reflected to continue oxygen; monitor SpO2 (oxygen saturation); avoid hyperoxia (high oxygen levels); tracheostomy present *8UN85H (trach tube flexible cuffless 8.5 millimeter); tracheostomy care BID (twice a day), change tracheostomy every 8 (eight) weeks-next due on 05/01/23 and Humidified oxygen via TC at 38%. The progress notes also revealed that the case was discussed with nursing and primary care team aware of plan. A review of APN #2's PO, dated 04/06/23, reflected the following: Please put patient on a humidified trach collar TODAY. Please have 3 (three) #6UN75h trachs at bedside. Please place 1 (one) box of appropriately sized inner cannulas at bedside. Trach care BID and as needed. Weekly trach tie changes. I will change the trach every 8 weeks while the patient is admitted . Suction PRN two times a day for trach care BID. A review of the April 2023 active physician's orders did not reflect a change in the PO to a trach size of #8UN85H or the recommended oxygen and humidification. A nurses note, dated 04/06/23 at 13:49 (1:49 PM), revealed that Resident #313 returned form the acute hospital with no new orders or discharge paperwork. The nurse called the hospital to see if the paperwork could be forwarded. A review of the sending hospital after visit summary and medical records from Resident's #313's acute hospitalization from 02/17/23 through 03/23/23 did not reveal any documentation of the size tracheostomy, oxygen or if humification was recommended. The following physicians order for oxygen were not clarified or transcribed during Resident#313's admission to the facility from 03/23/23 to 04/18/23: 1.Give O2 @ (specify)via trach. mask continuous with (specify) % humidified air every shift for Trach Care- Start Date 03/24/2023 0700-Hold Date from 04/05/2023 2135 to 04/06/2023 1347-Hold Date from 04/08/2023 1439 to 04/09/2023 2213-D/C Date 04/18/2023 0112. 2. [Name redacted] Size:8UN85H Routine trach care daily and as needed, change fastener weekly, and please order 3 appropriately sized tracheostomies to keep at the bedside, I will change the trach at my next visit. Please also order a box of appropriately sized inner cannulas to keep at the bedside. [NAME] one time a day for trach care. Ordered 03/31/23. 3. Please put patient on a humidified trach collar TODAY Please have 3 6UN75h trachs at bedside Please place 1 box of appropriately sized inner cannulas at bedside Trach card BID an as needed Weekly trach tie changes I will change the trach every 8 weeks while the patient is admitted Suction PRN two times a day for trach care BID. Ordered 04/06/23. On 10/01/24 at 10:18 AM, the surveyor interviewed LPN #3 who stated that when administering medications or treatments, the nurse should sign out the medications after they were given or completed and there should not be any blanks (not initialed as given) on the MAR or TAR. If there were blanks on the MAR or TAR it could mean that the nurse forgot to sign it out or forgot to do it. LPN #3 further stated If it wasn't documented, it wasn't done. LPN #3, in the presence of the surveyor, reviewed the oxygen Physician Order (PO), dated 03/23/23, and stated that the PO should have a specific number of liters of oxygen to be given and how the oxygen should be given. It was important to have a PO for oxygen because oxygen was a medication that needed to be prescribed by the doctor. When asked how the nurse would know how much oxygen to provide to Resident #313 with the PO as written, LPN #3 stated the nurses wouldn't know by that order. On 10/01/24 at 10:36 AM, the surveyor interviewed the LPN/UM who stated that all medication and treatment should be signed out as soon as they were administered. If there are blanks on the MARs and TARs, it was not done. The LPN/UM stated, If it's not documented, then it is not done. The LPN/UM further stated that if the resident was in the hospital, out of the facility or refused, there was a space to document why the medication or treatment was not given and there should not be any blanks in the MARs and TARs. At that time, the LPN/UM and the surveyor reviewed the above oxygen order dated 03/23/23 and the LPN/ UM stated that the order was an incomplete PO because it did not include how many liters of oxygen and the percentage of humified oxygen to administer to the resident. She further stated that the nurse should have called the doctor and clarified the oxygen order because oxygen was a medication. The LPN/UM, in the presence of the surveyor, reviewed the PO's as written below: 1.Please put patient on a humidified trach collar TODAY Please have 3 6UN75h trachs at bedside Please place 1 box of appropriately sized inner cannulas at bedside Trach card BID an as needed Weekly trach tie changes I will change the trach every 8 weeks while the patient is admitted Suction PRN two times a day for trach care BID. Ordered 03/31/23. 2.Tracheostomy Type: [Name redacted] Size:8UN85H Routine trach care daily and as needed, change fastener weekly, and please order 3 appropriately sized tracheostomies to keep at the bedside, I will change the trach at my next visit. Please also order a box of appropriately sized inner cannulas to keep at the bedside. [NAME] one time a day for trach care. Ordered 04/06/23. The LPN/ UM stated that the above orders should have been clarified because it had too many orders in one PO, and they were not transcribed onto the TAR. The LPN/UM further stated, the nurse should have called the doctor and clarified the order when the nurse acknowledged the PO in the electronic MAR or during the 24-hour chart check. On 10/01/24 at 12:03 PM, the surveyor interviewed the DON who stated that all medication and treatments were to be signed out upon rendering the treatment or medication and there should not be any blanks on the MARs and TARs. The DON, in the presence of the surveyor, reviewed the above oxygen and tracheostomy orders and the DON stated that the PO's should have been clarified either when the nurse acknowledged the order or during the 24-hour chart check. When a nurse acknowledged a PO, they would review the order to make sure it was a complete order and if they had any questions, they would call the doctor to get the order clarified. The DON confirmed that the physician orders were not ordered correctly and were not transcribed onto the MARs and TARs. The DON further stated the above POs should have been clarified because it was important to prevent respiratory distress in a resident with a tracheostomy. A review of the facility's Oxygen Administration policy, undated, indicated to verify that there is a physician order and to review the physician's orders or facility's procedure for oxygen administration. A review of the facility's Medication Orders policy undated, revealed that for Oxygen Orders to specify the rate of flow, route, and rationale (i.e., O2 (Oxygen) 2/3 L/min per nasal cannula prn SOB). A review of the facility's Physicians Orders policy undated, reflected that orders for medications must include a. Name and strength of the drug; b. Quantity and specific duration of therapy; c. Dosage and frequency of administration; d. Route of administration if other than oral; and e. Reason or problem for which given. A review of the facility's Charting/Documenting Policy undated, reflected that the purpose of these guidelines is to ensure complete comprehensive and timely documentation of the residents'/patient 'care, treatment, response to care, signs, symptoms, change in condition as well as the progress of the resident/patient. Under Medication Administration: the date and time medication administered on the Medical Administration Record. Document reason for refusal of medication on the nurses note. Initial of person in appropriate body on Medex. Under treatments: All treatments requiring a physician's order, or nursing intervention must be documented on Treatment Record. The Nurse completing the treatment must initial in the appropriate section on the record. A review the facility's Physician Order Chart check Policy,undated, included: is to ensure that physicians orders are correctly carried over from the (POS) Physician Order Summary to MAR/TAR. The 11pm -7am Nurse will: Review each chart checking for medication orders, lab orders, consultation sheets against the MAR/TAR and Lab book. if the order has been missed, the 11-7 nurse will transcribe the order sign that it was noted on the TAR/MAR/Lab sheet and sign the POS and fax it to the pharmacy. At the bottom of the POS the nurse will write 24-hour chart check and sign it. The nurse will review all newly admitted resident's medication orders and check that they were processed correctly as above and write 24-hour chart check on the admission POS and sign it. 4.The nurse will report any missed orders to the unit manager to educate staff members on the importance of accuracy in health care. NJAC 8:39 25.2(b), (c)4, 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT# 165731 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to identify a high-risk resident (Resident #1) who was complaining of feeling hot, sweaty and not feeling well and respond in a manner that adheres to professional standards of nursing practice to assess, identify, respond, and call the physician at the time when the resident was verbalizing a change in condition caused from environmental heat. There was no air conditioning in the resident's room, no fan, and the resident's room temperature exceeded 86 degrees Fahrenheit. Two LPN's and one RN who each saw Resident #1 stated that this was the resident's baseline. A night shift LPN stated that the resident might be admitted to hospice but was not on hospice service. The Nurse Practitioner arrived at 1:30 AM and assessed the resident and stated that this was not the resident's normal behavior or baseline and the resident had irregular heart rate and elevated blood pressure. The resident was sent to the hospital during the early morning hours of 7/16/23. Interview with the night shift agency LPN stated that she was aware of the heat situation in the facility but that she didn't need to do anything different for the residents, no additional monitoring, no additional vital signs. She stated that nobody told her anything extra that she needed to do. Symptoms of heat exhaustion include headache, nausea, dizziness, irritability, muscle cramps, sweating, thirst, elevated body temperature which can quickly lead to heat stroke when the body temperature can rise to 106 degrees F within 10-15 minutes of prolonged heat exposure, causing serious adverse health consequences, hospitalization and death. This resulted in an immediate jeopardy situation for Resident #1 who was known by the nurse to have known chronic respiratory diagnosis and utilized oxygen for respiratory relief. The resident had no fan and no air conditioner in the room and room temperature readings were in excess of 86 degrees. The Resident complained to the surveyor, it's hot, I'm sweating, and I don't feel good. Resident was perspiring and wiped the sweat from the forehead. The facility's failure to ensure room temperatures did not exceed 81 degrees with knowledge of the HVAC system not functioning on 7/6/23 but failed to implement measures to assess and maintain the resident's room temperature and failed to follow professional standards of practice when the resident complained of feeling hot, sweaty and not feeling good, act in an manner to prevent worsening of the condition by calling physician, intervening to address the lack of cooling in the room or offering to transporting the resident to another area of the building until surveyor inquiry. The immediate jeopardy began on 7/15/23. The facility was notified of the immediate situation on 7/16/23. An acceptable written Removal Plan was received on 7/17/23. The surveyors verified the Removal Plan on 7/19/23. The immediacy was lifted on 7/17/23. This deficient practice was identified for 1 of 1 residents reviewed for hospitalization on 7/16/23 (Resident #1). The evidence was as follows: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 7/15/23 at 5:02 PM, the surveyor arrived at the facility for an unannounced visit to investigate the issue regarding the malfunctioning air conditioning system at the facility. The surveyor noted that the local outdoor temperature at that time was 89 degrees Fahrenheit and humid. The surveyor entered through the main lobby and noted a heavy duty floor fan blowing air across the floor with a long extension cord. The surveyor observed a Security Guard (SG #2) at the front desk and the surveyor asked the SG #2 about the fan on the floor and he stated that he didn't know why it was there. He acknowledged that it was not there for a housekeeping reason. The surveyor asked if the facility had any issue with maintaining air temperatures in the building, and the SG #2 stated that he didn't know anything as he just started his shift and was filling in for someone else. At 5:07 PM, the surveyor interviewed the Registered Nurse/Supervisor (RN/S) who stated that he started the shift at 3 PM and that he took over for another nurse supervisor. At that time, the RN/S didn't want to answer any of the surveyor's questions and called the Director of Nursing (DON). At 5:09 PM, the surveyor conducted a phone interview with the DON. The DON stated that the air conditioning in the building was not functioning due to a sparking issue, and it had to be shut down, but that the facility had implemented hydration stations and ice in response. She stated that she did not know the mechanics of the issue but the Regional Maintenance was on-site working on the issue. She stated that he should be on the roof right now looking at the issue. She stated they had been working on resolving it since yesterday (Friday 7/14/23), because there was no air conditioning in the kitchen. She stated that the air conditioning only affected the kitchen yesterday and not the resident areas. She stated because they knew the weather was going to be hot today, they purchased fans and water stations for the resident units just as a precaution. The DON also added that a nurse called her today to inform her that the building was warm. The surveyor asked the DON when the sparking issue occurred that required the shut down of the system, and the DON could not speak to an exact date. She could not speak to air conditioning issues within the resident units adding no residents told her it was hot and no one complained to her. She stated that they purchased fans yesterday. The surveyor asked why they purchased fans for the residents if it was not hot indoors and if the air conditioning was functioning on the units, and the DON stated that it was because they anticipated the weather to be hot outside today and reiterated that it was just for an added precaution. The surveyor asked if she had been on the resident units and felt a difference in air temperature, and the DON replied that I'm tropical, so heat doesn't hit me like the rest. The DON stated that it may have been a bit warm, but since no one complained to her that it was hot in the building, it couldn't have been too hot. She continued to state that the Director of Maintenance purchased the fans and returned to the facility today to find out more about the status of the air conditioning system. The surveyor asked what floors were affected, and the DON stated that it was only the third floor far hallway that was affected, which was where they put all the fans. The surveyor asked if there were any fans brought to the second floor, and the DON replied that there were no fans on the second floor. The surveyor asked if there were any temperature checks being done on any of the resident units and the DON stated that she didn't know about any room temperature checks being done. A review of the facility's Emergency Procedure for Utility Outage revised October 2012 included the following: Monitor Residents to ensure they are safe and check resident-used medical equipment .see attached Severe Cold and Hot Weather Procedures to prevent .hyperpyrexia [very high fever] during loss of cooling functions. If the outage is long term and threatens resident safety and welfare, initiate Evacuation Procedures establish and maintain contact with local emergency responders to advise them of the situation and keep them informed of potential needs as the situation worsens. The situation is only deemed under control after the outages has been restored and the Incident Commander has declared the situation safe . The attached Severe Hot Weather Procedures included: When the facility temperature reaches 85 degrees Fahrenheit and remains so for four hours: 1. Move residents to another air-conditioned part of the facility, if available. 2. Encourage residents to take in more fluids and keep the residents hydrated. Force fluids if necessary and record fluid intake. 3. Provide cold wash cloths as needed. 4. Open windows to let cooler outside air in and utilize fans to move air. 5. Monitor body temperatures of the residents and notify attending physicians if necessary. 6. Notify 911 if a resident/staff member appears to be in danger of heat-related stress. 7. Evacuate residents if necessary. 8. Monitor environmental thermometers. 9. Notify Medical Director. The Emergency Operations Plan located within the Evacuation Plan revised 7/10/15 included response for a Heat Emergency. The facility is equipped with air condition in all common areas and individual units in each patient room. Temperatures in the facility must be 81 degrees Fahrenheit and below. Should the temperature start to rise above 79 degrees Fahrenheit the following procedures should take place: .Nursing: 1. Conduct facility rounds. 2. Complete preliminary visual survey of all residents to establish a baseline assessment of their conditions. Determine residents at greatest risk utilizing the following guidelines: a. significant weight loss, b. dialysis, c. total dependence on staff for nutrition, d. Residents requiring enteral nutrition, e. any resident that is compromised and/or determined to be at high risk. Note: not all residents with the condition(s) listed are necessarily at-risk. Other physical and lifestyle factors must be considered. 4. Collate listing of residents at greatest risk and implement measures to stabilize and/or reduce the risk. Interventions include but are not limited to: a. notification of physician of any condition change. b. COPD [Chronic Obstructive Pulmonary Disease] -monitor O2 [oxygen] saturation every four (4) hours or as condition warrants. 5. If the internal temperature of the facility reaches 80 degrees Fahrenheit, obtain temperatures on all residents a minimum of every four (4) hours or as condition warrants. 7. Relocate residents to cooler areas of facility, if possible, as conditions warrant. 8. Continue visual rounds a minimum of hourly. 9. Complete physical assessment as residents' conditions warrant. 10. Maintain lightweight clothing on all residents 11. Initiate continuation hydration cart 7:00 AM to 10:00 PM .12. Revise staffing as needed, to appropriately implement and maintain action plan. At 5:50 PM, the Executive Director (ED) who had been working at the facility for only two weeks, told the surveyor that room temperatures were not to exceed 81 degrees Fahrenheit (F) according to the regulation. At 5:59 PM, the surveyor was introduced to the Director of Maintenance (DoM) who stated that he had only been employed by the facility for approximately four months since March 2023. The DoM stated that the last few days it's been hot in the facility and that there had been issues with the air conditioning systems. He stated that the facility had several bids out since the beginning of July 2023, since there was a leak in one of the systems. He added that there was also an air handler with a bad condenser for the second floor. He continued, that in addition to the second floor, the third floor had an issue with the air conditioner system causing sparking which required the entire air conditioning system on 3-North to be shut off or there would be a fire. The DoM stated that they received a bid on July 6th to address the problem, but it was not processed until yesterday on 7/14/23, and the bid was for $1,200 or so to diagnose the problem. The surveyor requested documented evidence of that diagnostic visit from the company and the findings. He stated that he didn't have a copy of it, but that he would look into finding out if anyone did. At that time, the surveyor observed that the DoM was holding a clipboard and loose leaf paper with a hand-written heading P-TAC (Rooms) and a list of resident rooms written under it. It was not dated. The surveyor asked the DoM about the list, and he stated that he has not HVAC licensed, but that he had been working on changing the malfunctioning PTAC units in the resident rooms and had made a list. He stated that he started this list about two weeks ago when he began replacing the units. The list indicated that there were three rooms that had new PTAC units, rooms [ROOM NUMBER]. The DoM confirmed that those rooms he had replaced the PTAC units with new ones and that the other 18 rooms had PTAC units that did not work. He stated that the process of replacing them had been going slow because he was only one person. The surveyor asked what has been done for these other resident rooms when the PTAC units do not work due to the heat, and the DoM stated that they purchased ten portable air conditioner units and put some of them in resident rooms, in addition to the purchase of 30 fans. The surveyor requested a receipt of the purchases. The surveyor asked other than purchasing 30 fans and ten portable air conditioner units, what had been doing regarding the malfunctioned air conditioning and he added that he purchased four to five jugs of water at Home Depot yesterday and 12 bags of ice, but other than that he had not been doing anything else. The DoM stated that the air handlers won't be fixed for a few days but that there was no definitive date because the bid had only been processed yesterday. He stated that he should be checking room temperatures, and indicated he did check a temperature earlier and it read 83 degrees F in a resident area. The surveyor asked where and when that was taken, and he could not speak to it. The surveyor asked if he kept any logs of temperature readings while the air conditioning system had been malfunctioning or not working at full capacity and the DoM stated that there were no room temperature logs. He stated that the last time he kept a room temperature log was about a month ago and had given it to the former administrator but he's gone. The DoM confirmed there were no room temperature logs and could not speak to how the facility was monitoring for compliance with temperatures if they were not checking them over a given period of time and recording them. The DoM stated that the resident rooms were generally cooler than the hallways, but the DoM was unable to provide any documented evidence of that being the case. At 6:07 PM, the surveyor continued to interview the DoM who stated that he does not routinely check room temperatures but that he uses the thermostats on each floor to determine if temperatures needed to be checked on the floors and that he looks at the thermostats all day everyday. He stated that if the thermostats read above 81 degrees F, he would go and take temperatures of the resident rooms. At 6:18 PM, the surveyor and the DoM entered the Third Floor through the elevators. Upon exiting the elevator, the surveyor felt the floor to be very warm in the hallways. The surveyor observed with the DoM that there was no ice in the ice cooler. The surveyor and the DoM observed the thermostat reading for the front end of 3-West which indicated a reading of 69 degrees F, and the back end of 3-West thermostat read it was 80 degrees F. At 6:25 PM, the DoM took the surveyor to the 3-North unit. At that time the DoM reiterated that the thermostat for this unit had no reading, because the system had to be shut down due to sparking. He stated that the overload relay and heavy duty relay were both bad which caused the sparking and they shut the machine down on 7/6/23 because of the fire risk. He stated that the switch is located in the ceiling and acknowledged that because the switch was off, this was why there was no thermostat reading. A review of the weather history report for [NAME], New Jersey reflected the following outdoor temperatures since 7/6/23: 7/6/23: 91 degrees F, 7/7/23: 91 degrees F, 7/8/23: 90 degrees F, 7/9/23: 85 degrees F, 7/10/23: 86 degrees F, 7/11/23: 89 degrees F, 7/12/23: 91 degrees F, 7/13/23: 93 degrees F, 7/14/23: 89 degrees F, 7/15/23: 92 degrees F. At 6:29 PM, upon entering the 3-North wing the surveyor felt that the air on the unit was very hot and heavy causing the surveyor to feel sweaty instantly. As the surveyor and DoM toured the 3-North wing, the surveyor noted beads of sweat dripping from the DoM's forehead. The DoM acknowledged that it was very hot and uncomfortable on this unit. The DoM took the indoor temperature of the 3-North hallway which read 88 degrees F. The DoM with the surveyor began taking room temperatures on the 3-North Unit which included the following temperatures: room [ROOM NUMBER]: 82.6 degrees F. room [ROOM NUMBER]: 88.9 degrees F. There was no fan or air conditioner on in the residents' room and both residents were in bed. The DoM stated that the air conditioner was not turned on and he turned the PTAC air conditioner on. The surveyor attempted to interview the residents in that room but the residents who were both awake did not verbally respond to the surveyor. Both residents were visibly perspiring. At 6:33 PM, the surveyor observed the Licensed Practical Nurse (LPN #3) assigned to 3-North in the hallway passing out medications to residents. The LPN #3 stated that the temperatures on this floor were unsettling. The surveyor asked about the temperatures and if she had to do anything different in response to the heat situation on the unit, and she stated that she was assigned 29 residents this shift and that she just had to pass out medications, do wound care, check the IV's of residents and perform basic resident care. She stated that we can encourage hydration and take vital signs and skin turgor if a resident becomes confused, but otherwise there was nothing different that she had to do. The surveyor asked if any residents had to be hospitalized and she stated that there were none. At 6:35 PM, the DoM took the room temperature of Unsampled Resident #10 which read 92.1 degrees F. The resident was visibly perspiring in bed in the room by the door had no fan and no air conditioner. The room by the window had an orange fan on the floor positioned between the bed and the window. Any airflow that was being produced by the fan was getting blocked by the bed and not reaching the unsampled Resident #10. The window was slightly open. The surveyor attempted to interview the resident, but the resident appeared angry and refused to be interviewed. At that time, the LPN #3 entered the resident's room and took a set of vital signs. The resident's body temperature was 98.6 F, the heart rate was 76 beats per minute, the blood pressure was 116/66 and the pulse oxygenation status was 96% on room air. The surveyor did not see the LPN #3 stop and count a respiratory rate and she exited the room with the vital sign machine. Upon exiting the room, the LPN #3 stated that there was a resident (Resident #1) who had known respiratory ailments and utilized supplemental oxygen for respiratory support and resided a few doors down the hall. At approximately 6:38 PM, the surveyor continued to interview residents on 3-North. The surveyor observed unsampled Resident #11, who was visibly perspiring. The resident stated that it's a lot- hot! The resident continued to state, I am sweating and It's been hot in here like this since May adding that he/she has two fans and that the air conditioner in their room is broken. The resident continued to state that he/she had asthma and because of the heat, he/she had to utilize their respiratory inhaler with an extra five pumps, because it's so hot and it makes it hard to breathe. The resident stated that sometimes they were provided ice, but the facility didn't have ice to give out yesterday. The resident stated that he/she didn't think they had ice today either, and added that I bet you they don't [have ice] .Watch! At that time, the resident called for the LPN #3 to request for ice. The LPN #3 took the resident's cup to get ice, and she returned and stated that We don't have anymore ice .I will have to go and get more somewhere else in a little bit. The LPN #3 put the resident's cup back on their side table left the resident's room. The resident stated to the surveyor, See, no ice! The resident stated that they may get ice in the morning, but that was it. At approximately 6:40 PM, the surveyor observed Resident #1 in bed next to the window. The resident was visibly perspiring and the room felt hot. The resident had no fan and no air conditioning in the room. The surveyor interviewed the resident at that time, and the resident stated, It's hot! I'm sweating and the resident began to wipe sweat from his/her forehead. At that time the resident stated, I don't feel good and indicated that he/she was having a hard time breathing. The surveyor observed humidified supplemental oxygen running at six liters/minute from the wall, but the resident was not wearing the oxygen. The surveyor asked the resident if he/she utilized oxygen and the resident responded that he/she would put it back on and wear it. The surveyor observed the resident place the nasal cannula back onto their nose and take some deep breaths through the nose. The resident confirmed there was no fan or air conditioning in their room. The resident stated that he/she would get the nurse. At 6:58 PM, the surveyor and the ED took the room temperature of a recreation room on the 3rd floor which felt cool. There were three ambulatory residents in there but no staff. The ED stated that the air conditioner works in here. The temperature read 72.7 degrees F. At that time, the ED stated that heat is subjective to a person and that residents may be comfortable in this heat and not want to leave their rooms. He stated that as long as the residents health was okay, they have a right to stay in their rooms and if their health deteriorated from the heat, then they would remove them. The surveyor asked the ED why they would wait until a resident's health deteriorated before proactively addressing the issue for each resident regarding the room temperatures, and the ED stated that they need to be proactive and not wait, but if residents don't want to move, they don't have to. The surveyor inquired how the facility was keeping the residents' rooms at an acceptable temperature for those that may not want to move or those that cannot verbalize it, and the ED stated that they provide ice, or the staff can provide a cool cloth for their face to cool the body down, offer and provide fans, and some residents received portable air conditioning units. He acknowledged that not all residents have fans or air conditioner units despite their malfunctioning PTAC units in their room and the central air conditioning system within the unit. He acknowledged that when conducting tour, no residents had a cool cloth on them. At 6:59 PM, the surveyor and the ED returned to the room of unsampled Resident #10 who was in bed. There was still no air conditioning and the airflow of a floor fan was being blocked by the roommates bed. The room temperature reading read 89 degrees F. At 7:00 PM, the surveyor interviewed the ED. The surveyor asked about how the facility chose to prioritize the use of fans and portable air conditioner units when the air conditioning had malfunctioned in the facility. The ED acknowledged the surveyor's questions and acknowledged that 88.5 degrees was too hot for any residents and that they would move them to the recreation room. The ED stated that he didn't know if doctors were called or how often nurses check or should check the vital signs in this situation. He stated that the staff do go around asking if the residents are feeling okay or if they are hot. At that time, the surveyor followed up with the ED about if he found out who the Licensed Nursing Home Administrator (LNHA) is at the facility, since the ED was not licensed in New Jersey, and the ED stated that he did not have their name yet, but the reason the LNHA was not in the building today was because it was a Saturday for their religious [NAME]. At approximately 7:05 PM, the surveyor entered the DON's office with the ED. The DON was in her office which was adequately air conditioned. The DON provided the surveyor the name of the LNHA on record and stated that she doesn't know where he is, and that she tried calling him but he didn't answer the phone because it was Saturday and his religious [NAME]. The DON stated that she only started working at the facility again in May 2023, and that the Regional LNHA was the LNHA on record in May 2023. She stated that the new LNHA started on or around 6/1/23. The DON continued to explain again that the DoM informed her only yesterday about the air conditioner issue and the room temperatures. She stated that there was a previous issue with temperatures and the air conditioner system that needed replacement and explained, I don't know if its been replaced. The DON added that she was aware of a thermostat reading of 69 degrees F and a room that was 80 degrees F, but that fans and hydration stations were purchased yesterday because they knew it would be very hot outside the next day. The DON and ED acknowledged that there were no room temperature logs and that they never instructed anyone to take log temperatures. They acknowledged that if temperatures were not monitored and logged, how can the facility have knowledge of and act upon the temperatures, especially when outdoor temperatures were 89 degrees F. Temperatures of the second and third floors were discussed with the DON and ED and the residents complaining of it being hot, humid and that they were sweating. The DON began stating that the residents were comfortable and not in distress and didn't want to leave their rooms. She stated that no residents complained to her about the heat. The surveyor asked the DON if she would wait until the residents were in distress before responding to the lack of adequate temperature control in their facility, and the DON could not speak to it, insisting that the resident's were comfortable. The DON acknowledged that the interruption in air conditioning service wasn't reported to the NJDOH until today after the NJDOH had reached out to her. The DON stated that she believed the room temperature requirement was not to exceed 82 degrees F. She stated that she she was not aware that the air conditioner system was shut down on 7/6/23. At 7:23 PM, the surveyor and the New Jersey Department of Health (NJDOH) management who conferenced in telephonically, informed the DON and the ED that the facility's failure to maintain adequate room temperatures in accordance with regulatory requirements, implement a system to monitor room temperatures when the air conditioning systems were known to not be operational or not functioning at full capacity during the heat of the summer months, including today when it was 89 degrees F outside, failure to identify high-risk residents to ensure they had adequate temperature control to reduce the risk for a heat related emergency, with limited access to sufficient cooling areas in the facility placed all residents on both floors in an immediate safety risk situation that required the activation of their Emergency Response Plan and the local Office of Emergency Management (OEM). The ED stated he would find the phone number of the local OEM and notify them. At 7:46 PM, the surveyor returned to the 3-North unit and interviewed the unsampled Resident #12 who stated, I'm sweating and it takes hours to get anything. The resident's roommate, unsampled Resident #11 stated that he/she was also sweating and that no one has offered them cool cloths for comfort or ice and that he/she only sees staff every few hours. Both residents reported that no one has checked their vital signs today. At 7:52 PM, the surveyor saw Certified Nursing Aide (CNA #2) walking down the hallway, and she stated that she has been employed at the facility since May 2023 and informed the facility about the indoor room temperatures on 3-North stating, It's been hot for a while-weeks! At 7:56 PM, the surveyor interviewed the LPN #3 again who was assigned to 3 North. The surveyor requested the LPN #3 to provide a printed copy of the unit census, and the LPN #3 stated that she just started at the facility only a week ago and that she doesn't know how to print the census or the medical records for any resident. The surveyor asked if a resident was transferred to the hospital, how she would print out the records such as the Medication Administration Record (MAR) to go with the resident, and she stated that she would have to ask someone else to do it. The surveyor asked if she had been trained on Emergency Preparedness at the facility and how to respond, and the LPN #3 replied that she had not been trained. She stated that if there was an emergency, she wouldn't know what what to do and because she didn't know how to print documents, she acknowledged it would make it difficult to send residents elsewhere with their electronic medical records. At 8:07 PM, the ED informed the surveyor he left a voicemail for the local OEM regarding the facility's indoor heat situation. At 8:18 PM, the surveyor noted the new outdoor temperature to be 73 degrees Fahrenheit, and began to take additional temperatures on 3 North, which revealed the following: Hallway: 83 degrees F. room [ROOM NUMBER]: 82 degrees F. room [ROOM NUMBER]: 76 degrees F. room [ROOM NUMBER]: 76 degrees F room [ROOM NUMBER]: 83.7 degrees F room [ROOM NUMBER]: 83.3 degrees F At 8:35 PM, two surveyors returned to the room of Resident #1 and took a room temperature which read 86.4 degrees F. The resident still had no fan or functioning air conditioner in their room. The resident stated that he/she was still hot and not feeling well. At that time, two surveyors went to get the RN/Supervisor. The RN/Supervisor brought the machine into the resident's room to take a set of vital signs, but then stepped out stating he had to look for gloves. There were no gloves accessible in or around the resident's room. The RN/Supervisor took approximately three minutes to find a pair of gloves before taking the resident's vital signs. The RN/Supervisor applied the pulse oximeter onto the resident's finger first to determine his/her oxygenation status which read 99% while the resident was on 6 liters of oxygen via nasal cannula. The heart rate began at 113 beats per minute (bpm) for several seconds on the machine, and slowly started to decline to 80 bpm then 77 bpm, then 66 bpm. The RN/Supervisor never accessed a stethoscope to get an apical heart rate when the heart rate was showing signs from the pulse oximetry device that there may be irregularities. The RN/Supervisor did not take or document the blood pressure reading or take a temperature, and he went to get the resident a n[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) Resident #15 (the victim) was safeguarded from abuse from Resident #99 (the aggressor) and b.) the facility's Residents/Patient Rights - Abuse, Neglect, Mistreatment or Misappropriation of Resident/Patient's Property was followed. This deficient practice was identified for one (1) of 12 resident's reviewed for abuse, (Resident #15). On 02/22/23 at 12:09 PM, Resident #15 was observed lying in bed. The surveyor interviewed Resident #15 who stated that they were involved in a resident-to-resident physical altercation with their roommate, Resident #99. Resident #15 stated that he/she was minding my own business when Resident #99 came up to them, hit him/her in the chest and stated he/she hated my guts. Resident #15 further stated the nurses, and the police were notified but felt that the altercation was not handled appropriately. Resident #15 stated upon returning from the emergency room he/she did not know why Resident #99 was still their roommate. Resident #15 concluded he/she was very frustrated about the altercation and that they could still feel the punch in their chest. The resident further stated that he/she was concerned about being in the same room with Resident #99. Resident #15 (the victim) was never separated from Resident #99 (the aggressor). The residents remained in the same room together. Upon interviews with facility staff and record review there were no prior physical altercations/incidents between Resident #15 and Resident #99. A review of the electronic Progress Notes (PN) reflected on 02/04/23 at 7:00 AM, Resident #15 (the victim) was punched in the chest by the roommate Resident #99 (the aggressor). A further review of the electronic PN revealed on 02/04/23 at 7:00AM, that Resident #15 requested to be sent out to the emergency room to have his/her defibrillator evaluated because he/she was punched in the chest and that the police were notified. Resident #15 returned from the hospital and the chest x-ray and EKG (electrocardiogram, a test that records the electrical signal from the heart to check for different heart conditions) were normal. A review of Resident #15's medical record (MR) did not reflect interventions to safeguard Resident #15 from abuse. A review of Resident #15's individualized Care Plan (CP) initiated 02/06/23, two (2) days after the abuse occurred, reflected Fear related to recent physical aggression which included the following interventions: A nurse will reassure safety, discuss the reality of the situation while acknowledging what can and cannot be changed to help the patient to feel in control, and reassure the patient that feelings of fear after a traumatic event are normal. On 2/23/23 at 12:41 PM, the surveyor interviewed Resident #99's primary care physician (PCP) who stated he was informed that the resident had a history of aggressive behaviors but was unable to specify. He further stated that after the physical altercation between the two residents, they should not have remained in the same room. A review of Resident #99's (the aggressor) MR did not reflect behavioral interventions after the resident-to resident altercation to prevent physical abuse. A review of Resident #99's CP initiated 02/06/23, two (2) days after he/she punched Resident #15 in the chest, reflected Aggression related to behavior disturbances which included the following interventions: The nurse will identify what is not appropriate, such as profanity and name-calling, and also what is appropriate, the nurse will provide positive feedback to let the client know he/she is meeting expectations, the nurse will recognize behaviors before they become violent and, the nurse will set limits on unacceptable behavior. The facility's failure to implement appropriate interventions to safeguard Resident #15 from physical abuse and follow their facility's Residents/Patient Rights -Abuse, Neglect, Mistreatment or Misappropriation of Resident/Patient's Property Policy and Procedure was likely to put Resident #15 at risk for future harm/abuse. This resulted in an Immediate Jeopardy (IJ) situation which began on 02/04/23. The facility's Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were notified of the IJ on 02/22/23 at 5:56 PM. On 02/23/23 at 5:30 PM, the facility provided an acceptable removal plan, and the immediacy was lifted. The evidence was as follows: Refer to F609 and F610 On 02/22/23 at 10:52 AM, during the initial tour, the surveyor observed Resident #99 sitting on the side of the bed watching TV and eating a bag of chips. Resident #99 stated everything was great and that he/she had no concerns. On 02/22/23 at 10:54 AM, during the initial tour, the surveyor observed Resident #99's roommate Resident #15 lying in bed watching TV. Resident #15 stated that he/she was doing okay. A review of the electronic PN reflected the following: On 02/04/23 at 7:00 AM, Resident #15 (the victim) was punched in the chest by the roommate Resident #99 (the aggressor). It further reflected Resident #15 requested to be sent out to the emergency room (ER) to have his/her defibrillator (devices that send an electric pulse or shock to the heart to restore a normal heartbeat) evaluated because he/she was punched in the chest and the police were notified. On 02/22/23 at 12:09 PM, Resident #15 was observed lying in bed. The surveyor interviewed Resident #15 who stated they were involved in a resident-to-resident physical altercation with their roommate Resident #99. Resident #15 stated that he/she was minding my own business when Resident #99 came up to them, hit him/her in the chest and stated he/she hated my guts. Resident #15 further stated the nurses, and the police were notified but felt that the altercation was not handled appropriately. Resident #15 stated upon returning from the ER that he/she did not know why Resident #99 was still their roommate. Resident #15 concluded he/she was very frustrated about the altercation and that they could still feel the punch in their chest. The resident further stated that he/she was concerned about being in the same room with Resident #99. On 02/22/23 at 12:21 PM, the surveyor interviewed the Licensed Practical Nurse/Unit manager (LPN/UM) for the second-floor nursing unit who confirmed Resident #15 and Resident #99 were roommates and were involved in a recent resident-to-resident altercation. The LPN/UM stated that both residents were confused at times and that Resident #99 punched Resident #15 in the chest. He further stated that Resident #15 did not sustain any injuries and that the resident was sent out to the ER. The LPN/UM stated that he educated both residents on notifying the staff if they had any disagreements. He further stated that Resident #99 (the aggressor) had no history of violent behaviors, and that the physical altercation was unexpected. The LPN/UM stated that he spoke with Resident #99 two (2) days later, on 02/06/23, when he arrived back to work and that the resident stated he punched Resident #15 because the television [TV] was loud. He further explained Resident #99 informed him that he/she didn't mean to punch Resident #15. The LPN/UM stated that the interventions they initiated were 30-minute safety checks to ensure that the residents were okay. He further stated Resident #99's family and staff explained to him/her that it was not acceptable to punch another resident. The LPN/UM stated that Resident #15 and Resident #99 generally got along and that during their investigation they felt it was not personal and the physical altercation occurred only because the TV was loud. He then stated, It was just an unpleasant situation for both. The LPN/UM stated Resident #15's family was made aware of the physical altercation and that the family had wanted to make sure that he/she was monitored frequently and was safe. The LPN/UM concluded the psychiatrist came every Monday and that both residents were seen by them. A further review of the electronic PN revealed the following: On 02/04/23 at 7:43 AM, Resident #15 was noted with increased anxiety but was easily redirected. On 02/04/23 at 19:14 (7:14 PM), Resident #15 returned from the hospital and the chest x-ray and the electrocardiogram (EKG) were normal. The Progress Notes further revealed that Resident #15 (the victim) returned to the same room with the same roommate Resident #99 (the aggressor). There were no interventions initiated to safeguard Resident #15 from being physical abused again. A review of Resident #15's MR did not reflect interventions to safeguard Resident #15 from abuse. The surveyor reviewed the electronic MR for Resident #15. A review of the resident's admission Record (AR) reflected that the resident was admitted to the facility in September of 2022, with diagnoses which included: Cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), Anxiety disorder, Presence of Automatic (implantable) Cardiac Defibrillator, and Epilepsy (neurological disorder in which brain activity becomes abnormal, causing seizures). A review of the most recent quarterly Minimum Data Set (MDS-an assessment tool used to facilitate the management of care) dated 12/16/22, reflected a Brief Interview for Mental Status (BIMS) score of 07 out of 15, which indicated the resident had a moderately impaired cognition. A review of Resident #15's individualized CP initiated 02/06/23, two (2) days after the abuse occurred, reflected Fear related to recent physical aggression which included the following interventions: A nurse will reassure safety, discuss the reality of the situation while acknowledging what can and cannot be changed to help the patient to feel in control, and reassure the patient that feelings of fear after a traumatic event are normal. The surveyor reviewed the electronic MR for Resident #99. A review of the resident's AR reflected that the resident was admitted to the facility in October of 2022, with diagnoses which included: Hypertension (HTN- high blood pressure), Dysphagia (swallowing difficulties) and Cerebral Infarction (a result of disrupted blood flow to the brain). A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 13 out of 15, which indicated an intact cognition. A review of Resident #99's CP initiated 02/06/23, two (2) days after he/she punched Resident #15 in the chest, reflected Aggression related to behavior disturbances which included the following interventions: The nurse will identify what is not appropriate, such as profanity and name-calling, and also what is appropriate, the nurse will provide positive feedback to let the client know he/she is meeting expectations, the nurse will recognize behaviors before they become violent and, the nurse will set limits on unacceptable behavior. A review of the February 2023 Order Summary Report revealed Resident #99 had an active order dated 10/19/22 for Seroquel (used to treat certain mental/mood conditions) Tablet 25 Milligrams (mg) one (1) tablet by mouth two (2) times a day for agitation. A review of the 24-Hour Communication Sheet for the 2 North Wing revealed the following: On the sheet originally marked 02/04/23, with the date 02/04/23 crossed out and marked 02/03/23, and the Day of Week marked Saturday, the morning shift (7:00 AM to 3:00 PM) and the evening shift (3:00 PM to 11:00 PM) areas were left blank, and the night shift (11:00 PM to 7:00 AM) area indicated for both Resident #15 and Resident #99: Resident to resident with roommate, 911 called. On the sheet marked 02/04/23 and the Day of Week marked Saturday, for Resident #15, the morning shift area was left blank; the evening shift area was marked: Returned from hospital, left note in EMR, no issues; and the night shift area was marked: Safety maintained, s/p [status post] resident to resident incident. On the same sheet for Resident #99, the morning shift area was left blank; the evening shift area was marked: No issues; and the night shift area was marked: s/p resident to resident incident. On the sheet marked 02/05/23 and the Day of Week marked Sunday, for Resident #15, the morning shift and evening shift areas were left blank, and the night shift was marked: No issues, Safety maintained s/p incident. On the same sheet for Resident #99, the morning shift and evening shifts areas were left blank, and the night shift was marked: No issues. A further review of the February 2023 24-Hour Communication log did not reflect any documentation regarding the resident-to-resident altercation until 02/22/23 evening shift: Resident #15 transferred to a new room and okay. A review of Resident #15's electronic PN did not reflect documentation related to the 30-minutes safety checks or monitoring of the residents. A further review of electronic PN revealed on 02/19/23 at 13:25 (1:25 PM), PCP #1 evaluated Resident #15 and documented the following: Problems: trauma to chest after altercation - unaware seen in ED [emergency department], cxr [chest x-ray] without signs of injury, no trauma noted. A review of Resident #99's electronic PN revealed on 02/07/23 at 21:26 (9:26 PM), PCP #2 evaluated Resident #99 and documented the following: evaluated on monthly facility rounds. Patient is stable, awake and alert .has aggressive and combative behavior. Continue to monitor. A further review of the electronic PN for Resident #99 did not reflect any additional documentation related to monitoring the resident. On 02/22/23 at 1:22 PM and 1:23 PM, the surveyor attempted to call Resident #15's representative. On 02/22/23 at 1:22 PM, the surveyor interviewed the Certified Nursing Aide (CNA)#1 who stated that he had worked at the facility for eight (8) years and was not aware of a resident-to resident altercation between Resident #15 and Resident #99. On 02/22/23 at 1:23 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #15 was alert and oriented to person and place with confusion at times. The LPN gave the example that the resident would sometimes forget what time of day it was because the resident didn't recall if it was breakfast or dinner time, and that the resident could remember staff member's names. When the surveyor asked if the resident had behaviors, the LPN replied, no and stated that the resident would keep to himself/herself, would come out of their room for medications and doesn't bother anybody. On 02/22/23 at 1:25 PM, the surveyor continued to interview the LPN who stated that Resident #99 had resided at the facility for approximately two (2) to three (3) months and had a diagnosis of a stroke. The LPN further stated that the resident had behaviors, but not with staff. When the surveyor asked the LPN what kind of behaviors Resident #99 presented with, the LPN explained that one day when she came to work she received report that Resident #99 was not very nice to his/her roommate and hit Resident #15 and Resident #15 was sent out to the hospital for an evaluation due to the physical altercation. The LPN further stated that the evaluation at the hospital determined that Resident #15 did not sustain injuries from being hit and was put back into the same room with Resident #99 after the physical altercation. When asked what the facility did to protect Resident #15 from Resident #99 after the physical altercation the LPN stated that she would check on them to make sure nothing funny happened in there. The LPN did not state how frequently she checked on the residents. The LPN stated that Resident #99 did not get agitated very often but had little behaviors that were usually directed at Resident #99's family members. The surveyor further inquired about what the behaviors Resident #99 had towards his/her family. The LPN told the surveyor that Resident #99 would have temper tantrums and say mean things to the family if he/she did not get their way. The LPN further stated that Resident #99's family came to the facility every day and it was a family thing and nothing that we needed to be concerned about. The surveyor asked the LPN if the facility documented behavior monitoring for the residents in the facility after a behavior was identified. The LPN explained that sometimes the staff would document resident behaviors on the 24-hour report or in progress notes; however, behavior documentation never occurred after the physical altercation between Resident #15 and Resident #99 because the staff kept an eye on them and would check to see if they were in a bad mood. On 02/22/23 at 1:26 PM, the surveyor interviewed CNA#2 who stated that she was employed at the facility for three (3) years. She stated that she was not made aware that Resident #15 was hit by his/her roommate. CNA#2 stated that she had not personally provided care for the residents; however, she felt it would have been important for her to have known about the situation because she worked on that end of the hallway and could have been watching to make sure nothing else happened because they were still roommates. CNA#2 told the surveyor that the normal process after a resident-to resident altercation was for the residents to be separated and stated, I'm not sure what happened. On 02/22/2 at 1:32 PM, the surveyor interviewed CNA#3 who stated that she worked at the facility for approximately two (2) years and was the primary care giver for the two residents but was not working when the resident-to-resident altercation took place. CNA#3 further stated that when she arrived to work after the incident, another CNA told her that Resident #15 hit Resident #99 in the chest. When Resident #15 returned from the hospital, it was the next day that she saw the resident and stated there was nothing special that she needed to do. CNA#3 stated that she was not told to document anything or perform any special monitoring for the residents. CNA#3 further explained that Resident #99 did not have behaviors and had no history of hitting another resident. She stated that she had asked Resident #99 why he/she had hit Resident #15 and Resident #99 could not provide her with an answer. CNA#3 told the surveyor that facility management did not talk to her about the incident. On 02/22/23 at 1:40 PM, the surveyors interviewed the LPN/UM who stated that Resident #15 had resided at the facility for approximately four (4) years and had intermittent confusion and forgetfulness. The LPN/UM explained that the resident resided at the facility for care related to activities of daily living and was unable to do for himself/herself. The LPN/UM further stated that there was an incident not too long ago between Resident #15 and Resident #99 in which Resident #99 punched Resident #15 in the chest. The LPN/UM explained that after the physical altercation Resident #15 told the nurse to call the police on his/her behalf. The LPN/UM explained that the nurse working interviewed Resident #99 who told her that he/she punched Resident #15 in the chest because the television in the room was too loud. The LPN/UM further stated that the nurse working notified the resident's families and Resident #15 was taken to the hospital for an evaluation after being punched in the chest and was then sent back to the facility from the hospital with no apparent injuries or fractures. The LPN/UM told the survey team that when Resident #15 returned from the hospital the resident was placed back into the same room with Resident #99 because the resident promised not to do anything and was educated. The LPN/UM stated that Resident #15 had never in his/her four years of residing at the facility had behaviors towards other residents or staff. The LPN/UM explained that Resident #99 was forgetful at times, had a history of anxiety and was on medication to treat his/her mental health diagnoses. The survey team asked the LPN/UM if he considered punching someone physically aggressive behavior and he stated, absolutely. The survey team further interviewed the LPN/UM and asked what interventions were implemented after the physical altercation between Resident #15 and Resident #99 took place? The LPN/UM stated that the facility did frequent 30-minute checks to make sure there were no issues going on and educated the resident to discuss their needs with staff. The survey team asked the LPN/UM how the staff evaluated Resident #99's understanding of the education and the LPN/UM explained that they asked Resident #99, if you had anything going on with your roommate what would you do? The LPN/UM stated that Resident #99 told staff that he/she would ask the staff for help. The survey team inquired further if the facility documented on the implemented interventions. The LPN/UM stated that the facility did not document the interventions in the resident's medical records. The LPN/UM stated that Resident #99 was already being monitored for behaviors because the resident was on psychotropic medications (medications that treat mental illnesses) and because the resident was already on these medications, monitoring behaviors was not a new intervention for Resident #99. The LPN/UM further stated that after the physical altercation between Resident #15 and Resident #99 occurred, he and the facility's Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), and Social Worker (SW) all met together, discussed the incident, and put the interventions in place on 02/06/23. The LPN/UM was unable to produce documentation that 30-minute checks were conducted by staff and stated that the checks occurred by word of mouth from the CNAs and primary nurse on duty. On 02/22/23 at 1:44 PM, the surveyor interviewed CNA#4 who stated that he was employed at the facility for four (4) years and worked on the second floor. CNA#4 told the surveyor that the day of the altercation, Resident #15 was sitting at the nurse's station and was upset so he asked the resident what was wrong. CNA#4 told the surveyor that the resident told him that he/she wasn't feeling good, but CNA#4 was not made aware that Resident #99 attacked him. CNA#4 told the surveyor that no one reported the incident to him. CNA#4 stated that he then spoke with Resident #99 who just made it seem like a verbal argument. CNA #4 further stated that management staff never told him of the resident-to-resident altercation and there was no special monitoring that needed to be done. On 02/22/23 at 2:26 PM, the survey team interviewed the facility's SW who stated that Resident #15 had resided at the facility for a few years, was forgetful and a really nice person. The SW further explained the resident was quiet and that he/she needed another person to initiate a conversation with him/her, liked playing cards, doing puzzles, and watching television. The SW stated that Resident #15 liked to quietly walk around the hallways of the facility. The SW told the survey team that Resident #99 had recently moved to the facility, kept to himself/herself, did not leave his/her room, and would sometimes be observed pacing and walking around in circles in the room. The SW further stated that the resident's family came to the facility every two (2) to three (3) days and the resident needed to be encouraged to participate in activities. The SW explained to the survey team that she never saw Resident #99 get out of line with staff or residents, but the resident did demonstrate anger issues such as anger in the tone of his/her voice. The SW stated that you could hear anger in the resident's voice because the resident would speak in a deeper tone of voice, get loud, and would often be observed pacing back and forth from one side of his/her room to the other. The survey team asked the SW if she ever saw Resident #99 demonstrate this behavior. The SW stated that she had seen the resident appear angry after an interaction with his/her family that made the resident upset. The SW recalled a scenario in which Resident #99's family had called her to notify her that the Resident was upset over a situation with finances, so she went to the resident's room and observed this behavior herself. The SW told the survey team that Resident #99's family had communicated to her that the resident was short fused and that was one of the reasons why they brought the resident to reside in the facility. However, the family had never reported that Resident #99 was physically aggressive, only short fused and explained to her that the resident could get angered very easily. The survey team continued the interview with the facility's SW who stated that she was not aware of the physical altercation that took place during the 11:00 PM - 7:00 AM shift on 02/04/23, until 02/06/23, two (2) days after the event occurred. The SW stated that she was unsure who the Licensed Practical Nurse/Night Supervisor (LPN/NS) contacted to make them aware of the incident, but she would have expected the LPN/NS or whomever was on-call that evening to have notified the LNHA or ADON because a physical altercation had taken place and the police and Emergency Medical Technicians (EMTs) had to come to the facility to assess the residents. The SW further explained that on 02/06/23, she, the ADON, the LNHA, and the second and third floor Unit Managers discussed the incident. She told the survey team that Resident #15 decided not to press charges against Resident #99 and the facility's psychiatrist was made aware of the incident on 02/06/23, because the psychiatrist made rounds at the facility early that morning. The SW further stated that she was unsure if anything was done to protect Resident #15 when he/she came back to the facility, but she would have done a room change right then and there because we work and live in a hard climate and the residents that reside here have mental illnesses and histories of aggressive behavior. The SW stated that if she was the Nursing Supervisor, she would have done a room change to keep the residents safe. On 02/22/23 at 3:03 PM, the survey team interviewed the ADON who stated that she started working at the facility on 01/25/23. The ADON stated that Resident #15 was alert, oriented and non-aggressive and that she did not know Resident #99 because she was new to her position. The ADON told the survey team that she learned about the residents because there was an incident with the roommates. The ADON explained that the 11:00 PM - 7:00 AM LPN/NS notified the DON that there was a physical altercation between Resident #15 and Resident #99 and crisis was called. The ADON stated that Resident #15 was hit by Resident #99, sent to the hospital, and came back cleared. The ADON further stated that the roommates decided not to press assault charges with the police department and that the incident occurred over an argument about the television. The surveyors asked the ADON how Resident #15 was protected upon return to the facility. The ADON stated that besides the resident's CP being updated she did not know of any intervention off hand. The ADON further stated that the residents squashed the issue and she guessed it was a no hard feelings type of thing. The ADON stated that the process for investigation should have been conducted by risk management in which statements were obtained by the residents and staff. The ADON explained that the purpose of the investigative process was to implement interventions and then, safeguard the residents. The ADON told the survey team that the facility's DON and LNHA were responsible for reporting abuse and investigating. On 02/22/23 at 3:18 PM, the survey team interviewed the DON who stated that she started her position as DON for the facility on 02/01/23. The DON stated that Resident #15 was forgetful at times and cooperative with staff. The DON told the survey team that Resident #99 was more alert than Resident #15, also forgetful, and could get a little agitated when he/she did not get their way. The DON stated that when Resident #99 looked frustrated that he/she would huff and puff like a child, turn his/her head and dismiss the person that was speaking. The DON stated that she received a phone call on 02/04/23 that Resident #99 hit Resident #15 because Resident #99 was agitated and did not like what Resident #15 was watching on television. She further stated that she told the nurse that called her to call crisis and then call 911. The DON explained that 911 evaluated both residents and took Resident #15 to the hospital and that he/she came back to the facility that same night with no injuries. The survey team asked the DON what interventions were put in place to safeguard Resident #15 and the DON stated that the LPN/UM called the psychiatrist for Resident #15 (the victim). The DON told the survey team that she was unsure when Resident #15 was seen by the psychiatrist. The DON explained to the survey team that she never spoke to either of the residents regarding a room change but was told by the LPN/UM that the residents were offered a room change and neither one of the residents wanted to move out of their room. The DON stated that the LPN/UM spoke with both residents, but to her knowledge it was not documented in the either of the resident's medical records. On 02/22/23 at 3:30 PM, the survey team conducted a follow up interview with the LPN/UM who stated that an incident report, not an investigation, was completed when Resident #99 hit Resident #15 in the chest. The LPN/UM told the survey team that the most important thing that should have happened was that Resident #15 was protected from future abuse, and the residents should have been separated. The LPN/UM stated, I think separation would have been the best because it was the easiest way to ensure safety. The LPN/UM told the surveyors that he was not in the facility when the police came and he did not speak to the residents until 02/06/23, two days after the incident occurred, and that when he spoke to the residents on 02/06/23, they did not tell him that they wanted to stay in the same room together. The LPN/UM stated that he wasn't exactly sure if Resident #15 or Resident #99's psychiatrists or primary care physicians were notified, but he was told they were notified. The LPN/UM further stated that everything that happened should have been documented in the resident's medical record when the resident-to-resident altercation took place. On 02/22/23 at 3:48 PM, the survey team interviewed the facility's LNHA who stated that his first day working at the facility was 01/23/23. The LNHA stated that there were different types of abuse and physical abuse was one of them. The LNHA stated that the process when abuse occurred was to isolate the situation and take away the alleged abuser. The LNHA stated the first thing we do is separate. The LNHA told the surveyors that according to the state and federal regulations the NJDOH should have been notified of the event between Resident #15 and Resident #99 within two (2) hours because physical abuse had occurred. The LNHA further stated that he wasn't familiar with the investigative findings of the event because nursing handled the situation. The LNHA told the survey team that it was his understanding that there was a resident-to-resident altercation, the police were notified and both residents in question did not want to press charges. The LNHA could not speak to why Resident #99 (the aggressor) would legally be able to press charges against Resident #15 (the victim). The LNHA stated that it was also his understanding that when Resident #15 returned from the hospital, the nurse spoke with both residents and the residents wanted to stay in the room together. The LNHA stated that he[TRUNCATED]

Part A Based on observation, interviews, and review of other pertinent documentation, it was determined that the facility failed to a.) ensure a physician's order for a diet change to nectar thick liquids was followed and communicated to dietary staff for a resident with a history of aspiration on thin liquids; b.) ensure staff who were caring for a resident were aware of their modified diet order; and c.) develop a policy to ensure staff were aware of the process to communicate physician's orders, diet changes, and therapeutic diets. This deficient practice was identified for 1 of 2 residents (Resident #94) reviewed for tube feeding. On 3/1/23 at 12:16 PM, the surveyor observed Resident #94 in bed with two unopened apple juices and one opened twenty-four-ounce bottle of soda. The resident stated the liquids were thin; he/she drank thin liquids. On 3/1/23 at 12:26 PM, the surveyor observed the resident's Certified Nursing Aide (CNA #1) deliver the resident's lunch meal tray which contained a mechanically altered diet with apple juice that CNA #1 confirmed was thin liquid. Interview with both the resident's CNA #1 and Licensed Practical Nurse (LPN #1) revealed the resident was on a thin liquid diet. Review of the resident's medical record reflected a Progress Note (PN) dated 2/14/23, that the resident returned from an appointment with aspiration (accidental breathing in of fluid or food into the lungs) on thin liquids and penetration (making a way through) of the lungs on nectar thick (liquids thickened with an agent for a nectar-like consistency) liquids. A review of the physician's orders (PO) revealed a PO dated 2/22/23 for nectar thick liquids. Interview with the Speech Language Pathologist (SLP) indicated that the resident had a swallowing study performed on 2/14/23, with the results of aspiration on thin liquids and penetration of the lungs on nectar thick. The SLP stated the resident was picked up by therapy on 2/17/23 to improve swallowing of nectar thick liquids and should have been started on nectar thick liquids on 2/14/23. Interview with the dietary staff revealed there was no communication with them for the resident's diet change. Follow-up observation with LPN #1 confirmed the resident had thin liquids present in their room. LPN #1 verified the PO and confirmed the resident had a PO dated 2/22/23 for nectar thick liquids. The facility's failure to ensure a resident with a history of aspiration on thin liquids and a physician order for nectar thick liquids was provided nectar thick liquids posed a serious and immediate threat for adverse effects, including aspiration, which is likely to result in serious harm, impairment, or even death. This resulted in an Immediate Jeopardy (IJ) situation that began on 2/22/23 at 10:11 AM, when the physician ordered the nectar thick liquids. The facility's administration was notified of the IJ on 3/1/23 at 4:51 PM. The facility submitted an acceptable written Removal Plan on 3/3/23 at 9:35 AM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 3/3/23. The evidence was as follows: On 3/1/23 at 12:16 PM, the surveyor observed Resident #94 lying in bed awake with a overbed table located to his/her side. The overbed table contained an opened twenty-four-ounce bottle of soda with approximately one-third of the liquid removed and two unopened apple juices. The resident informed the surveyor that the soda was purchased by themself a few months ago and he/she now and then would sip on it, and the two apple juices were from that morning's breakfast tray. The surveyor asked if the resident's liquids were thickened, and the resident responded that the nurses sometimes put something in his/her drinks to thicken it he/she thought. The surveyor asked if the soda contained thickener, and the resident stated, no, and that he/she just sipped on it. The surveyor asked the resident if he/she was on speech therapy, and they responded, no. The surveyor asked the resident if he/she had a feeding tube (FT; a tube surgically placed into the stomach to provide nutrition), which the resident stated he/she had a FT, but they did not receive their nutrition from the tube, they only received water flushes for patency. On 3/1/23 at 12:20 PM, the surveyor observed the lunch trays arrive on the Second-floor nursing unit [NAME] wing. On 3/1/23 at 12:26 PM, the surveyor observed CNA #1 deliver Resident #94's meal tray to their room. The meal tray contained thin apple juice (not thickened) served in a plastic cup, lactaid ice cream, vanilla pudding, a pulled pork sandwich, vegetables, and an oatmeal sandwich cookie. The surveyor observed the resident put the apple juice to their lips and place the cup back down. There was no significant amount of apple juice removed from the cup, the cup still appeared untouched. A review of the resident's meal ticket located on their tray, revealed the resident received a mechanical altered diet (texture-modified diet for difficulty chewing and swallowing), but it did not specify the liquids. On 3/1/23 at 12:28 PM, the surveyor interviewed CNA #1 who stated that the resident had a FT but received all their food and beverages by mouth. CNA #1 confirmed the apple juice was a thin liquid with no added thickener and she stated the resident's diet ordered was a mechanical altered diet and regular thin liquids. CNA #1 stated the resident had something wrong with their throat, but that was years ago and did not require thickened liquids. On 3/1/23 at 12:30 PM, the surveyor interviewed LPN #1 who confirmed she was the resident's nurse for the day and familiar with the resident. LPN #1 stated the resident had a FT, but only received medication through the tube. LPN #1 stated the resident was on a regular textured diet and received thin liquids. The surveyor reviewed the medical record for Resident #94. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in April of 2022 with diagnoses which included unspecified protein-calorie malnutrition, malignant neoplasm of esophagus (cancer of the tube that runs from the throat to the stomach), essential hypertension (high blood pressure), and failure to thrive. A review of the most recent quarterly Minimum Data Set (MDS-an assessment tool utilized to facilitate the management of care) dated 2/10/23, reflected a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated a moderately impaired cognition. A further review indicated for Activities of Daily Living (ADLs), the resident required supervision of setup help only for eating. A review of Section K Swallowing/Nutritional Status reflected the resident had a mechanically altered diet which required change in texture of food or liquids. A review of the Order Summary Report included a physician's order (PO) dated 2/22/23, for a regular diet mechanical altered texture, nectar thick consistency. A review of the Progress Notes for 2/22/23, did not include any documentation why the resident's diet was changed that day. A review of the individualized person-centered care plan included a focus area initiated 4/20/22 and last revised 11/7/22, that the resident had nutritional problems with regards to esophageal cancer and dysphagia (difficulty swallowing), need for mechanical soft diet and refusal of tube feedings and noncompliance with recommended diet, with planned weight gain trend. Interventions included to provide diet as ordered - mechanically altered; to explain and reinforce to the resident the importance of maintaining the diet ordered, encourage the resident to comply, explain consequences of refusal; provide food preferences - yogurt at meals; Registered Dietitian (RD) to evaluate and make diet change recommendations as needed; tube flushes to keep tube patent; and weight as ordered. The care plan did not include the resident's nectar thick liquids. On 3/1/23 at 1:39 PM, the surveyor interviewed the Rehabilitation Director (Rehab Director) who stated the resident was followed by speech therapy for swallowing and dysphagia. The surveyor requested a copy of the resident's speech therapy notes and to speak with the Speech Language Pathologist (SLP). On 3/1/23 at 1:47 PM, the SLP provided the surveyor with the resident's speech therapy notes. The SLP stated that she had only been at the facility for three weeks now but did evaluate Resident #94 who was referred to her after a swallow study. The SLP stated on 2/14/23, the resident received a fiberoptic endoscopic evaluation of swallowing (FEES) which was a camera attached to a small tube that went down the resident's throat and the evaluator was able to see that the resident aspirated on thin liquids, which meant liquids went into the windpipe. The SLP stated that there was also penetration of the lungs with nectar thick liquids, which meant liquid went into the lungs when the resident had nectar thick liquids. The surveyor asked if penetration of the lungs was bad, and the SLP stated yes, because it could cause pneumonia if the resident continued with nectar thick liquids. The SLP stated the purpose of speech therapy was to teach the resident techniques to block the airway to tolerate the nectar thick liquids so that was why nectar thick liquids were recommended. The SLP stated she thought the resident was already on nectar thick liquids when she started at the facility on 2/14/23, and the resident was evaluated on 2/17/23 by her. The SLP stated the resident at this time would not be a candidate for thin liquids because of the aspiration risk. On 3/1/23 at 2:09 PM, the surveyor interviewed the Dietary Aide (DA) who stated the kitchen had a list of diet orders for all residents that was updated and printed daily. The nursing staff, RD, or SLP sent the kitchen a Diet Order & Communication form with any changes to the residents' diets. The DA provided the surveyor with a copy of the List of Residents and Diet for Crosscheck which revealed Resident #94 was to receive thin liquids. At this time, the Food Service Director (FSD) joined the surveyor and the DA who confirmed the document provided by the DA contained all the residents' diet orders. The FSD stated the diet order was printed on the residents' meal tickets. The surveyor asked how staff thickened resident's beverages, and the FSD stated the kitchen ordered pre-thickened nectar thick water, juices, and coffee. The FSD showed the surveyor an unopened case of nectar thickened apple juice that was stored in the dry storage area. The FSD stated that the kitchen had powder thickener that could be added to liquids in the event the kitchen ran out of pre-thickened liquids, but the FSD stated that the kitchen always had pre-thickened liquids. On 3/1/23 at 2:23 PM, the surveyor accompanied by LPN #1 went into Resident #94's room, and she confirmed the resident had an opened twenty-four-ounce soda and two unopened apple juices. LPN #1 confirmed all the liquids were thin. At this time, the surveyor asked LPN #1 to confirm the resident's diet order, and LPN #1 confirmed the resident had a PO for nectar thick liquids that was changed on 2/22/23. LPN #1 stated the CNAs checked the meal trays when they arrived at the nursing floor prior to be delivered to the resident to ensure accuracy of the meal. LPN #1 confirmed she did not check the lunch meal trays today when they arrived from the kitchen. LPN #1 stated giving a resident thin liquid when nectar thick liquids was ordered, could cause aspiration. LPN #1 stated a copy of all diet orders was located in the resident's paper medical record. A review of the resident's paper medical record included two Diet Order & Communication forms; one completed 6/3/22 for a regular mechanical soft diet and thickened liquids were not indicated, and the last form was dated 8/16/22 for room change only. On 3/1/23 at 2:32 PM, the surveyor asked the SLP who communicated diet changes with the kitchen, and she responded the RD informed the kitchen. On 3/1/23 at 2:41 PM, the surveyor asked the FSD if they kept a record for the residents' Diet Order & Communication forms, and she responded yes. The surveyor asked if she received a diet change for Resident #94 in February, and the FSD looked through her forms and confirmed no. The FSD stated the resident had been at the facility for a while and did not recall having any diet changes recently. At this time, the DA stated the last change for Resident #94 was for a room change and not diet change. The surveyor continued to review the medical record. A review of the Progress Notes included a Nurses Note dated 2/14/23 at 6:58 PM, that the resident returned from appointment with findings of aspiration on thin liquids and penetration (of the lungs) with nectar thick liquids. There was a diagnosis of mild oral and moderate pharyngeal (hollow tube that starts behind the nose and ends at the top of the windpipe) dysphagia. The note did not indicate if the diet was changed, or the physician was notified. A review of the Progress Notes included a Plan of Care Note dated 2/15/23 at 7:03 PM, signed by Physician #1 which did not include the results of the resident's FEES test with aspiration on thin liquids and penetration on nectar thick. The note included nutrition - FT. A further review of the notes from 2/14/23 until 2/22/23, did not include the resident's results from their FEES test on 2/14/22 or the diet recommendation of nectar thick liquids. On 3/1/23 at 3:05 PM, the surveyor asked the SLP when Resident #24 should have started on thickened liquids, and she responded on 2/14/23 when the resident was seen by the Hospital SLP. At this time, the Rehab Director stated that therapy picked the resident up at that time and gave the RD the referral as well. On 3/1/23 at 3:17 PM, the surveyor attempted to interview the RD via telephone with no response. The surveyor left a message for the RD to return the call, but never received a call back for the rest of the survey. On 3/1/23 at 3:20 PM, the surveyor interviewed the Medical Director (MD), via telephone, who was the resident's primary care physician. The MD stated he did not have the resident's notes present, but stated he heard the resident's eating had improved and their weight was stable. The MD stated he was unsure why the resident's diet was not changed until 2/22/23, and not after the FEES test on 2/14/23, but stated to call back in thirty minutes. On 3/1/23 at 3:33 PM, the surveyor interviewed the Director of Nursing (DON) who stated that nursing staff, the SLP, or the RD could inform the kitchen of diet changes. The DON stated the nurse called the physician to obtain an order; the nurse completed the Diet Order & Communication form and sent to the kitchen and placed a copy in the resident's paper medical record; put the PO into the computer; and the kitchen changed their diet order to send the appropriate diet. The DON stated the RD was currently out of the building on medical leave that started today, and she was unsure when she would return. The DON stated if the resident had an issue with chewing or swallowing, they would be referred to the SLP. The DON acknowledged it was important to follow a diet; a resident with a history of aspiration on thin liquids and a PO for nectar thick liquids should receive nectar thick liquids because thin liquids could cause aspiration or fluid in the lungs which could cause infection or pneumonia. The surveyor asked how the nurse knew a PO was changed, and the DON stated it should be on the twenty-four-hour report and the diet was on the computer in the PO section as well as when administering medications. The DON stated she thought the CNAs had a Kardex system which provided all the information for the care of the resident, as well as it was indicated on their meal ticket. The surveyor asked who checked the meal trays when they arrived on the nursing floor prior to be delivered to the residents, and the DON stated the CNAs checked the trays with the meal ticket to ensure meal accuracy. At this time, the surveyor requested a copy of the resident's Kardex, and a copy of the following policies which included the process for physician's orders, therapeutic diets, and meal ticket changes. On 3/1/23 at 3:52 PM, the surveyor interviewed the MD via telephone who stated he was unsure if the facility had only received the preliminary report on 2/14/23 or the official report, and he was waiting to hear back from the hospital. The MD stated he would look into the surveyor's concern and would be in touch the next day. On 3/1/23 at 4:43 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and Regional DON. The Regional DON stated the facility had no policy for physician's orders; the facility followed standards of practice. The surveyor asked the LNHA if he was aware the facility had no policy for physician's order, and he stated no. The surveyor asked what the standard of practice for physician's orders was, and the Regional DON stated they would need to look it up. The LNHA confirmed the facility had nothing in writing, would be standards of practice. The LNHA confirmed the expectation would be to follow a physician's order. The DON then confirmed there was no policy for obtaining diet orders. The DON confirmed the expectation was the nurse gave kitchen staff a diet order slip and a copy went in the resident's paper medical record. The Administration team confirmed there was no policy for therapeutic diets or giving residents food. The DON stated if a diet changed, the same procedure as diet order. The LNHA confirmed the expectation would be to provide the resident with the appropriate consistency of the therapeutic diet as ordered. The facility's failure to ensure a resident with a history of aspiration on thin liquids and a physician order for nectar thick liquids was provided nectar thick liquids posed a serious and immediate threat for adverse effects, including aspiration, which is likely to result in serious harm, impairment, or even death. This resulted in an immediate jeopardy situation. The IJ was identified on 2/22/23, when the resident received a PO for nectar thick liquids, and the LNHA, DON, and Regional DON was notified of the IJ on 3/1/23 at 4:51 PM. The facility submitted an acceptable written Removal Plan on 3/3/23. The Removal Plan included communication was sent to dietary staff to change Resident #94's to nectar thick liquids; LPN #1 and CNA #1 were educated on the resident's diet and the importance of meal accuracy; education was provided to staff on nectar thick liquids and modified diets; a procedure was put into place to ensure residents on modified diets that staff were aware and following physician's orders; and staff were educated on new procedure. On 3/2/23 at 10:17 AM, the surveyor interviewed the MD who stated after surveyor inquiry, he completed a thorough review of the resident's medical record and spoke with the SLP and Rehab Director. The MD confirmed that the resident had an evaluation (FEES) on 2/24/23 and returned to the facility that day with a recommendation for nectar thick liquids. The MD stated since he did not have the actual report just the preliminary report, so he did not want to change the resident's diet until he received the final report. The MD continued that the resident received an evaluation with the SLP on 2/17/23, and on 2/22/23 there was still no final report and the MD felt he could not wait any longer, so he then changed the resident's liquids to nectar thick liquids. The MD stated since the resident did not want thickened liquids, he delayed the order as well. The MD confirmed he did not document any of this in the resident's medical record. The MD stated the SLP thought it was a good idea for the resident to be on nectar thick liquids, but my medical judgement was based on the resident's history, so I waited until 2/22/23 to have the report but then I did not want to wait any longer. The MD stated the Social Worker (SW) also documented a note in the Progress Notes on 2/22/23, that the resident did not want thickened liquids. The surveyor asked the MD if the expectation was to follow the PO, which the MD confirmed. The MD stated the resident should be on nectar thick liquids as a precautionary matter. The MD was also unaware that the facility did not have policies for physician's orders, dietary orders, or therapeutic diets. The MD stated the facility should have these policies and maybe they were unaware; he also confirmed he did not review facility policies annually, just when the policy was updated. On 3/2/23 at 11:07 AM, the surveyor reviewed the Progress Notes which now included a Late Entry Social Services note created on 3/1/23 at 6:53 PM (after the IJ was called), and back dated to 2/22/23 at 6:37 PM, to reflect the SW spoke to the resident regarding the PO to change their diet, and the resident stated he/she wanted regular food, coffee, and soda. A review of the facility's Care Plans - Comprehensive policy dated revised 11/22/22, included our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident maybe expected to attain .each resident's care plan is designed to: incorporate identified problems; incorporate risk factors associated with identified problems .reflect the resident's expressed wishes regarding care and treatment goals .identify professional services that are responsible for each element of care; aid in preventing and reducing declines in the resident's functional status and/or functional levels .reflect currently recognized standards of practice for problem areas and conditions .assessments of residents are ongoing and care plans are to be revised as information about the resident and resident's condition change . NJAC 8:39-17.4(a)(1)(2); 27.1(a) F689 remains a deficiency at a scope and severity level of a D based on the following: Part B Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide the diet ordered of nectar thick liquids for an observed lunch meal for a resident with a history of aspiration on thin liquids. This deficient practice was identified for 1 of 6 residents (Resident #17) reviewed for accidents and was evidenced by the following: On 3/2/23 at 12:44 PM, the surveyor reviewed the facility's List of Residents and Diets for Crosscheck which revealed Resident #17 received a diet of double portions pureed foods and nectar thick (liquids thickened with an agent for a nectar-like consistency) liquids. On 3/2/23 at 12:45 PM, the surveyor observed the lunch meal trays arrive for the Second-floor nursing unit North side. The surveyor observed Certified Nursing Aide (CNA #2) perform hand hygiene using alcohol-based hand rub (ABHR) and started to deliver residents' meal trays. CNA #2 informed the surveyor that the nurse needed to check the meal trays to ensure accuracy of the meal tray with the meal ticket prior to delivering them to the residents, but the surveyor did not observe the nurse check the trays. The surveyor observed CNA #2 continue to deliver meal trays to the residents without checking the trays to ensure accuracy. On 3/2/23 at 12:48 PM, the surveyor observed Resident #17 in bed with their lunch meal tray on their overbed table. The resident informed the surveyor that he/she received a diet of pureed food and thick liquids, thick like milk. The resident then informed the surveyor that he/she could not drink the apple juice they received because the juice was a thin liquid and not thickened like he/she was supposed to receive. The resident stated this happens all the time. The surveyor asked the resident what he/she did when they received the inappropriate liquids, and the resident stated they throw the tray in the hallway because they cannot have it. At this time, the resident stood up and placed their lunch meal tray on their wheelchair and ambulated to the hallway pushing their wheelchair. In the hallway, the surveyor observed the Director of Nursing (DON) checking meal trays, and the surveyor asked the DON to speak. The resident informed the DON that he/she cannot have this tray. The surveyor asked the DON the consistency of the apple juice on the meal tray, and she responded thin. The surveyor then asked the DON what consistency the resident was on, but the DON was unsure. The surveyor then asked the resident what consistency liquids they were supposed to receive, and he/she stated thick. The surveyor showed the DON the resident's meal ticket, and she confirmed the resident was supposed to receive nectar thick liquids and not the thin liquids on the tray. On 3/2/23 at 12:56 PM, the surveyor observed Licensed Practical Nurse (LPN #2) now checking the residents' lunch meal trays. The surveyor asked if she checked Resident #17's meal tray, and she stated no, she had just started checking trays now. On 3/2/23 at 12:58 PM, the surveyor interviewed CNA #2 who stated she was not the resident's aide, but she delivered their lunch meal tray today. The surveyor asked CNA #2 if she checked the meal tray with the meal ticket prior to delivering the resident's tray, and CNA #2 stated no, LPN #2 checked it. The surveyor asked if she knew what diet the resident was on, and CNA #2 stated puree foods with thickened liquids. CNA #2 stated if she was unsure of the resident's diet, she could always look at the resident's meal ticket. On 3/2/23 at 1:00 PM, the surveyor interviewed LPN #2 who stated the resident was on pureed foods which he/she disliked as well as nectar thick liquids. The surveyor asked LPN #2 what the process was when meal trays arrived at the floor? LPN #2 responded that whoever the nurse was on the floor checked the meal trays with the meal tickets to ensure accuracy, meaning the diet matched the ticket as well as preferences and dislikes. LPN #2 stated Resident #17's tray came on the first cart, and she was not present when the cart arrived, so she did not check the trays. The surveyor asked what the process was if the nurse was not present, and LPN #2 stated the CNAs or Unit Manager would then check the trays. On 3/2/23 at 1:05 PM, surveyor interviewed the DON who confirmed Resident #17 received the wrong diet. The surveyor asked what the process was when the meal trays arrived on the floor, and the DON responded either the nurse or the CNA checked the trays for accuracy. The DON continued it was okay for the CNAs to check the meal trays because the aides fed the residents, so they were aware of the appropriate consistencies of diets. The surveyor asked the DON if it was okay for a meal tray to be delivered to a resident without being checked, and the DON stated no. The DON stated if the resident's meal tray was incorrect, staff were expected to put the tray aside and call the kitchen to deliver the appropriate meal tray. The surveyor reviewed the medical record for Resident #17. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in February of 2022 with diagnoses which included unspecified protein-calorie malnutrition, dysphagia (difficulty swallowing), and anemia. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/4/23, reflected the resident had a brief interview for mental status (BIMS) score of a 10 out of 15, which indicated a moderately impaired cognition. A review of Section K Swallowing/Nutritional Status revealed the resident had a significant weight gain on a prescribed diet and received a mechanically altered diet which required change in texture of food or liquids. A review of the Order Summary Report included a physician's order dated 1/12/23, for a regular diet pureed texture double portions with nectar thick liquids. A review of the individualized person-centered care plan included a focus area initiated on 2/19/22 and last revised on 2/1/23, that the resident was at nutritional risk related to history of drug abuse with diagnoses of protein-calorie malnutrition, dementia, and dysphagia requiring a mechanical altered diet with increased protein needs due to surgical wound and low albumin (protein made by liver). Interventions include to obtain and monitor laboratory/diagnostic work as ordered, report results to physician's and follow up as indicated; provide and serve diet as ordered; provide protein-calorie dense foods with meals - pudding with meals, requests double portions; provide resident food preferences; speech therapy as ordered; and weight as ordered. On 3/2/23 at 1:36 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and Regional DON, and the surveyor informed them of the observation with Resident #17 who received thin liquids and not nectar thick liquids at lunch today. The DON confirmed this observation. The Regional DON confirmed the facility had no policy regarding therapeutic diets or ensuring residents received their diets as ordered. The surveyor asked if there was no policy and procedure, how were staff expected to know what to do? The surveyor received no answer. On 3/3/23 at 9:20 AM, the Regional DON in the presence of the [NAME] President of Operations (VP of Operations) informed the survey team that the facility as of 3/3/23, will now be adapting and implementing the Med-Pass Therapeutic Diet policy. On 3/3/23 at 10:29 AM, the surveyor interviewed the Rehabilitation Director (Rehab Director) who stated Resident #17 was currently not on speech therapy. The Rehab Director stated the resident was evaluated by speech therapy on 12/8/22 after a modified barium swallow study (X-ray test that takes pictures of the mouth and throat as a person swallows) on 12/6/22. There was a recommendation on 12/8/22, for puree foods with nectar thick liquids for aspiration risk, but the resident refused the diet change. The Rehab Director stated the current Speech Language Pathologist (SLP) was not at the facility during this time. The surveyor requested additional information on why the diet was then changed on 1/12/23. A review of the Speech Therapy SLP Evaluation and Plan of Treatment document dated 12/8/22, with a recommendation for puree and nectar thick liquids with small single sips. The resident currently refusing puree diet with nectar thick liquids. Nursing, dietary, Physician, Social Worker, and SLP (former) educated resident on health and aspiration risk however resident adamantly refusing. Resident will remain on mechanical soft diet with thin liquids per physician's orders. The surveyor continued to review the resident's medical record. A review of the Progress Notes did not include documentation as to why the resident's diet was changed on 1/12/23 to pureed foods with nectar thick liquids. On 3/3/23 at 10:53 AM, the surveyor interviewed the Food Service Director (FSD) who stated that all diet orders were put into a computer system that printed the resident's diet as well as their likes and dislikes on the meal ticket. The FSD continued that during meal service, there were three dietary aides on the tray line whose job was to check the accuracy of the meal on the tray with the meal ticket. The FSD stated as of yesterday, she was checking all meal trays with their meal tickets to ensure accuracy. The surveyor asked if the FSD checked all the lunch trays yesterday, and the FSD stated yes, she could not explain how Resident #17 received thin liquids. The FSD stated the facility only had three residents on modified liquids. On 3/3/23 at 1:28 PM, the surveyor in the presence of the LNHA, Consultant LNHA (Consult LNHA), DON, Regional DON, VP of Operations, and survey team requested additional information on why Resident #17's diet was downgraded on 1/12/23. On 3/6/23 at 11:19 AM, the Regional DON in the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to: a.) report actual resident-to-resident physical abuse to the New Jersey Department of Health (NJDOH) in accordance with state and federal guidelines, b.) report resident-to-resident verbal abuse to the NJDOH in accordance with state and federal guidelines, and c.) follow their Resident/Patient - Abuse, Neglect, Mistreatment or Misappropriation of Resident/Patient's Property Policy and Procedure. This deficient practice was identified for 12 of 12 residents, (Resident #13, #15, #26, #63, #64, #72, #82, #98, #99, #114, #115, and #320) reviewed for abuse. The facility failed to report actual incidences of abuse for Resident #15 (the victim), Resident #26 (the victim), Resident #63 (the victim), Resident #72 (the victim), Resident #82 (the victim), and Resident #114 (the victim) to the NJDOH. On 02/04/23 on the 11 PM to 7 AM shift, Resident #99 (the aggressor) punched Resident #15 (the victim) in the chest. Resident #15 was sent to the hospital for an evaluation and the police were called on 02/04/23. On 02/22/22, Resident #15 told the surveyor that Resident #99 hit him/her in the chest. Resident #15 stated that he/she did not understand why Resident #99 was still their roommate and stated that he/she still felt the punch in their chest and was concerned about being in the same room with Resident #99. Upon interviews with facility staff, it was identified that the facility staff did not report the resident-to-resident abuse to the NJDOH but should have. On 02/15/23, Resident #98 (the aggressor) hit Resident #72 (the victim) with a cane on the left arm and hand. The resident was sent to the hospital for evaluation and the police were called on 02/15/23. On 02/22/23 at 10:57 AM, the surveyor interviewed Resident #72 who stated that Resident #98 hit him/her with a cane three (3) times on the upper body. Resident #72 showed the surveyor injuries that were sustained on the left hand which consisted of bruising, swelling and abrasions on the top of the left hand. Resident #72 stated that he/she did not have a fracture of the left hand where the injuries were but stated that he/she was so angry about the resident hitting him/her with the cane, that he/she went into the dayroom and punched the wall with his/her right hand which resulted in a boxer's fracture of the right hand. He/she admitted that the injury to the right hand was self-inflicted. Review of Resident #72's Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15, which meant the resident was cognitively intact. Review of Resident #98's BIMS revealed a score of 12 out of 15, which meant this resident was also cognitively intact. Upon interviews with facility staff, it was identified that the facility staff did not report the resident-to-resident abuse to the NJDOH but should have. A review of the Audit Tool dated 02/23/23, reflected the following: -02/03/23 Resident #114 (the victim) and Resident #320 (the aggressor). Verbal aggression; abuse - yes; reported- no; comments - will report. -02/04/23 Resident #13 (the aggressor) and Resident #26 (the victim). Physical aggression; abuse- yes; reported - no; comments - will report. -02/05/23 Resident #82 (the victim) and Resident #115 (the aggressor). Physical aggression; abuse yes; reported - no; comments - will report. -02/07/23 Resident #64 (the aggressor). Physical aggression; abuse yes; reported - no; comments - will report. Resident #63 (the victim) was not listed on the facility's audit tool. On 02/03/23 at 8:22 PM, Resident #114 stated that he/she had a prior incident with Resident #320 and that Resident #320 came into their room. Resident #114 stated he/she felt scared and unsafe and 911 was called. On 02/04/23 at approximately 3:30 PM, Resident #26 stated that they were attacked by their roommate, Resident #13. Resident #26 stated he/she was punched in the legs and knees. An x-ray was done, and no injuries were identified. On 02/05/23 at 10:14 PM, Resident #82 was assaulted by their roommate, Resident #115. Police were called and Resident #115 was taken to crisis. No injuries were noted. On 02/07/23 at approximately 11:40 AM, Resident #64 hit Resident #63 with a stick. No injuries were noted. On 02/28/23 at 10:52 AM, the Licensed Nursing Home Administrator (LNHA) stated he reported the above listed incidents on 02/27/23. Upon interviews with facility staff, it was identified that the facility staff did not report the resident-to-resident abuse to the NJDOH but should have. A review of the facility's Resident/Patient - Abuse, Neglect, Mistreatment or Misappropriation of Resident/Patient's Property Policy and Procedure, reviewed 05/22/22, indicated that staff should report abuse to their supervisor immediately and appropriate agencies will be contacted by telephone to report incidences of abuse. The facility's failure to immediately report to the NJDOH and follow their facility's Residents/Patient Rights -Abuse, Neglect, Mistreatment or Misappropriation of Resident/Patient's Property Policy and Procedure resulted in an Immediate Jeopardy (IJ) situation which began on 02/04/23. The facility's LNHA and Director of Nursing (DON) were notified of the revised IJ Template on 02/23/23 at 1:56 PM. An additional revised IJ Template was provided to the LNHA and DON on 02/28/23 at 4:04 PM. On 02/28/23 at 5:43 PM, the facility provided an acceptable removal plan, and the immediacy was lifted. The evidence was as follows: Refer to F600 and F610 1.) On 02/22/23 at 12:09 PM, Resident #15 was observed lying in bed. The surveyor interviewed Resident #15 who stated they were involved in a resident-to-resident physical altercation with their roommate, Resident #99. Resident #15 stated that he/she was minding my own business when Resident #99 came up to them, hit him/her in the chest and stated he/she hated my guts. Resident #15 further stated that the nurse and the police were notified but felt that the altercation was not handled appropriately. Resident #15 stated upon returning from the emergency room (ER) that he/she did not know why Resident #99 was still their roommate. Resident #15 concluded he/she was very frustrated about the altercation and that they could still feel the punch in their chest. The resident further stated that he/she was concerned about being in the same room with Resident #99. The surveyor reviewed the electronic medical record (EMR) for Resident #15. A review of the resident's admission Record (AR) reflected that the resident was admitted to the facility in September of 2022, with diagnoses which included: Cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), Anxiety disorder, Presence of Automatic (implantable) Cardiac Defibrillator, and Epilepsy (neurological disorder in which brain activity becomes abnormal, causing seizures). A review of the most recent quarterly Minimum Data Set (MDS-an assessment tool used to facilitate the management of care) dated 12/16/22, reflected a BIMS score of 7 out of 15, which indicated that the resident had a moderately impaired cognition. A review of Resident #15's individualized Care Plan (CP) initiated on 02/06/23, two (2) days after the abuse occurred, reflected Fear related to recent physical aggression which included the following interventions: A nurse will reassure safety, discuss the reality of the situation while acknowledging what can and cannot be changed to help the patient to feel in control, and reassure the patient that feelings of fear after a traumatic event are normal. The surveyor reviewed the EMR for Resident #99. A review of the resident's AR reflected that the resident was admitted to the facility in October of 2022, with diagnoses which included: Hypertension (HTN- high blood pressure), Dysphagia (swallowing difficulties) and Cerebral Infarction (a result of disrupted blood flow to the brain). A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 13 out of 15, which indicated an intact cognition. A review of Resident #99's individualized CP initiated 02/06/23, two (2) days after he/she punched Resident #15 in the chest, reflected Aggression related to behavior disturbances which included the following interventions: The nurse will identify what is not appropriate, such as profanity and name-calling, and also what is appropriate, the nurse will provide positive feedback to let client know he/she is meeting expectations, the nurse will recognize behaviors before they become violent and the nurse will set limits on unacceptable behavior. On 02/22/23 at 2:26 PM, the survey team interviewed the facility's Social Worker (SW) who stated that she was not aware of the physical altercation that took place on 02/04/23 between Resident #15 and Resident #99 until 02/06/23, two days after the event occurred. The SW stated that she was unsure who the Nursing Supervisor (NS) contacted to make them aware of the incident, but she would have expected the NS or whomever was on-call that evening to have notified the LNHA or Assistant Director of Nursing (ADON) because a physical altercation had taken place and the police and Emergency Medical Technicians (EMTs) had to come to the facility to assess the residents. The SW further explained that on 02/06/23, she, the ADON, the LNHA, the second and third floor Unit Managers, and the Minimum Data Set Coordinator discussed the incident. She told the survey team that Resident #15 decided not to press charges against Resident #99 and that the facility's psychiatrist was made aware of the incident on 02/06/23 because the psychiatrist made rounds at the facility early that morning. The SW further stated that she was unsure if anything was done to protect Resident #15 when he/she came back to the facility, but she would have done a room change right then and there because, we work and live in a hard climate and the residents that reside here have mental illnesses and histories of aggressive behavior. The SW stated that if she was the NS, she would have done a room change to keep the residents safe. The SW did not speak to time frames for reporting or investigating a resident-to-resident altercation. On 02/22/23 at 3:09 PM, the survey team asked the ADON if the incident of physical altercation between Resident #99 and Resident #15 was investigated and reported to the NJDOH. The ADON stated that the incident should have been reported to the NJDOH within a two-hour time frame and thoroughly investigated. The ADON stated that anytime there was a physical altercation between two residents that it was a reportable event. The ADON told the survey team that after the facility reported the incident to the NJDOH, the facility had 72 hours to thoroughly investigate the incident. The ADON stated that the process for investigation should have been conducted by risk management in which statements were obtained by the residents and staff. The ADON explained that the purpose of the investigative process was to implement interventions and then safeguard the residents. The ADON told the survey team that the facility's DON and LNHA were responsible for reporting and investigating abuse. On 02/22/23 at 3:18 PM, the survey team interviewed the DON who stated that she started her position as DON for the facility on 02/01/23. The DON stated that Resident #15 was forgetful at times and cooperative with staff. The DON told the survey team that Resident #99 was more alert than Resident #15, also forgetful, and could get a little agitated when he/she did not get their way. The DON stated that when Resident #99 looked frustrated, he/she would, huff and puff like a child turn his/her head and dismiss the person that was speaking. The DON stated that she received a phone call on 02/04/23 that Resident #99 hit Resident #15 because Resident #99 was agitated and did not like what Resident #15 was watching on television. She further stated that she told the nurse that called her to call crisis and then call 911. The DON explained that 911 evaluated both residents and took Resident #15 to the hospital, and that the resident came back that same night to the facility with no injuries. The survey team asked the DON what interventions were put in place to safeguard Resident #15 and the DON stated that the Licensed Practical Nurse Unit Manager (LPN/UM) called the Psychiatrist for Resident #15 who was the victim. The DON told the survey team that she was unsure when Resident #15 was seen by the Psychiatrist. The DON further explained to the survey team that she never spoke to either of the residents regarding a room change but was told by the LPN/UM that the residents were offered a room change and neither one of the residents wanted to move out of their room. The DON stated that the LPN/UM spoke with both residents, but to her knowledge it was not documented in the either of the resident's medical records. The DON told the survey team that an incident report was completed, and statements were obtained. The DON further stated that the incident should have been reported to the NJDOH immediately and then the facility would have had time to investigate the issue. When the survey team asked the DON if she could provide documentation related to the incident the DON shook her head from side to side, indicating no. On 02/22/23 at 3:30 PM, the survey team conducted a follow up interview with the LPN/UM who stated that an incident report, not an investigation, was completed when Resident #99 hit Resident #15 in the chest. The LPN/UM further stated that there was no documentation that he could provide to reflect the resident-to-resident altercation. The LPN/UM told the surveyors that he was not in the facility when the police came and he did not speak to the residents until 02/06/23, two days after the incident occurred. The LPN/UM told the surveyors that when he spoke to the residents on 02/06/23 they did not tell him that they wanted to stay in the same room together. The LPN/UM stated that he wasn't exactly sure if Resident #15's or Resident #99's Psychiatrist or Primary Care Physicians were notified, but he was told they were notified. The LPN/UM further stated that everything that happened should have been documented in the resident's medical record. The LPN/UM told the surveyors that the facility should have reported the incident to the NJDOH immediately and an investigation should have been completed and that everything should have been documented to ensure that things were done. On 02/22/23 at 3:48 PM, the survey team interviewed the facility's LNHA who stated that his first day working at the facility was 01/23/23. The LNHA stated that there were different types of abuse and physical abuse was one of them. The LNHA stated that the process when abuse occurred was to isolate the situation and take away the alleged abuser. The LNHA stated, the first thing we do is separate. The LNHA told the surveyors that according to the Federal Regulations the NJDOH should have been notified of the event between Resident #15 and Resident #99 within two (2) hours because physical abuse had occurred. On 02/23/23 at 09:35 AM, in the presence of the survey team, the surveyor interviewed the LPN/Night Supervisor (LPN/NS) via the telephone who stated that Resident #15 informed her that he/she was punched in the chest and wanted to be evaluated at the ER. The LPN/NS stated that Resident #99 admitted to hitting Resident #15. She stated that she evaluated Resident #15 and there were no injuries and that the EMTs also evaluated Resident #15 prior to taking him/her to the ER. The LPN/NS stated that crisis evaluated Resident #99. She further stated that both residents did not want to press charges once the police arrived. The surveyor continued to interview the LPN/NS who stated she wrote a progress note in the EMR but never completed a witness statement until the facility called her last night on 02/22/23. She stated that the physical altercation occurred over the weekend, and that she notified the DON, the ADON, the LPN/UM, the SW, the LNHA, as well as both residents' families and the doctors. The LPN/NS stated that the resident-to-resident altercation was considered abuse because Resident #15 was touched. She stated that she was in-serviced on abuse and that according to the facility's policy the first things after a resident-to-resident altercation would have been to ensure the residents were separated and evaluated, and that the situation was assessed. She further stated that the residents were considered separated because Resident #15 (the victim) was brought to the nurse's station while Resident #99 (the aggressor) stayed in their shared room. The LPN/NS explained since they were not in the same room after the altercation that was how the residents were separated. She stated she was not at the facility when Resident #15 returned from the hospital. She further stated that she was told during report on 02/06/23 that Resident #15 and Resident #99 were asked if they wanted to remain in the shared room and they both agreed. The LPN/NS stated that the LPN/UM was responsible for the CP. She stated that Resident #15's CP was updated after he/she returned from the hospital but was not sure if Resident #99's CP was updated. The LPN/NS was unable to provide a response on if the CP should be updated immediately. The LPN/NS concluded that to have been protected during a physical altercation, the residents should have been separated and made sure that they were both individually in a safe space. On 02/24/23 at 09:45 AM, the surveyor interviewed LPN#1, who stated the process for reporting an incident was that the risk management form was completed in the EMR and that the nurse would have assessed the resident. She further stated that if it was an unwitnessed incident then the nurse would have done a neurological check, called the medical doctor and determined if the resident needed to be taken to the ER. On 02/24/23 at 09:52 AM, the surveyor interviewed the LPN/UM, who stated that all incidents were reported to the immediate supervisor, the DON and the LNHA. He further stated that they needed to be made aware immediately because they would have determined if the incident needed to be reported. The LPM/UM stated that if abuse was suspected then they were required to investigate the situation. On 02/24/23 at 12:12 PM, the LNHA provided three (3) Reportable Event Record/Reports which included the physical abuse between Resident #15 and Resident #99. The LNHA stated those were the only three (3) incidents in the last three (3) months. A further review of the Reportable Event Record/Report form reflected that the 02/04/23 physical abuse between Resident #15 and Resident #99 was not reported until 02/23/23. The surveyor reviewed the incident Audit Tool dated 02/23/23, which reflected the following: 02/03/23 Resident #114 and Resident #320 verbal aggression; abuse - yes; reported- no; comments - will report. 02/04/23 Resident #13 and Resident #26 Physical aggression; abuse- yes; reported - no; comments - will report. 02/05/23 Resident #82 and Resident #115 Physical aggression; abuse yes; reported - no; comments - will report. 02/07/23 Resident #64 Physical aggression; abuse yes; reported - no; comments - will report. Resident #63 was not listed A review of the electronic PN revealed the following: On 02/03/23 at 8:22 PM, Resident #114 stated that he/she had a prior incident with Resident #320 and that Resident #320 came into their room. Resident #114 stated he/she felt scared and unsafe and 911 was called. On 02/04/23 at approximately 3:30 PM, Resident #26 stated that they were attacked by their roommate, Resident #13. Resident #26 stated he/she was punched in the legs and knees. An x-ray was done, and no injuries were noted. On 02/05/23 at 10:14 PM, Resident #82 was assaulted by their roommate, Resident #115. Police were called and Resident #115 was taken to crisis. No injuries were noted. On 02/07/23 at approximately 11:40 AM, Resident #64 hit Resident #63 with a stick. No injuries were noted. 2.) The surveyor reviewed the EMR for Resident #114. A review of the resident's AR reflected that the resident was admitted to the facility in January of 2023, with diagnoses which included: Major Depressive Disorder, Hypertension (HTN- high blood pressure), and Type 2 [two] Diabetes Mellitus (DM- high blood sugar). A review of the most recent admission MDS dated [DATE], reflected a BIMS score of 15 out of 15, which indicated an intact cognition. A review of Resident #114's individualized CP, initiated 01/20/23 and revised 02/17/23, did not reflect the residents fear after the altercation with Resident #320. A further review revealed, Focus: the resident has a psychosocial well-being problem potential related to recent admission. The interventions included: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears as needed. The surveyor reviewed the EMR for Resident #320. A review of the resident's AR reflected that the resident was admitted to the facility in October of 2022, with diagnoses which included: Major Depressive Disorder, Psychoactive Substance Abuse, and Acute Kidney Failure. A review of the most recent admission MDS dated [DATE], reflected a BIMS score of 14 out of 15, which indicated an intact cognition. A review of Resident #320's individualized CP, revised 02/06/23, does not reflect the resident's previous history of inappropriate behaviors with other residents and staff. A further review revealed, Focus: the resident has a psychosocial well-being problem potential related to anxiety, ineffective coping, and recent admission. The interventions included: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears as needed. 3.) The surveyor reviewed the EMR for Resident #13. A review of the resident's AR reflected that the resident was admitted to the facility in July of 2022, with diagnoses which included: Schizophrenia, Anxiety disorder, HTN, and DM. A review of the most recent admission MDS dated [DATE], reflected a BIMS score of 00 out of 15, which indicated a severely impaired cognition. A review of Resident #13's individualized CP initiated 02/06/23, two (2) days after he/she hit Resident #26, reflected Aggression related to behavior disturbances which included the following interventions: The nurse will identify what is not appropriate, such as profanity and name-calling, and also what is appropriate, the nurse will provide positive feedback to let client know he/she is meeting expectations, the nurse will set limits on unacceptable behavior. The surveyor reviewed the EMR for Resident #26. A review of the resident's AR reflected that the resident was admitted to the facility in August of 2020, with diagnoses which included: schizoaffective disorder, altered mental status, generalized anxiety disorder and DM. A review of the most recent Significant Change MDS dated [DATE], reflected a BIMS score of 11 out of 15, which indicated a moderately impaired cognition. A review of Resident #26's individualized CP initiated 02/06/23, two (2) days after the alteration occurred, reflected Fear related to recent physical aggression which included the following interventions: A nurse will reassure safety, discuss the reality of the situation while acknowledging what can and cannot be changed to help the patient to feel in control, and reassure the patient that feelings of fear after a traumatic event are normal. 4.) The surveyor reviewed the EMR for Resident #82. A review of the resident's AR reflected that the resident was admitted to the facility in January of 2023 and readmitted in February of 2023, with diagnoses which included: presence of Automatic (implantable) cardiac defibrillator, heart failure, and DM. A review of Resident #82's CP, initiated 02/08/23, does not reflect any interventions related to the altercation the resident had with Resident #115. The surveyor reviewed the EMR for Resident #115. A review of the resident's AR reflected that the resident was admitted to the facility in January of 2023, with diagnoses which included: Asthma and fractured neck. A review of the most recent admission MDS dated [DATE], reflected a BIMS score of 14 out of 15, which indicated an intact cognition. A review of Resident #115's individualized CP, initiated 01/25/23 and revised 02/08/23, does not reflect the resident's previous history of physical aggression. A further review revealed, Focus: the resident has a psychosocial well-being problem potential related to lack of motivation and recent admission which included the following interventions: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears as needed. 5.) The surveyor reviewed the EMR for Resident #63. A review of the resident's AR reflected that the resident was admitted to the facility in December of 2021, with diagnoses which included: muscle weakness and pneumothorax (collapsed lung). A review of the most recent Annual MDS dated [DATE], reflected a BIMS score of 11 out of 15, which indicated a moderately impaired cognition. A review of Resident #63's individualized CP, initiated 02/07/23, reflected Fear related to recent physical aggression which included the following interventions: A nurse will reassure safety, discuss the reality of the situation while acknowledging what can and cannot be changed to help the patient to feel in control, and reassure the patient that feelings of fear after a traumatic event are normal. The surveyor reviewed the EMR for Resident #64. A review of the resident's AR reflected that the resident was admitted to the facility in January of 2023, with diagnoses which included: Psychoactive substance abuse, generalized anxiety disorder, Major Depressive disorder, and opioid dependence with opioid-induced mood disorder. A review of the most recent Significant Change MDS dated [DATE], reflected a BIMS score of 10 out of 15, which indicated a moderately impaired cognition. A review of Resident #63's individualized CP initiated 02/08/23, reflected Aggression related to behavior disturbances which included the following interventions: The nurse will identify what is not appropriate, such as profanity and name-calling, and also what is appropriate, the nurse will provide positive feedback to let client know he/she is meeting expectations, the nurse will recognize behaviors before they become violent, the nurse will set limits on unacceptable behavior. On 02/28/23 at 10:52 AM, the survey team interviewed the DON in the presence of the Regional DON (RDON) and the LNHA who stated that she was still learning the progress but that she was responsibe for filling out the audit tool for abuse. The DON further stated that the Regional Nurse/Infection Preventionist (RN/IP), had filled out the audit tool that was provided to the survey team. At that time, the LNHA stated for the incidents listed on the audit tool that he did not report them at the time of the incidents. He further stated that he did not report them until yesterday, 02/27/23. On 02/28/23 at 10:58 AM, the survey team continued to interview the DON who stated that abuse included verbal and physical. The DON stated that suspected abuse should have been reported immediately to the supervisors and then the LNHA would have reported it to the NJDOH. On 02/28/23 at 11:09 AM, the survey team interviewed the RN/IP in the presence of the RDON who stated she completed the abuse audit tool on 02/23/23. The RN/IP stated that the administrative team was not sure if the incidents on the audit tool were considered reportable but that they aired on a side of caution and reported them yesterday, 02/27/23. The RN/IP acknowledged any allegation of abuse was considered a reportable event. The RN/IP stated that there was no other abuse audit done prior to the survey team inquiry. She further stated that all alleged abuse should have been reported immediately but that the administrative team investigated all the incidents and concluded they were unsubstantiated and were not considered abuse. On 03/06/23 at 11:00 AM, in the presence of the survey team, the DON and the Regional DON, the Consultant LNHA stated that there was a lack in the investigation and reporting process regarding resident-to-resident altercations. A review of the facility's Abuse Coordinator job description signed by the LNHA on 1/23/23 included the following: 1. The Administrator has the overall responsibility for the coordination and implementation for our facility's abuse prevention program. 2. The Abuse Coordinator will oversee, and delegate education and in-services related to allegations of abuse, identifying abuse and reporting abuse. A review of the facility's Incident/Occurrence Investigation Policy revised 05/22/22, included 1. All incidences of alleged abuse, mistreatment, or neglect of a resident by staff, other residents, visitors, etc. will be investigated. 4. The results of investigation that indicates that abuse, neglect, or mistreatment has occurred, or cannot be conclusively ruled out, will be reported to the DOH [Department of Health] utilizing standard reporting procedures. A Review of the facility's Resident/Patient Rights - Abuse, Neglect, Mistreatment or Misappropriation of Resident/Patient's Property reviewed 05/22/22, included IV. Identification. B1. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish 4. Physical abuse is defined as hitting, slapping, pinching, kicking, etc VII. Protection A. While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to the resident/patientA review of the facility's Incident/Occurrence Investigation Policy revised 05/22/22, included 1. All incidences of alleged abuse, mistreatment, or neglect of a resident by staff, other residents, visitors, etc. will be investigated. 4. The results of investigation that indicates that abuse, neglect, or mistreatment has occurred, or cannot be conclusively ruled out, will be reported to the DOH [Department of Health] utilizing standard reporting procedures. A Review of the facility's Resident/Patient Rights - Abuse, Neglect, Mistreatment or Misappropriation of Resident/Patient's Property, reviewed 05/22/22, included IV. Identification. B1. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish 4. Physical abuse is defined as hitting, slapping, pinching, kicking, etc . VI. Investigation Procedure B. The Nursing Supervisor or designee will contact the Abuse Coordinator and provide any supporting documentation relative to the investigation. C. The representative's investigation shall consist of 1. A comprehensive review of the event or incident; 2. An interview with the person(s) reporting the incident; 3. Interviews with any witness of the incident .6 Interview with all staff members (on all shifts) having contact with the resident .8 A review or all circumstances surrounding that incident VII. Protection A. While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to the resident/patient. 6.) According to the AR, Resident #72 was admitted to the facility with diagnoses which included but were not limited to, alcohol abuse, cirrhosis of the liver, major depressive disorder, and fracture of the neck. The MDS dated [DATE], indicated that the resident scored a 15 out of 15 on[TRUNCATED]

Based on observation, interview, record review, and review of pertinent facility documentation it was determined, that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility's policies and procedures were implemented to ensure resident safety and well-being, by failing to: a.) ensure Resident #15 (the victim) was safeguarded from physical abuse from Resident #99 (the aggressor), b.) report an actual incident of abuse between Resident #15 and Resident #99; Resident #72 and Resident #98; Resident #13 and Resident #26; Resident #63 and Resident #64; Resident #82 and Resident #115; Resident #114 and Resident #320 to the New Jersey Department of Health (NJDOH), and c.) provide safe meal delivery for Resident #94, who was at risk for aspiration (when food, drink, or foreign objects are breathed into the lungs), according to the physician prescribed diet order to include nectar thickened liquids. The LNHA's failure to ensure that the facility's policies and procedures were implemented to ensure resident safety and well-being posed a serious risk of adverse outcome to the resident's residing at the facility and resulted in an Immediate Jeopardy (IJ) situation. The facility's LNHA was made aware of the IJ situation on 03/01/23 at 4:51 PM and an acceptable Removal Plan was received on 03/03/23 at 9:35 AM. The IJ began on 02/04/23 when the facility's LNHA failed to safeguard Resident #15 (the victim) from physical abuse from Resident #99. The LNHA further failed to notify the NJDOH of the incident between Resident #15 and Resident #99 on 02/04/23. A further review of the facility's resident-to resident altercations indicated that the facility failed to report an additional five (5) reportable events involving 10 resident's. The facility's failure to ensure a resident with a history of aspiration on thin liquids and a physician order for nectar thick liquids was provided nectar thick liquids posed a serious and immediate threat for adverse effects, including aspiration, which was likely to result in serious harm, impairment, or even death. The deficient practice was evidenced by the following: Refer to F600J, F609K, and F689J 1.) On 02/22/23 at 12:09 PM, Resident #15 was observed lying in bed. The surveyor interviewed Resident #15 who stated that they were involved in a resident-to-resident physical altercation with their roommate, Resident #99. Resident #15 stated that he/she was minding my own business when Resident #99 came up to them, hit him/her in the chest and stated he/she hated my guts. Resident #15 further stated the nurses, and the police were notified but felt that the altercation was not handled appropriately. Resident #15 stated upon returning from the emergency room he/she did not know why Resident #99 was still their roommate. Resident #15 concluded he/she was very frustrated about the altercation and that they could still feel the punch in their chest. The resident further stated that he/she was concerned about being in the same room with Resident #99. Resident #15 (the victim) was never separated from Resident #99 (the aggressor). The residents remained in the same room together. Upon interviews with facility staff and record review there were no prior physical altercations/incidents between Resident #15 and Resident #99. A review of the electronic Progress Notes reflected on 02/04/23 at 7:00 AM, Resident #15 (the victim) was punched in the chest by the roommate Resident #99 (the aggressor). A review of Resident #15's individualized Care Plan (CP) initiated 02/06/23 two (2) days after the abuse occurred, reflected Fear related to recent physical aggression which included the following interventions: A nurse will reassure safety, discuss the reality of the situation while acknowledging what can and cannot be changed to help the patient to feel in control, and reassure the patient that feelings of fear after a traumatic event are normal. On 2/23/23 at 12:41 PM, the surveyor interviewed Resident #99's primary care physician who stated he was informed that the resident had a history of aggressive behaviors but was unable to specify. He further stated that after the physical altercation between the two residents, they should not have remained in the same room. A review of Resident #99's (the aggressor) medical record did not reflect behavioral interventions after the resident-to resident altercation to prevent physical abuse. A review of Resident #99's Care plan initiated 02/06/23 two (2) days after he/she punched Resident #15 in the chest, reflected Aggression related to behavior disturbances which included the following interventions: The nurse will identify what is not appropriate, such as profanity and name-calling, and also what is appropriate, the nurse will provide positive feedback to let client know he/she is meeting expectations, the nurse will recognize behaviors before they become violent and, the nurse will set limits on unacceptable behavior. On 02/22/23 at 3:48 PM, the survey team interviewed the facility's LNHA who stated that his first day working at the facility was 01/23/23. The LNHA stated that there were different types of abuse and physical abuse was one of them. The LNHA stated that the process when abuse occurred was to isolate the situation and take away the alleged abuser. The LNHA stated the first thing we do is separate. The LNHA told the surveyors that according to the Federal Regulations the NJDOH should have been notified of the event between Resident #15 and Resident #99 within two (2) hours because physical abuse had occurred. The LNHA further stated that he wasn't familiar with the investigative findings of the event because nursing handled the situation. The LNHA told the survey team that it was his understanding that there was a resident-to-resident altercation, the police were notified and both residents in question did not want to press charges. The LNHA could not speak to why Resident #99 (the aggressor) would legally be able to press charges against Resident #15 (the victim). The LNHA stated that it was also his understanding that when Resident #15 returned from the hospital, the nurse spoke with both residents and the residents wanted to stay in the room together. The LNHA stated that he was the person responsible for making sure that abuse was thoroughly investigated in the facility. On 03/06/23 at 11:00 AM, the Consultant LNHA in the presence of the survey team, DON and Regional DON acknowledged that Resident #15 and Resident #99 should have been separated after the incident. The Consultant LNHA stated that there was a lack in the investigation and reporting process regarding resident-to-resident altercations. A review of the facility's Abuse Coordinator job description, signed by the LNHA on 01/23/23, included the following: 1. The Administrator has the overall responsibility for the coordination and implementation for our facility's abuse prevention program. 2. The Abuse Coordinator will oversee, and delegate education and in-services related to allegations of abuse, identifying abuse and reporting abuse. 2.) The facility failed to report actual incidences of abuse for Resident #15 (the victim), Resident #26 (the victim), Resident #63 (the victim), Resident #72 (the victim), Resident #82 (the victim), and Resident #114 (the victim) NJDOH. On 2/4/23, Resident #99 (the aggressor) punched Resident #15 (the victim) in the chest. Resident #15 was sent to the hospital for an evaluation and the police were called on 2/4/23. On Wednesday 2/22/22, Resident #15 told the surveyor that Resident #99 hit him/her in the chest. Resident #15 stated that he/she did not understand why Resident #99 was still their roommate and stated that he/she still felt the punch in their chest and was concerned about being in the same room with Resident #99. Upon interviews with facility staff, it was identified that the facility staff did not report the resident-to-resident abuse to the NJDOH but should have. On Wednesday 2/15/23, Resident #98 (the aggressor) hit Resident #72 (the victim) with a cane on the left arm and hand. The resident was sent to the hospital for evaluation and the police were called on 02/15/23. On 02/22/23 at 10:57 AM, the surveyor interviewed Resident #72 who stated that Resident #98 hit him/her with a cane three (3) times on the upper body. Resident #72 showed the surveyor injuries that were sustained on the left hand which consisted of bruising, swelling and abrasions on the top of the left hand. Resident #72 stated that he/she did not have a fracture of the left hand where the injuries were but stated that he/she was so angry about the other resident hitting him/her with the cane, that he/she went into the dayroom and punched the wall with his/her right hand resulting in a boxers' fracture of the right hand. He/she did admit that this injury to the right hand was self-inflicted. Upon review of the Resident #72's Brief interview for Mental Status (BIMS) score of 15, the resident was cognitively intact. Upon review of Resident #98's BIMS score of 12, this resident was also cognitively intact. Upon interviews with facility staff, it was identified that the facility staff did not report the resident-to-resident abuse to the NJDOH but should have. On 02/24/23 at 12:12 PM, the LNHA provided three (3) Reportable Event Record/Reports which included the physical abuse between Resident #15 and Resident #99. The LNHA stated those were the only three (3) incidents in the last three (3) months. A further review of the Reportable Event Record/Report form reflected that the 02/04/23 physical abuse between Resident #15 and Resident #99 was not reported until 02/23/23. The surveyor reviewed the incident Audit Tool dated 2/23/23, which reflected the following: A review of the Audit Tool dated 2/23/23, reflected the following: -2/3/23 Resident #114 (the victim) and Resident #320 (the agressor). Verbal aggression; abuse - yes; reported- no; comments - will report. -2/4/23 Resident #13 (the agressor) and Resident #26 (the victim). Physical aggression; abuse- yes; reported - no; comments - will report. -2/5/23 Resident #82 (the victim) and Resident #115 (the agressor). Physical aggression; abuse yes; reported - no; comments - will report. -2/7/23 Resident #64 (the agressor). Physical aggression; abuse yes; reported - no; comments - will report. Resident #63 (the victim) was not listed on the facility's audit tool. On 02/28/23 at 10:52 AM, the survey team interviewed the DON in the presence of the Regional DON (RDON) and the LNHA who stated that she was still learning the progress but that she was responsibility for filling out the audit tool for abuse. The DON further stated that the Regional Nurse/Infection Preventionist (RN/IP), had filled out the audit tool that was provided to the survey team. At that time, the LNHA stated for the incidents listed on the audit tool he did not report at the time of the incidents. He further stated that he did not report them until yesterday 2/27/23. On 2/3/23 at 8:22 PM, Resident #114 stated that he/she had a prior incident with Resident #320 and that Resident #320 came into their room. Resident #114 stated he/she felt scared and unsafe 911 was called. On 2/4/23 at approximately 3:30 PM, Resident #26 stated that they were attacked by their roommate Resident #13. Resident #26 stated he/she was punched in the legs and knees. An x-ray was done, and no injuries were identified. On 2/5/23 at 10:14 PM, Resident #82 was assaulted by their roommate Resident #115. Police were called and Resident #115 was taken to crisis. No injuries were noted. On 2/7/23 at approximately 11:40 AM, Resident #64 hit Resident #63 with a stick. No injuries were noted. On 2/28/23 at 10:52 AM, the Licensed Nursing Home Administrator (LNHA) stated he reported the above listed incidents on 2/27/23. Upon interviews with facility staff, it was identified that the facility staff did not report the resident-to-resident abuse to the NJDOH but should have. On 02/24/23 at 10:52 AM, the surveyor interviewed the DON who stated that she was made aware of the altercation between Resident #72 and Resident #98, and she investigated the incident. She stated that it was not reported to her that Resident #98 had struck Resident #72 with a cane, and she was not aware that this was a physical altercation. She stated that she thought that the altercation between the two residents was just a verbal altercation. She stated that she investigated the incident but could not speak to why she did not know that Resident #72 was struck with a cane by Resident #98 and had injuries to his/her left hand. The DON further stated that the LNHA and the DON were responsible to make sure that the investigation was complete and through. She stated that when both the residents retuned from the hospital that Resident #98 (aggressor) was moved to a different hallway and away from Resident #72 (victim). She stated that both residents were seen by the psychiatrist. The DON did not have an answer to as why the Care plan (CP) was not updated after the altercation to include these behaviors or why interventions were not implemented on the CP for Resident #98's or Resident #72's. The DON also revealed that she did not know if the altercation between the two residents was reported to the NJDOH. She stated that she did not interview Resident #98 because the resident had PTSD and heard voices and she did not think that this resident would be reliable. The DON further revealed that she did not interview Resident #72 regarding the altercation because the resident was blacked out mad. She explained that the resident did not lose consciousness however Resident #72 was blacked out mad and she did not think if she interviewed him/her that he/she would be reliable. The DON also did not have a response as to why there were no skin assessment done on either resident after the altercation and did not know that Resident #72 suffered injuries on his/her left hand after being hit by Resident #98's cane. On 02/24/23 at 11:07 AM, the surveyor interviewed the LNHA who stated he was aware that there was some sort of altercation between Resident # 72 and Resident #98 however was not aware there was an actual strike with a cane to Resident #72 left arm or hand. The LNHA stated that the nursing administration was responsible to investigate and conduct a thorough and complete investigation. The LNHA confirmed that the incident was not reported to the NJDOH. The LNHA did not have an answer as to why the DON did not interview Resident #72 or Resident #98 during her investigation and the LNHA was not aware that Resident #72 suffered injuries to his/her left hand during the altercation with Resident #98. The surveyor reviewed the facility policy titled, Incident/Occurrence Investigation Policy dated 05/22/22, which indicated that all incidences of alleged abuse, mistreatment, or neglect of a resident by staff, other residents, visitors, etc. will be investigated. The procedures were as follows according to the facility policy: -Following the occurrence or notification or complaint the Registered Nurse Manager or Registered Nurse Supervisor will submit to the DON, a copy of the accident/report with staff members statements. -The DON-nursing/designee will promptly notify the Administrator that the investigation has occurred. -Nursing Administration or Social Services will conduct their initial investigation and review all pertinent documentation related to the event within 24 hours. -A summary will of the investigation will be documented and the Administrator, DON-nursing designee will meet to review the summary of the investigation to decide if an event is reportable to the NJDOH. The medical director and social services may be asked to participate in the decision-making process depending on the type of event that has occurred. -The Administrator, DON-Nursing designee will notify the DOH when applicable. 3.) On 03/01/23 at 12:16 PM, the surveyor observed Resident #94 in bed with two unopened apple juices and one opened twenty-four-ounce bottle of soda. The resident stated the liquids were thin; he/she drank thin liquids. On 03/01/23 at 12:26 PM, the surveyor observed the resident's Certified Nursing Aide (CNA) deliver the resident's lunch meal tray which contained a mechanically altered diet with apple juice that CNA confirmed was thin liquid. Interview with both the resident's CNA and Licensed Practical Nurse (LPN) revealed the resident was on a thin liquid diet. Review of resident's medical record reflected a Progress Note dated 02/14/23, that the resident returned from an appointment with aspiration (accidental breathing in of fluid or food into the lungs) on thin liquids and penetration (making a way through) of the lungs on nectar thick (liquids thickened with an agent for a nectar-like consistency) liquids. A review of the physician's orders (PO) revealed a PO dated 02/22/23 for nectar thick liquids. Interview with the Speech Language Pathologist (SLP) indicated the resident had a swallowing study performed on 02/14/23, with the results of aspiration on thin liquids and penetration of the lungs on nectar thick. The SLP stated the resident was picked up by therapy on 02/17/23 to improve swallowing of nectar thick liquids and should have been started on nectar thick liquids on 02/14/23. Interview with the dietary staff revealed there was no communication with them for the resident's diet change. Follow-up observation with LPN confirmed the resident had thin liquids present in their room. LPN verified the PO and confirmed the resident had a PO dated 02/22/23 for nectar thick liquids. On 3/1/23 at 1:47 PM, the SLP provided the surveyor with the resident's speech therapy notes. The SLP stated that she had only been at the facility for three weeks now but did evaluate Resident #94 who was referred to her after a swallow study. The SLP stated on 02/14/23, the resident received a fiberoptic endoscopic evaluation of swallowing (FEES) which was a camera attached to a small tube that went down the resident's throat and the evaluator was able to see the resident aspirated on thin liquids, which meant liquids went into the windpipe. The SLP stated that there was also penetration of the lungs with nectar thick liquids, which meant liquid went into the lungs when the resident had nectar thick liquids. The surveyor asked if penetration of the lungs was bad, and the SLP stated yes, because it could cause pneumonia continuing with nectar thick liquids. The SLP stated the purpose of speech therapy was to teach the resident techniques to block the airway to tolerate the nectar thick liquids so that was why nectar thick liquids were recommended. The SLP stated she thought the resident was already on nectar thick liquids when she started at the facility on 2/14/23, and the resident was evaluated on 2/17/23 by her. The SLP stated the resident at this time would not be a candidate for thin liquids because of the aspiration risk. On 3/1/23 at 3:05 PM, the surveyor conducted a follow up interview with the SLP and asked the SLP when Resident #24 should have started on thickened liquids. She responded on 2/14/23 when the resident was seen by the Hospital SLP. At this time, the Rehab Director stated that therapy picked the resident up at that time and gave the Registered Dietician the referral as well. On 3/1/23 at 4:43 PM, the survey team met with the LNHA, Director of Nursing (DON), and Regional DON. The Regional DON stated the facility had no policy for physician's orders; the facility followed standards of practice. The surveyor asked the LNHA if he was aware the facility had no policy for physician's order, and he stated no. The surveyor asked what the standard of practice for physician's orders was, and the Regional DON stated they would need to look it up. The LNHA confirmed the facility had nothing in writing, would be standards of practice. The LNHA confirmed the expectation would be to follow a physician's order. The DON then confirmed there was no policy for obtaining diet orders. The DON confirmed the expectation was the nurse gave kitchen staff a diet order slip and a copy went in the resident's paper medical record. The Administration team confirmed there was no policy for therapeutic diets or giving residents food. The DON stated if a diet changed, the same procedure as diet order. The LNHA confirmed the expectation would be to provide the resident with the appropriate consistency of the therapeutic diet as ordered. A review of the facility's newly implemented Therapeutic Diets policy implemented 3/3/23, included therapeutic diets will be prescribed by the Attending Physician .mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. A therapeutic diet must be prescribed by the resident's Attending Physician. The physician's diet order should match the terminology used by Food Services .the Food Service Manager will establish and use a tray identification system to ensure each resident received his or her diet as ordered . A review of the Administrator Job Description, signed by the LNHA on 01/23/23, included the following: The Administrator establishes, directs and is responsible for the overall operation of the Facility's internal and external activities and works to ensure regulatory and corporate compliance, quality assurance, and the fiscal viability of the facility . Responsible for the overall organization and management of the facility Maintains a fundamental knowledge and awareness of the status of all residents .Develops, revises, and implements policies and procedures to enhance service provision and operations .Protects residents' rights and develops mechanisms for protection Ensures accurate documentation, implementation, and compliance of all issues. N.J.A.C. 8:39-9.2(a)