Every finding on record at Acclaim Rehabilitation and Nursing Center

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 3/31/25 at 9:14 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour. 1. In walk-in refrigerator #1, the surveyor observed a blackish dust like substance in the gasket. 2. The surveyor observed on the 3-spout coffee machine a hard water build up on top of machine and on the first coffee spout had a brownish sticky substance on the spout. 3. The surveyor observed puddle of water below the hand washing, the water was coming from a leaking pipe. 4. In the Chef preparatory area, the surveyor observed a standing blender with a crumblike substance on base and outside of blender along with a sticky blackish colored substance on blender. 5. On top of the standing oven, the surveyor observed a blackish dust-like substance and on the inside of the oven was observed with a burnt on blackish colored substance. 6. The surveyor observed the Tilt skillet with yellowish grease-like substance that had pooled in the corner. 7. The surveyor observed 1 Dietary aide (DA#1) with large hoop earrings and 1 Dietary aide (DA#2) observed with hair not fully covered under hairnet. Both DAs interviewed, DA#1 stated she forget to take, DA#2 stated they are aware hair needs to be fully covered and had not realized their hair was not covered On 4/01/25 at 10:00 AM, during the follow up inspection of the kitchen, the surveyor observed Dietary aide (DA#3) observed with large hoop earrings. DA #3 stated they had forgot to take them before work started. On 4/1/25 at 11:30 AM, the FSD provided the surveyor with two facility policies, Uniform policy and procedures with an effective date of 1/20/2022. The uniform policy stated under the procedure section, wear hair restraints to prevent from contacting exposed food. Jewelry is kept to a minimum; facial piercings are to be removed or covered. Surveyor asked on two occasions for a policy regarding kitchen equipment cleaning but was not provided by facility. On 4/3/25 at 1:04 PM, the surveyor met with the Licensed Nursing Home Administrator (LHNA), Director of Nursing (DON), Regional Nurse (RRN) and Chief Operations Officer (COO) to review survey concerns. The LHNA stated they kitchen equipment cleaning policy the surveyor requested would be provided by tomorrow morning. On 4/3/25 at 11:00 AM, the surveyor met with the LHNA, DON, RRN and COO for the exit conference. The facility did not provide any further pertinent information. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to develop and implement smoking policies in accordance with state law and regulations to provide smoke-free air which prohibits indoor smoking in healthcare facilities. This deficient practice was observed for 1 of 1 designated smoking areas and was evidenced by the following: Reference: N.J.A.C. 8:6 Smoke-Free Air prohibits smoking in most workplaces as well as in indoor public areas. It included a list of all of the indoor public places and workplaces where smoking was banned, which included healthcare facilities. A review of the Smoking Policy last updated 7/7/24, provided by the LNHA on 3/31/25, included that the smoking area for the facility was located on the K floor (3rd floor) of the facility (provisional due to renovations) down the hallway from the dayroom close to the high side room numbers. On 3/31/25 at 11:15 AM, during the initial tour of the K-Unit on the third floor, the surveyor observed double doors that led to the designated smoking room (DSR). Inside the room, there were two residents observed smoking cigarettes. The surveyor observed that the windows in the room were unable to be opened. There was a designated employee, the SRM, outside of the smoking room who was monitoring the residents who were inside the smoking room. At that same time, the surveyor interviewed the SRM who stated that the windows did not open and that the patio door was locked and was closed off. She further stated that the residents were only permitted to smoke inside of the room and did not go outside to smoke. On 3/31/25 at 11:20 AM, the surveyor observed Resident #47 in the DSR sitting next to an open ashtray smoking a cigarette. On that same date and time, the surveyor interviewed Resident #47, who stated they smoke in the DSR three times per day and have been since their admission into the facility. The resident further stated that the windows in the DSR did not open and that the residents who smoked did not go onto the adjoined patio. Resident #47 further stated they had a smoking assessment completed on their third day in the facility and signed a contract stating they understood and would not break the facility's smoking rules and regulations. On that same date and time, the surveyor observed that all windows were unable to be opened and a balcony door was closed off and locked in the DSM which was verified by the SRM. The surveyor observed two standing ashtrays and four outdoor Cease-Fire ashtrays that were missing the self-closing lids. A review of the manufacture's specifications for the ashtrays provided by the LNHA, revealed that the two standing ashtrays were made of stainless steel and the four outdoor Cease-Fire ashtrays were made of [NAME] steel. On 3/31/25 at 11:30 AM, the LNHA acknowledged that the six ashtrays in the DSM did not have covers. On 3/31/25 at 12:00 PM, the surveyor reviewed the medical record for Resident #47. A review of Resident #47's face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; anxiety disorder, unspecified fall, and essential hypertension. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 3/19/25, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had an intact cognition. A review of Resident #47's New/Re-admission Assessments created on 3/12/25, revealed under the smoking assessment tool, that the resident displayed a safe smoking technique and was able to smoke safely. A further review of Resident #47's medical record revealed a form titled, Acknowledgement of smoking polices and agreement to follow the smoking rules, that was signed by Resident #47 and witnessed on 3/14/25. A review of Resident #47's individualized comprehensive care plan (ICCP) included a focus area dated 3/15/25, that the resident has an activity: smoking related to (r/t) known history of smoking. Interventions included: I verbalize and demonstrate knowledge and understanding of the smoking rules, I will only smoke in designated areas, and I will remain compliant with the smoking contract as per facility policy. On 3/31/25 at 11:20 AM, the surveyor observed Resident #119 in the DSR finish smoking a cigarette and placed the cigarette into an open ashtray. At that same time, the surveyor interviewed Resident #119 who stated this is where I was told by facility staff, we can smoke. On 3/31/25 at 12:10 PM, the surveyor reviewed the medical record for Resident #119. A review of Resident #119's face sheet revealed the resident was admitted to the facility with diagnoses that included but were not limited to; muscle wasting and atrophy, anxiety disorder, and hyperlipidemia. A review of the resident's quarterly MDS dated [DATE], reflected a BIMS score of 15 out of 15, which indicated that the resident had intact cognition. A review of Resident #119's Recreation Admission/Readmission Assessments created on 9/25/24, revealed under the smoking assessment tool, that the resident displayed a safe smoking technique and was able to smoke safely. A further review of Resident #119's medical record revealed a form titled, Acknowledgement of smoking polices and agreement to follow the smoking rules, that was signed by Resident #119 and witnessed on 1/17/25. A review of Resident #119's ICCP included a focus area dated 9/27/24, that the resident has an activity: smoking related to (r/t) known history of smoking. Interventions included: I verbalize and demonstrate knowledge and understanding of the smoking rules, I will only smoke in designated areas, and I will remain compliant with the smoking contract as per facility policy. On 3/31/25, at 1:49 PM, the surveyor conducted an interview with the Housekeeping Director (HD), who stated that the cigarette ashes were disposed of four times per day, placed into a metal container after water was poured into the container and all ashes were disposed of with the regular trash in the facility. On 3/31/25 at 2:30 PM, the surveyor interviewed the LNHA who stated that indoor smoking had been on-going since April 2022, but was not sure of the exact date. NJAC 8:39-31.6(e)

Based on observation, interview, and record review, it was determined that the facility failed to ensure (a). that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 8 (eight) residents (Resident #34) observed during the medication observation pass and (b), to follow acceptable standards of clinical practices for accurately administering medications according to PO. This deficient practice was identified in 1 (one) and 7 (seven) residents (Resident #10 ) reviewed for medication administration. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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. A). On 04/02/25 at 9:10 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN#1) in the room of Resident #34. The surveyor observed RN #1 checking the resident's identification bracelet and informed Resident #34 that she would be administering the resident's medications. On 04/08/25 at 8:35 AM, the surveyor observed LPN #1 preparing to administer nine (9) medications to Resident #34 which included the following: Triphrocaps capsule (supplement), Metoprolol ER 25 mg tablet (blood pressure), Aspirin 81 mg, Depakote 125 mg tablet (seizures), Bisacodyl (laxative), Acetaminophen (pain), Xanax 0.25 mg (anxiety), Gabapentin (pain) and Keppra 750 mg (seizures). Prior to LPN#1 preparing the resident's Xanax, the surveyor noticed the amount of tablets in the bingo card (medication packaging) did not match the amount remaining in the narcotic inventory book. At that time, the surveyor interviewed LPN#1 who stated that she just took over the medication cart from the Registered Nurse/Unit Manager (RN#1/UM) who had to take care of another situation on the nursing unit. She stated that the RN#1/UM) already administered Resident #34's Xanax. LPN#1further acknowledge that both the electronic medication administration record (EMAR) and narcotic inventory book were both not documented as being administered by the RN#1/UM. On 4/08/25 at 8:40 AM, the surveyor interviewed RN#1/UM who acknowledge that she administered Resident #34's Xanax and that she should have documented both the EMAR and the narcotic inventory book. She stated that the proper practice is to full out the narcotic log book while preparing the medication for administartion and signing the EMAR after the medication was administered. On 4/8/25 at 8:45 AM, during medication administration, LPN#1 informed the resident that they were not receiving the Xanax since that other nurse already administered the medication. At that time, the surveyor interviewed Resident #34 who's cognitvely intact. The resident told the surveyor that they already received Xanax. On 4/8/25 at 10:15 AM, the surveyor inspected all of the facility's medication storage areas which included 6 (six) medication carts and three (3) medication refrigerators. The surveyor inspected all narcotic storage area and conducted a narcotic count with all nurses who were present during medication storage inspection. The surveyor found no discrepancies with the narcotic counts with all narcotics in the facility being accounted for and all nurses who were interviewed stating that narcotic counts are done with every shift change. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), hypertension (a condition in which the force of the blood against the artery walls is too high), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). A review of the annual Minimum Data Set, an assessment tool used to facilitate the management of care, dated 12/26/24, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident's cognition was cognitively intact. A review of the April 2025 Physician's Orders (PO) revealed a Physician's Order dated 4/1/25, for Xanax 0.25 mg tablet, give 1 tablet (0.25mg) by oral route every 12 hours (9:00AM and 9:00PM) for generalized anxiety. A review of the April 2025 EMAR revealed an order dated 04/1/25, for Xanax 0.25 mg give a tablet (0.25mg) by oral route every 12 hours (9:00 AM and 9:00 PM) for generalized anxiety. B). On 3/31/25 at 12:08 PM, the surveyor observed Resident #10 during initial tour seated in their wheelchair on the J unit activity room watching television with other residents. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), hypertension (a condition in which the force of the blood against the artery walls is too high), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 1/23/25, reflected that the resident's cognitive skills for daily decision-making score was 7 out of 15, which indicated severe cognitive impairment . A review of the April 2025 Physician's Orders (PO) revealed a Physician's Order dated 02/27/25 for Insulin Lispro (U-100) 100 unit/ml subcutaneous solution, inject units' subcutaneous route 3 times per day (7:30 AM, 11:30 AM and 4:30 PM). Inject per sliding scale, 150-199 = 2 units, 200-249 = 4 units, 250-299 = 6 units, 300-349 = 8 units, 350-400 = 10 units, call MD (Medical Doctor) with blood sugar levels of 400 and above or below 70. A review of the March 2025 EMAR revealed an order dated 02/27/25 for Insulin Lispro (U-100) 100 unit/ml subcutaneous solution, inject units' subcutaneous route 3 times per day (7:30 AM, 11:30 AM and 4:30 PM). Inject per sliding scale, 150-199 = 2 units, 200-249 = 4 units, 250-299 = 6 units, 300-349 = 8 units, 350-400 = 10 units, call MD (Medical Doctor) with blood sugar levels of 400 and above or below 70 with a plotted time of 7:30 AM, 11:30 AM and 4:30 PM. A further review of the March 2025 EMAR revealed that the amount of insulin units administered, and injection site location was omitted 66 times on the following dates and time: -3/1/25 at 7:30 AM 3/02/25 at 7:30 AM 3/02/25 at 4:30 PM 3/03/25 at 7:30 AM 3/03/25 at 11:30 AM 3/03/25 at 4:30 PM 3/04/25 at 11:30 AM 3/05/25 at 7:30 AM 3/05/25 at 11:30 AM 3/05/25 at 4:30 PM 3/06/25 at 7:30 AM 3/06/25 at 11:30 AM 3/06/25 at 4:30 PM 3/07/25 at 7:30 AM 3/07/25 at 11:30 AM 3/07/25 at 4:30 PM 3/08/25 at 7:30 AM 3/08/25 at 11:30 AM 3/08/25 at 4:30 PM 3/09/25 at 7:30 AM 3/10/25 at 11:30 AM 3/10/25 at 4:30 PM 3/11/25 at 4:30 PM 3/12/25 at 4:30 PM 3/13/25 at 7:30 AM 3/13/25 at 11:30 AM 3/13/25 at 4:30 PM 3/14/25 at 4:30 PM 3/15/25 at 7:30 AM 3/15/25 at 11:30 AM 3/15/25 at 4:30 PM 3/16/25 at 7:30 AM 3/16/25 at 11:30 AM 3/16/25 at 4:30 PM 3/17/25 at 7:30 AM 3/17/25 at 11:30 AM 3/17/25 at 4:30 PM 3/18/25 at 7:30 AM 3/18/25 at 11:30 AM 3/18/25 at 4:30 PM 3/19/25 at 7:30 AM 3/19/25 at 11:30 AM 3/19/25 at 4:30 PM 3/20/25 at 7:30 AM 3/20/25 at 11:30 AM 3/21/25 at 11:30 AM 3/22/25 at 4:30 PM 3/23/25 at 7:30 AM 3/24/25 at 7:30 AM 3/24/25 at 11:30 AM 3/25/25 at 7:30 AM 3/25/25 at 11:30 AM 3/26/25 at 4:30 PM 3/27/25 at 7:30 AM 3/27/25 at 11:30AM 3/27/25 at 4:30 PM 3/28/25 at 7:30 AM 3/28/25 at 11:30 AM 3/28/25 at 4:30 PM 3/29/25 at 7:30 AM 3/29/25 at 11:30 AM 3/29/25 at 4:30 PM 3/30/25 at 7:30 AM 3/30/25 at 11:30 AM 3/30/25 at 4:30 PM 3/31/25 at 4:30 PM A review of the April 2025 EMAR revealed an order dated 02/27/25 for Insulin Lispro (U-100) 100 unit/ml subcutaneous solution, inject units' subcutaneous route 3 times per day (7:30 AM, 11:30 AM and 4:30 PM). Inject per sliding scale, 150-199 = 2 units, 200-249 = 4 units, 250-299 = 6 units, 300-349 = 8 units, 350-400 = 10 units, call MD (Medical Doctor) with blood sugar levels of 400 and above or below 70 with a plotted time of 7:30 AM, 11:30 AM and 4:30 PM. A further review of the March 2025 EMAR revealed that the amount of insulin units administered, and injection site location were omitted 5 times on the following dates and time: 4/01/25 at 7:30 AM 4/01/25 at 4:30 PM 4/02/25 at 11:30 AM 04/02/25 at 4:30 PM 04/03/25 at 7:30 AM On 04/03/25 at 10:45 AM, the surveyor in the presence of LPN#2 and LPN#3 reviewed Resident #10's PO for Insulin Lispro for sliding scale administration. Both LPN#2 and LPN#3 (two medication nurses on the J unit) acknowledge that they were no documentation on how many units of insulin that were administered. Both LPN #2 and LPN#3 stated that the amount of insulin that was administered should have been documented on the EMAR. On 4/3/25 at 1:00 PM, the surveyor discussed the above concerns with the Licensed Nursing Home Administrator, Director of Nursing, the Regional Nurse and the Regional Administrator. There was no additional information provided. A review of the facility's policy for controlled substances dated 1/8/25, included the following: 5. Nurse must document administration in the electronic health record and the declining sheet. A review of the facility's policy for Medication Administration dated 1/8/25, included the following: 16. Document administration of medication in the EMAR immediately following administration. Notes in EMAR medications not administered (i.e refused, etc.) and identifies. NJAC 8:39-11.2 (b), 29.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to notify the resident's representative in writing for an emergency transfer to the hospital. This deficient practice was identified for 2 of 2 residents, Resident #101 and #105 reviewed for hospitalization. On 04/1/25 at 4:06 PM, the surveyor reviewed the electronic medical records for resident #101. A review of Resident #101's face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; asthma (chronic resp9iatory disease which the airway narrows and swells mking it difficult to breath), hypertension (the force of the blood against the artery walls is too high) and anemia (low red blood cells). A review of the nursing progress note dated 3/10/25 at 1:58 PM, revealed that the resident was hospitalized and admitted with a diagnosis of sepsis. A review of the Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 3/10/25, reflected that Resident #101 was discharged to the hospital with a return anticipated back to the facility. On 4/1/25 at 11:56 AM, the surveyor interviewed the Social Service Director who stated that they did not send letters to the families when a resident had an unplanned discharge and stated that would have been the nursing department. On 4/2/25 at 9:35 AM, the surveyor interviewed the admission Director who stated that the facility does not send a letter to the family for unplanned discharge and that they would just call the family to inform them. On 4/2/25 at 10:00 AM, The Licensed Nursing Home Administrator (LNHA) who stated that the facility does not send a letter to the family for unplanned discharges. A review of the facility's policy titled, Discharge Policies and Procedures with a review date of 1/8/25, included for am emergency transfer the facility will notify the responsible party. The admission Director would complete the bed hold and Notification of any transfer to the hospital form and notifies resident/family via phone/email/regular mail depending on availability or preferences. NJAC 8:39-5.3; 5.4 2. On 4/3/25 at 10:54 AM, the surveyor reviewed the EMR for resident #105. A review of Resident #105's face sheet revealed the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction, essential hypertension, hyperlipidemia and major depression disorder. A review of the nursing progress note dated 2/13/25 at 10:39 PM, revealed that the resident was hospitalized and admitted with a diagnosis of chest pain. A review of the Discharge MDS, dated [DATE], reflected that Resident #105 was discharged to the hospital with a return anticipated back to the facility. On 4/1/25 at 11:56 AM, the surveyor interviewed the Social Service Director who stated that they did not send letters to the families when a resident had an unplanned discharge and stated that would have been the nursing department. On 4/2/25 at 9:35 AM, the surveyor interviewed the admission Director who stated that the facility does not send a letter to the family for unplanned discharge and that they would just call the family to inform them. On 4/2/25 at 10:00 AM, The Licensed Nursing Home Administrator (LNHA) who stated that the facility does not send a letter to the family for unplanned discharges. A review of the facility's policy titled, Discharge Policies and Procedures with a review date of 1/8/25, included for am emergency transfer the facility will notify the responsible party. The admission Director would complete the bed hold and Notification of any transfer to the hospital form and notifies resident/family via phone/email/regular mail depending on availability or preferences. NJAC 8:39-5.3; 5.4

Based on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 6 (six) of 28 residents (Resident #3, #10, #29, #47, #68, and #138) reviewed. This deficient practice was evidenced by the following: The MDS is a comprehensive tool federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. On 4/3/25 at 11:00 AM, the surveyor provided the MDS Coordinator (MDSC) with the list of 6 residents who completed more than 14 (fourteen) days after an entry date. The surveyor also requested a copy of the resident's final validation report (a report generated after every MDS transmission) from the Centers for Medicare and Medicaid Services (CMS). On 4/3/25 at 11:05 AM, the surveyor interviewed the MDSC, who stated that the Regional MDSC (R/MDSC) would submit the assessment as soon as she was done. The MDSC further indicated that they followed the RAI (Resident Assessment Instrument, a tool that helps gather information about a resident's strengths and needs, which is used to create an individualized care plan) Manual. On 4/4/25 at 9:05 AM, the surveyor interviewed the R/MDSC, who stated that she tried to submit the MDS assessment at least every day and she was made aware that the assessment was signed on the past date but needed to wait for every discipline to sign their section before submitting it. The surveyor and the R/MDSC reviewed the 6 residents' MDS assessments that were not submitted within 14 days of completion as follows: 1. Resident #3 had an admission MDS (A/MDS) assessment with an Assessment Reference Date (ARD - the last day of the observation period) of 1/16/25 that was signed as completed on 2/5/25 and was not transmitted until 2/6/25. 2. Resident #10 had A/MDS assessment with an ARD of 10/29/24 that was signed as completed on 11/6/24 and was not transmitted until 11/6/24. 3. Resident #29 had A/MDS assessment with an ARD of 12/4/24 that was signed as completed on 12/13/24 and was not transmitted until 12/17/24. 4. Resident #47 had the following assessment and was completed late: a. The A/MDS with an ARD of 12/2/24. It was signed as completed and transmitted on 12/11/24. b. The discharge return not anticipated MDS (DCRNA/MDS) with an ARD of 12/11/24 was signed as completed on 1/7/25 and was not transmitted until 1/8/25. c. The A/MDS assessment with an ARD of 3/19/25, It was signed as completed and transmitted on 3/30/25. 5. Resident #68 had A/MDS assessment with an ARD of 3/12/25 that was signed as completed on 3/21/25 and was not transmitted until 3/25/25. 6. Resident #138 had A/MDS assessment with an ARD of 3/14/25 that was signed as completed on 3/22/25 and was not transmitted until 3/24/25. On 4/4/25 at 10:30 AM, the surveyor met with the Licensed Nursing Home Administrator, Director of Nursing, Chief Operating Officer, and Regional Nurse regarding the above concern, and no further information was provided. NJAC 8:39-11.1

Based on interview, record review, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse by another resident for four of four residents (Resident (R)19, R83, R26, and R74) reviewed for abuse in a total sample of 34 residents. Findings include: Review of a Reportable Event Record/Report, provided to the survey team by the facility, dated 06/19/23, revealed the facility reported to the State Agency (SA) the following: Around 2:30 PM [R83] came to speak to [R19] As per [R19], [R83] came too close to his face; they started arguing, and the staff immediately separated them; while the nurse went inside the nurse station to sign the out on pass for [R83], [R19] came close to [R83] and hit him with a cane that he was carrying back to his room. [R83] fought back [R19] and hit him on the left side of his face. Both residents were separated immediately. A complete body assessment was done on both residents without any apparent injuries noted. 1. Review of R19's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction) and anxiety disorder. Review of R19's annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 04/21/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R19 was moderately cognitively impaired. Review of R19's Care Plan dated 04/19/23, located in the EMR under the Care Plan tab, indicated R19 had attention seeking behaviors. Review of R19's Progress Notes located in the EMR under the Progress Notes tab dated 06/19/23, revealed, At 2:30 pm [R19] and [R83] was arguing and yelling at each other, then we separated them. After 5 minutes [R19] came with his cane and started hitting [R83] on his legs. [R83] starting [sic] hitting back, he hit [R19] on his left check [sic]. And then we separated them. NP [Nurse Practitioner] made aware, MD [Medical Director] aware order to monitor and neuro check for [R19]. 2. Review of R83's Admission Record located in the EMR under the Profile tab, revealed an admitted [DATE] with diagnoses of adjustment disorder, and major depressive disorder. R83 was discharged on [DATE]. Review of R83's quarterly MDS, located in the EMR under the MDS tab with an ARD of 05/12/23, revealed the resident had a BIMS score of 14 out of 15, indicating R83 was cognitively intact. Review of R83's Care Plan dated 07/22/22, located in the EMR under the Care Plan tab, indicated R19 had non-compliant behaviors related to diet order. Review of R83's Progress Notes located in the EMR under the Progress Notes tab dated 06/19/23, revealed, It was reported to me by H floor low side nurse that resident was arguing with another resident [R19] both resident were arguing and yelling at each other staffs intervened separated them, 5 minutes later resident [R19] came back with his cane starting hitting him on his lt leg then resident [R83] punch resident [R19] in his face left side, staffs separated from each other. Body assessment done no apparent injury noted, denied pain. Resident stated, I was signing my oop [out on pass] form at the station when the resident [R19] came to me hit me in my left leg with his cane, he hit me twice so I punched him in the face. Both resident were arguing and yelling at each other staffs separated them, 5 minutes later resident [R19] came back with his cane starting hitting him on his lt [left] leg then resident [R83] punch resident [R19] in his face left side, staffs separated from each other. During an interview on 08/21/23 at 1:23 PM, R19 stated, I hit him twice on his leg with my cane. R19 further stated, I'm nice. I don't like to cause trouble for anyone. I'm sorry. During an interview on 08/24/23 at 9:35 AM, the Director of Nursing (DON), who was also the Abuse Coordinator, gave a recapitulation of the incident. The DON stated the incident was definitely abuse when they hit each other, and I substantiated it as such. The DON stated the facility substantiated the incident as abuse because one resident hit another resident. During an interview on 08/24/23 at 10:40 AM, Licensed Practical Nurse (LPN)1 stated, I was at the nurses' station and heard [R19] and [R83] talking. They always joke and play with each other. [R83] had just returned from a pass so I'm not sure what made [R19] irritated but he did get that way and hit [R83] with the cane. [R83] then hit [R19] in the face. [Certified Nursing Assistant (CNA)2] helped me stop them and then I called the DON. They [R19 and R83] had never argued before. They were friends. Neither one of them is aggressive. I don't know why they got upset that day. During an interview on 08/24/23 at 10:47 AM, CNA2 stated R83 and R19 were at the nursing station. CNA2 stated R83 had just returned from being out of the facility and was checking in with the nurse. CNA2 stated that R19 said R83 was too close to him and yelled at him and hit him with the cane. CNA2 further stated that R83 then hit R19 in the face. CNA2 stated he and LPN1 separated the two residents. CNA2 confirmed there were no prior incidents involving R19 and R83. Review of the facility's policy titled Abuse Prevention and Reporting, revised 05/20/23, indicated, Residents of [Facility Name] will be protected from abuse, neglect, mistreatment, or misappropriation of property in accordance with state and Federal Regulations. 29728 3. Review of R26's Admission Record located in the EMR under the Admission tab revealed an initial admitted [DATE] with diagnoses that included dementia with behavioral disturbances and an adjustment disorder with anxiety and depression. Review of the quarterly MDS located in the EMR under the MDS tab with an ARD of 06/30/2023, revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact. The resident did not exhibit any behaviors during the MDS assessment period of the incident. Review of the Care Plan, located in the EMR under the Care Plan tab and revised on 07/12/23, revealed R26 was identified as exhibiting behavioral problems related to verbal aggression and using profanity towards the nurses and staff and was non-compliant with facilities policies. 4. Review of R74's Admission Record, located in the EMR under the Admission tab revealed an initial admitted [DATE] with diagnosis of bipolar disorder and major depression. Review of the annual MDS located in the EMR under the MDS tab with an ARD of 06/02/2023, revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact. The MDS indicated the resident exhibited verbal behavior symptoms directed toward others. Review of R74's Care Plan revised on 07/26/23 located in the EMR under the Care Plan tab, identified the resident was argumentative and belligerent with staff and refused to take medication for psychiatric behaviors. Review of the facility's investigation of the Reportable Event Record/Report, submitted by the facility on 04/26/23, revealed the front desk receptionist observed R74 and R26 arguing and swinging at each other. Both residents were separated immediately and assisted back to their room. R74 stated that R26 wheeled his wheelchair into his legs so, he fought back. R26 was noted with blood in his mouth but upon inspection, no apparent injuries were identified. R26 stated R74 was blocking the entrance and he could not pass. Both residents were placed on 1:1 supervision. Both refused to be moved to another unit and R26 refused to go to the hospital for evaluation. The investigation also noted there were no further alterations between R74 and R26. It was also documented that R11 had resided in the facility for the past six years without any aggressive behaviors towards other residents. Review of the summary and conclusion of the facility's investigation revealed the following: Around 6:37 PM, the receptionist called the unit to report that two residents got involved in a physical altercation. Around 6:37 PM, R26 and R74 were back from out on pass separately, and they started exchanging words right before they entered the building. According to the receptionist, R74 stopped at the front desk to sign back in from his out-of-on-pass [out on pass]. R26 followed R74 into the building and continued to verbally insult R74. R74 ignored R26 and started to leave the receptionist area when R26 turned his wheelchair and wheeled his wheelchair into R74's legs. R74 stated that he had to fight back against R26. R74 hit R26 on his face and they were seen engaging in a physical altercation. Residents were seen throwing punches and pulling on each other. Both residents were separated immediately. R74 called the police to report the incident; the police came in and advised R74 to stay away from R26. The facility's investigation concluded with the following actions taken to protect the residents: Both residents were immediately separated. Support: Emotional reassurance rendered and will continue as needed. Psych consultation Family and MD notification Neurological checks as per facility protocol Trauma Assessment Both residents refused to be moved off the unit. Review of the EMR under the task tab, revealed that on 4/28/23, R74 was evaluated by Senior Care Therapy, psych services, after the incident to address coping skills and problem-solving skills to deescalate difficult situations. The resident will continue to receive follow up visits with psych. Review of the EMR under the task tab, revealed that on 04/27/23, R 26 was evaluated by NYNJ Psychiatric Services, after the incident. The evaluation revealed, Pt presents as irritable & not interested in evaluation. States, Hey, you are a psych doctor, GOODBYE. With much encouragement, pt agreed to talk. Pt shared he was outside when his peer provoked him. Denies feeling depressed/anxious. Denies S/H/I. Denies sleep disturbance or change in appetite. No ongoing agitation. The plan included follow up as needed, continued non-pharmacological interventions, and monitor and document any behavior concerns. During an interview with the Social Worker on 08/23/23 at 9:21 AM, she stated that R26 has his days, he is not as pleasant as he should be but his moods shift. Regarding the incident between R26 and R74, she stated there were some words exchanged, they were separated, they calmed down and they have kept their distance. Both residents declined room changes and psychological counseling. She stated there have not been any further exchanges between the two residents since this episode. She was not aware of R74 having any altercations with other residents prior to this incident. NJAC 8:39-4.1(a)5

Based on observations, record review, interviews, and facility procedure review, the facility failed to ensure that two (Resident (R)3 and R114) of the 34 sampled residents were treated with dignity and respect that promotes enhancement of quality of life. Findings include: 1. Review of the electronic medical record (EMR) for R3 revealed diagnoses of unspecified cerebral infarction, hemiplegia and hemiparesis affecting right side following cerebral infarction, unspecified dementia, dysphagia following cerebral infarction, aphasia following cerebral infarction. According to the most recent quarterly Minimum Data Set (MDS) assessment with reference date (ARD) of 08/18/23, R3 has a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated the resident was moderately cognitively impaired. He was also noted to be incontinent of bowel and bladder. Interview with Family Member (FM)1of R3 on 08/22/23 at 11:29 AM revealed the privacy curtain in the bedroom of R3 was broken and could not be pulled shut. FM1 stated I've told all the nurses and nurse aides on the unit for months and nothing is done about it. I'm frustrated. She stated the privacy curtains had been in this condition since the day he moved in October 2022. Attempts to interview R3 regarding the privacy curtain revealed a nod of the head to indicate the privacy curtain was broken as observed on 08/22/23 at 3:55 PM. Review of the red binder at the nursing station on the third floor labeled maintenance revealed the log since October of 2022 or since R3's admission. The log revealed no reference to maintenance requests to repair the privacy curtains in R3's bedroom. Observation on 08/23/23 at 3:55 PM revealed the privacy curtain in R3's bedroom, a double room was broken. The curtain could not pull beyond the foot of the bed. In addition, the privacy curtain for the roommate or R114 was also broken and could not pull beyond the window side of the bed. Therefore, both curtains provided no privacy for either resident. 2. Review of the EMR for R114 revealed diagnoses of major depressive disorder, acute respiratory failure, cardiac arrest, and bipolar disorder. Review of R114's most recent quarterly MDS with an ARD date of 08/04/23 indicated a BIMS score of 11 out of 15 which indicated the resident was moderately cognitively impaired. was also noted to be incontinent of bowel and bladder. Interview with R114 on 08/22/23 at 3:56 PM revealed neither curtain could be used to shield each resident from the other or provide privacy. When asked if R114 could see R3 getting his brief changed in R3's bed, he said yes I can, and he can see me. There is no privacy. Interview with the Registered Nurse (RN)2 on 08/22/23 at 4:00 PM verified the curtains for both beds did not slide on the track properly and supply R3 and R114 with full visual privacy. She stated she would report to maintenance to have the problem corrected. Interview with Certified Nurse Aide (CNA)1 on 08/23/23 at 9:55 AM revealed I try to change each resident when the other is out of the room to provide privacy. She verified the curtains for both residents did not work to provide full visual privacy. Interview with the Maintenance Man (MM) on 08/23/23 at 10:20 AM indicated the curtains were fixed. He stated he did not know if this issue had been reported in the past. He stated this was the first time he looked at the problem. Observation of the curtains on 08/23/23 at 11:00 AM revealed the curtains still did not close or move any further to provide full visual privacy than when first reported. Interview with the Administrator on 08/24/23 at 10:14 AM indicated the curtains in the bedroom for R3 and R114 were fixed. Further observation on 08/24/23 at 10:30 AM revealed the curtains had not been fixed and were in the same condition. Further interview with the Administrator on 08/24/23 at 11:00 AM indicated that both residents would be moved to another room while maintenance removed the tracks and replaced R3 and R114's privacy curtain tracks and privacy curtains. NJAC 8:39-4.1(a)12

Based on observation, record review, interview, and facility policy review, the facility failed to assist one resident (Resident (R)50) of the total 34 residents sampled in obtaining dentures. Findings include: Review of policy for titled Dental Services, with effective date as 11/28/16 revealed that it is the policy of the facility to order a prompt referral for dental services as resident would need. It also revealed that Long Term residents should be seen annually. It further revealed that upon assessment of a dental issue by the nurse, it should be reported to the physician and a referral made to the Dentist. The policy stated that the nursing staff would monitor the resident's diet and ability to eat and report changes as needed to include speech therapy referral. Review of the resident's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed R50 was initially admitted to the facility on [DATE] with a re-admitted [DATE] with diagnoses to include malignant neoplasm (cancer) of head, face and neck, and dysphagia (difficulty swallowing) as his admitting diagnoses. Record review of the resident's Care Plan located in the Care Plan tab of the EMR revealed no concerns for dentures were documented. Review of the resident's Care Plan, updated on 05/24/23, revealed dysphagia due to R50's neck cancer. It also revealed that R50 was on a mechanical (chopped) thin liquids diet. Review of the resident's annual Minimum Data Set Assessment (MDS), with an Assessment Reference (ARD) date of 07/21/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident had intact cognition. R50 had no natural teeth or tooth fragments. During an observation and interview on 08/21/23 at 2:55 PM R50 was in his room watching TV. R50 said he had been without his dentures for almost five years and had been asking for them but had not received them. He further stated he could not chew his food well. Record review of handwritten Dentist Progress Notes, located in the paper chart, revealed an initial exam on 11/23/16, where R50 was requesting dentures. On 05/03/17, R50 had a denture fitting exam and required an adhesive. A dental visit on 01/04/21 revealed that R50 stated his dentures did not fit and did not have them. Twelve other visits occurred until 08/14/23, and dentures were not mentioned. On 08/14/23, the resident again requested dentures. There was no documentation of the status of the resident's dentures. An interview on 08/24/23 at 10:53 AM with Social Service Director (SSD) revealed that she was not aware that R50 had denture needs. She stated nursing usually had dentist order dental needs. SSD stated there were denture resources that could be used for the residents. An interview on 08/24/23 at 3:30 PM with Regional Social Worker (RSW) revealed that R50 required a dysphagia diet to prevent aspiration [not due to having no dentures]; however, that did not mean the resident should not have dentures. An Interview on 08/23/23 at 2:10 PM with Registered Nurse (RN)4 revealed that R50 had had several dental appointments, and she was not aware that R50 needed dentures. An interview on 08/24/23 at 3:30 PM with the Director of Nursing (DON) and Speech Therapist revealed that R50 was placed on a dysphagia diet for swallowing issues. Both agreed that R50's dysphagia diet for swallowing and not chewing should not affect R50 receiving dentures. NJAC 8:39-15.1(b)

NJ00158785 Based on observation, interview and record review on 1/18/23, it was determined that the facility failed to accurately assess and encode a resident wounds in the Minimum Data Set (MDS) assessments for 1 of 3 residents (Resident #2) reviewed for MDS accuracy. This was evidenced by the following: The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual Section M Skin Conditions reflected Coding Instructions Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days. Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back period. Then skip to M1030, Number of Venous and Arterial Ulcers. Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. According to the Admission Record, Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to; Alzheimer's Disease, Anemia, and Metabolic Encephalopathy. A review of the MDS, an assessment tool used to facilitate the management of care, dated 7/8/22 reflected under Section M (used to assess skin condition during a 7-day look-back period), the resident had unhealed pressure ulcer. Section M further reflected that Resident #2 had sacral stage 3 wound and that these were presented at the time of admission. A review of the resident's Medicare - 5 Day MDS, dated [DATE] reflected under Section M that resident had no unhealed pressure ulcers. However, there was no evidenced documentation that the sacral pressure ulcer was resolved. A review of the resident's Discharge Return Anticipated /End of PPS Part A Stay MDS, dated [DATE] reflected under Section M that the resident had no unhealed pressure ulcers. However, there was no evidenced documentation that the sacral pressure ulcer was resolved. The Order Summary Report reflected an order for Mupirocin Ointment 2 % Apply to sacrum topically every day shift for wound care on 7/5/22. The TREATMENT ADMINISTRATION RECORD (TAR) for the month of 7/2022 and 8/2022 revealed the aforementioned order. The TAR further revealed that the aforementioned medications were applied to the Resident's sacral wound from 7/6/22 to 8/23/22 and on 8/24/2022 wound care was not provided because the resident was transferred to the hospital. A review of the facility Wound Tracker from 7/11/22 to 8/17/22 revealed the following: On 7/11/22, Resident #2 had stage 2 sacral wound measuring 4 centimeter (cm) x 3 cm. On 7/18/22, Resident #2 had stage 2 sacral wound measuring 4 cm x 2.8 cm. On 7/27/22, Resident #2 had stage 2 sacral wound measuring 4 cm x 2.5 cm. On 8/3/22, Resident #2 had stage 2 sacral wound measuring 3.9 cm x 2.5 cm. On 8/10/22, Resident #2 had stage 2 sacral wound measuring 2.8 cm x 2 cm. On 8/17/22, Resident #2 had stage 2 sacral wound measuring 2.5 cm x 1.5 cm. A review of the resident's medical records (MR), dated from 7/5/22 through 8/24/22 revealed there was no documented evidence to indicate that the aforementioned wound was resolved and the treatment was discontinued. The surveyor conducted and interview with the Registered Nurse (RN #1) on 1/18/23 at 3:45 pm. The RN confirmed that she had coded Resident #2's 5-day MDS for ARD 7/12/22 on 7/19/22 at 8:07 pm. The RN stated that she had coded Section M wrong on the MDS with ARD 7/12/22. The surveyor conducted an interview with the Regional MDS Coordinator (RMDSC) on 1/18/23 at 3:51 pm. The RMDSC confirmed that she had coded Resident #2's Discharge Return Anticipated MDS for ARD 8/24/22 on 9/18/22 at 3:29 pm. The RMDSC acknowledged that the MDS assessment dated [DATE] was inaccurately coded in Section M. The surveyor conducted an interview with the Administrator and DON on 1/18/23 at 4:43 pm, they both stated that when coding MDS, the RN and RMDSC have to check the residents medical record for accuracy. They further added that it is important to code correctly because the MDS reflects the resident status. The MDS COORDINATOR Job Description indicated Duties and Responsibilities Conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations and guidelines that govern the resident assessment NJAC 8:39-11.2(e)(1)

C #: Covid-19 Infection Control Based on observation, interviews and review of pertinent facility documentation on 5/12/22, it was determined that the facility failed to ensure that all staff and visitors entering the building were screened for Covid-19 signs and symptoms in accordance with the facility policy COVID-19 [CORONA VIRUS] and Centers for Disease Control and Prevention (CDC) guidelines for 7 of 15 employees (nursing and dietary staff) and 7 of 20 visitors, reviewed for Covid-19 screening. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/22, showed .1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic, Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. HCP [Health Care Provider] should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses. Recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2 . On 5/12/22 at 9:30 am, prior to entering the building the surveyor completed the screening form for Covid-19 screening and handed it over to the Reception Staff (RS). The RS instructed the surveyor to enter the facility without checking her body temperature. The surveyor requested the RS to take the surveyor's body temperature to complete the screening process before allowing her to enter the facility. During the entrance conference with the Administrator on 5/12/22 at 9:30 am, she provided the surveyor the Line Listing (LL) that showed that the Covid-19 outbreak started on 5/3/22 involving 4 employees and 7 residents. The last tested positive for Covid-19 was on 5/4/22 involving 2 employees. The LL further showed that the affected employees and residents were fully vaccinated including booster for Covid-19. The Staff/Visitor Screening form for COVID-19, showed that the staff/visitor were to answer yes or no to the following questions: diagnosed with Covid-19, travel last 14 days, Covid-19 symptoms ( fever, cough .) and contact with someone with or under investigation for Covid-19. The form further showed that if yes is circled for any above questions, and/or temperature is 100.5 or greater, entry would not be allowed. The .Visitor Screening form for COVID-19 dated from 5/3/22 to 5/12/22 showed that seven (7) visitors (Vs, fully vaccinated) did not complete the screening form prior to entering the facility which was not according to their policy and CDC guidelines: Vs' #1, #2, #3, #4, #5 and #6 showed no documented evidence that their body temperatures were taken prior to entering the facility. Vs' #2 and #7 did not answer yes or no to the aforementioned screening questions prior to entering the facility. The Staff .Screening form for COVID-19 dated from 5/2/22 to 5/12/22 showed that 7 employees (E, fully vaccinated) did not complete the screening form prior to entering the facility which was not according to their policy and CDC guidelines: E's #1, #2, #3 and #4 (nursing department, worked on the aforementioned dates) did not answer the yes or no to the aforementioned screening questions prior to entering the facility. E's #1, #5, #6 and #7 (nursing and dietary departments, worked on the aforementioned dates) did not have documented evidence that their body temperatures were taken prior to entering the facility. Interviewed with the Administration on 5/12/22 at 4:30 pm, they stated that reception staff and security staff should ensure that anyone entering the facility will actively screened for fever and symptoms of Covid-19. They were unable to explain why the aforementioned employees and visitors entered the facility without fully screened for Covid-19 symptoms. The surveyor attempted to conduct a telephone interview with aforementioned employees; however, they were not available. The facility policy titled, COVID-19 [CORONA VIRUS] dated 3/29/22, showed POLICY: It is the policy of this facility to follow CDC and DOH [Department of Health] guidelines for the management of the COVID-19 .Procedure: 1. All people entering this facility will be screened for symptoms consistent with COVID-19 and will have their temperature taken . NJAC 8:39-19.4(a)(b)

Based on observation, interview and review of facility records, it was determined that the facility failed to ensure an accurate inventory of controlled medications (narcotic medications) was dispensed from the facility's narcotic back up cabinet. The deficient practice occurred in 1 of 1 back up narcotic boxes inspected and evidenced by the following: On 6/3/21 at 11:17 AM, the surveyor checked the back-up narcotic cabinet located in the Supervisor's office, in the presence of the Director of Nursing (DON). The package labeled Oxycod/APAP 10-325 mg (a combination narcotic pain reliever) had 9 tablets in the package. When compared to the declining inventory sheet, a discrepancy was observed. The declining inventory showed 10 Oxycod/APAP 10-325 mg tablets remaining in the package. The surveyor asked the DON to recount the tablets and she confirmed the same discrepancy. The DON stated the oncoming and outgoing shift Supervisors are responsible to count the controlled medications in the narcotic back up cabinet. The last date that was documented on the declining inventory sheet was 5/25/21 at 5 PM which indicated one Oxycod/APAP 10-325 mg tablet was removed from inventory. The declining inventory sheet showed from 5/26/21 to 6/3/21 the last count remained at 10 tablets. On 6/3/21 at 11:53 AM, the surveyor interviewed the 7-3 Registered Nurse Supervisor (RN/S) and 11-7 Registered Nurse Unit Manager (RN/UM), who was supervising during the 11-7 shift on 6/3/21. The RN/UM stated that the two nurses started the control medication count at 7:30 AM on 6/3/21. The RN/UM stated that the RN/S counted controlled medications in the separate packages, while the RN/UM compared the tablets counted to the declining inventory sheet. The RN/S stated she did not notice the discrepancy. The RN/S confirmed with the surveyor that only the Supervisor has the keys for the back up narcotic cabinet. The RN/UM stated she did not notice the discrepancy when she counted with the evening shift Supervisor. On 6/3/21 at 12:31 PM, according to the DON, the 11-7 Supervisor who worked on 5/31/21 gave Oxycod/APAP 10-325 mg to a resident at 6 AM. The 11-7 Supervisor informed the DON that she forgot to document on the declining inventory sheet. At 1:42 PM, the surveyor discussed the above concern with the Administrator, Regional VP, Quality Assurance Nurse and the DON. The facility's policy titled Inventory Control of Drugs without a date indicated under Policy- Controlled drugs are inventoried and documented under the proper conditions with regard to security and state/federal regulations. And under Procedure #A-2 Schedule 11 medications are counted by the oncoming nurse and outgoing nurse at least once (1) a day or at the change of shift and documented on a Controlled Drug Count Verification (Shift Count Sheet for Narcotics). NJAC 8:39-29.7(c)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to provide full visual privacy during medication administration and during a physical examination for 2 of 22 residents reviewed, Resident # 14 and Resident # 81. The deficient practice was evidenced by the following: 1. On 6/2/21 at 10:21 AM, the surveyor observed the Registered Nurse (RN) lift the right pant leg of resident #14 and apply a pain patch on the right knee in the hallway while residents and staff were walking around the area. On 6/4/21 at 10:56 AM, the surveyor spoke with the resident about the observation of the nurse putting the pain patch on their knee in the hallway. The resident stated Yes, he did, I came out of the shower that day. The surveyor asked the resident if the nurse always put the pain patch on in the hallway. The resident said No, that day he did, I came out of the shower that day. The surveyor asked the resident if it bothered [the resident] to have the pain patch put on their knee in the hallway. The resident said No, it's ok, they don't do it all the time. On 6/4/21 at 12:00 PM, the surveyor reviewed the medical record of Resident #14 which revealed the following: The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order date was 10/1/18. The annual Minimum Data Set assessment tool dated 5/20/21, revealed the resident scored 14 out of a possible 15 when the Brief Interview for Mental Status was done which indicated the resident was cognitively intact. The current Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/4/21 at 1:21 PM, the surveyor spoke with the Director of Nursing (DON), the Licensed Nursing Home Administrator, the Regional VP and the Quality Assurance Nurse who were present about the observation of the nurse not offering physical privacy when applying the pain patch. The surveyor asked Would you expect that the nurse would apply the pain patch in the hallway? The DON replied No. 2. On 6/3/21 at 12:16 PM, the surveyor observed a physician on the observation unit. The physician went into the room of Resident # 81, and with the resident's door opened, the surveyor observed the physician lift the resident's pant legs to the knees and examine the resident's lower legs. At 12:25 PM, the surveyor asked the physician about providing privacy during an examination and the physician stated that she should have closed the resident's door during the examination for privacy. At 1:30 PM, the surveyor discussed the concerns with the Administrator and DON. The DON stated that the physician should have provided privacy when examining the resident. The surveyor reviewed the facility's policy and procedure titled Resident Rights to Privacy and Confidentiality which was revised 11/2020. The policy and procedure indicated that every nursing home resident has the right to personal privacy of not only his/her own physical body, but also of his/her personal space, including accommodations and personal care. The surveyor also reviewed the facility's policy and procedure titled Medication Administration which was updated 10/2020. It did not address the issue of providing physical privacy during the administration of medication. NJAC 8:39: 4.1 (a) 16

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection. This deficient practice was observed for 2 of 22 residents reviewed, Resident #81 and #103, as evidenced by the following: On 6/2/21 at 11:20 AM, the surveyor observed personal protective equipment (PPE) hanging on the door of Resident #81. There was also a STOP sign and a sequence for putting on and taking off PPE sign on the door which read droplet precautions, everyone must: clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, wear N95 mask, put on gown and gloves, and remove face protection before room exit. The surveyor interviewed the Registered Nurse, Unit Manager, Infection Preventionist (RN/UM/IP) who stated that the resident was readmitted to the facility and was on contact and droplet precautions in the observation unit (A unit where residents were quarantined for 14 days upon admission or re-admission to observe for signs and symptoms of Covid-19). Resident #81 was in the bed, located inside the resident's room. The surveyor reviewed the medical record of Resident #81 which revealed the following: An Admission Record, which indicated that Resident #81 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/3/21 at 12:16 PM, the surveyor observed a Physician on the observation unit. The RN/UM/IP explained to the Physician that the unit was an observation unit and all the residents were on contact and droplet precautions. The Physician went to Resident # 81's room with a blue surgical mask on and no N95 respirator mask, she donned gloves, gown, and a face shield. With the resident's door opened, the surveyor observed the Physician lift the resident's pant legs to examine both of the resident's lower legs. The surveyor observed the Physician doff her face shield, gloves, and gown and place in the appropriate bins. At 12:25 PM, the surveyor asked the Physician why she was not wearing an N95 mask. The Physician stated that she was not aware that she needed an N95 mask to enter the resident's room and did not have one with her. The Physician stated that she was only at the facility to visit that one resident. At 12:30 PM, the surveyor interviewed the RN/UM/IP who stated that the Physician should have worn an N95 mask and she did not realize that the Physician was not wearing one. At 1:30 PM, the surveyor discussed the concerns with the Administrator and Director of Nursing (DON). The DON stated that the Physician should have worn an N95 mask per the facility policy and procedure. On 6/6/21 at 9:22 AM, the surveyor observed a Laundry Aide (LA) on the observation unit. The LA entered Resident # 103's room wearing two surgical masks, face shield, gloves and gown. The LA did not don an N95 mask. The surveyor observed PPE hanging on Resident #103's door. There was also a STOP sign and sequence for putting on and taking off PPE sign on the door which indicated droplet precautions, everyone must: clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, wear N95 mask, put on gown and gloves, and remove face protection before room exit. The surveyor observed the LA doff her gloves, gown, surgical mask and face shield and place them in the appropriate bins as she exited the resident's room. The LA was observed performing appropriate hand hygiene. At 9:27AM, the surveyor interviewed the LA who stated that she recently received an in-service (a training session) provided by the DON which indicated that she only needed to wear a surgical mask if entering a resident's room who was on droplet precautions, as long as there was no close contact. The LA stated that she only worked on that unit and was done with her resident assignment at that time. At 9:40 AM, in the presence of the DON, the LA stated that she was in-serviced by the DON and that she only needed to wear a blue surgical if she was not to have close contact with the resident. The DON stated that if any staff entered the resident's room, whether it was close contact or not, the room of those resident's on quarantine were considered droplet precautions and an N95 mask must have been worn when entering the resident's room. At 10:10 AM, the DON provided the surveyor with an in-service dated 5/27/21 signed by the LA, which revealed that laundry staff should don gown, gloves, N95 mask, and face shield when going into the resident rooms on the observation unit. At 1:15 PM, the surveyor discussed the above concerns with the Administrator and DON, who stated that the LA should have worn an N95 mask when entering a resident's room who was on droplet precautions. The surveyor reviewed the policy and procedure titled PPE during the COVID-19 Public Health Emergency which was revised 6/7/21. The policy and procedure indicated that the cohort for new or readmission (observation unit) required droplet precautions including N95 mask use. N.J.A.C. 8:39-19.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to provide a safe environment to prevent a fall during the repositioning and care of a resident. The deficient practice occurred for 1 of 2 residents (Resident #62) reviewed for falls and evidenced by the following: On 6/2/21 at 12:23 PM, the surveyor observed Resident #62 in bed with eyes closed. The resident had a [CONDITION(S)] and was receiving oxygen. There was a floor mattress on either side of the bed. The surveyor reviewed Resident #62's medical records that revealed the following: According to the Admission Record, Resident #62 was admitted to the facility with diagnoses that included [CONDITION(S)] and [CONDITION(S)]. The Admission Minimum Data Set (MDS) dated [DATE] and recent Quarterly MDS dated [DATE] indicated that the resident was unable to express oneself or understand others. The facility determined that the resident was severely cognitively impaired. The facility assessed the resident's functional abilities in both the Admission MDS and Quarterly MDS as total assistance by two people for bed mobility, transfer, dressing, toilet use, which would consist of incontinent care, personal hygiene, and bathing. The resident had a risk for falls care plan that was initiated on 9/24/20. Included on the care plan was a notation that the resident had a fall on 3/28/21. Under Interventions dated 3/28/21, there was documentation for 2 people assist at all times during care. The Progress Notes dated 3/6/21 - 4/5/21 revealed the nurse documentated on 3/28/21 at 10:15 AM, she was called to the resident's room by the Certified Nursing Assistant (CNA). The nurse entered the resident's room and observed Resident #62 lying on the floor faced down next to the bed. The nurse documented that she inquired of the CNA what happened, and the CNA told the nurse that the resident rolled out of bed when trying to position resident in bed. The nurse documented that the resident had a skin tear to the forehead and was provided first aide. On 6/7/21 at 10:30 AM, the surveyor interviewed the Registered Nurse Unit Manager (RNUM) who stated the resident did have a fall on 3/28/21 and informed the surveyor that of what occurred. The surveyor asked the RNUM if the resident was a one or two person assist with positioning and she stated the resident was always a two person assist during care and positioning. The surveyor requested to review the fall investigation. At 1:29 PM, the Director of Nursing (DON) provided the fall investigation report. According to the investigation report dated 3/28/21, the CNA assigned to the resident wrote in her statement the following; while I was turning [the resident] to clean [the resident] back, I slightly pull him toward me and [the resident] had an involuntary movement causing [the resident] to roll off the air mattress into the floor mat. The IDT (Interdisciplinary Team) Meeting Note-Fall Incident notes indicated under New Interventions the following; floor mats next to bed, two person assist with all care, and rehab post fall screen. Under Conclusion the following was documented; .for the safety of the resident and staff, [the resident] will be two person assist for all care . There were additional IDT notes dated 3/16/21 and 3/23/21 reviewed that indicated the following: IDT Meeting Note - Care Plan Review dated 3/16/21 under #4 ADL's Bed Mobility, Dressing, Eating, Toileting, Hygiene - Total x2. The IDT Meeting Note - General dated 3/23/21, the team discussed Resident #62 current ADL status, and included in the documentation following ADL's: Total assist x2 in bed mobility, dressing, eating, toileting, hygiene and bathing. According to the form Rehab-General dated 3/25/21 under #44 and #44a; Bed mobility and Support Provided - dependent and 2+people. On 6/9/21 at 10:25 AM, the surveyor interviewed the CNA who was assigned to Resident #62 on 3/28/21. The CNA stated that she always calls another CNA to help her with the resident. She stated while she was waiting for the CNA to come into the room, she started to prepare to move [the resident] a little. She stated she pulled the sheet under [the resident] towards me and then [the resident] started to move like a spasm and fell to the floor mat. The surveyor asked the CNA if the resident was to be assisted by two people during care. Initially she said no and then changed her answer to yes. The surveyor and the CNA reviewed the MDS Kardex Report that CNAs use as a plan of care for the resident which indicated under ADL-Bed Mobility, total assistance, two + person's physical assist. The CNA stated she should have waited for the other CNA to assist her when she repositioned the resident. On 6/9/21 at 1:07 PM, the surveyor discussed the above concern with the Administrator and DON. The DON confirmed that the resident has been a two person's assistance since admission. A review of the facility's policy titled Repositioning Program dated 3/3/19 and revised 5/16/21, under Procedure for Bed Repositioning #3 indicated the following; Certified Nursing Assistant(s) will assist/provide residents on turning and repositioning program to reposition every two hours and as needed while in bed based on level of assist required (1 person or 2 person assist). NJAC 8:39-27.1(a)

C# 5 Based on interviews, review of medical records and review of other pertinent facility documents, it was determined that the facility failed to revise and update the comprehensive plan of care for 1 of 5 sampled residents (Resident #1) as evidenced by the following: A review Resident #1's medical record on 2/25/2020 revealed the following: The resident had Medical [DIAGNOSES REDACTED]. According to the Minimum Data Set, an assessment tool, dated 1/30/19, Resident #1 had a Brief Interview for Mental Status of 6/15, indicating the Resident was cognitively impaired and needed total assistance with bed mobility and transfers related to Activities of Daily Living. A Nursing Summary dated 4/3/2019, under Skin Integrity revealed the resident has a sacral wound as well as an opening on the left and right buttock. The Interdisciplinary Team Meeting Note -General, dated 4/8/2019 included that the care plans were reviewed and updated. A review of the Care Plan, with an admission date of [DATE] included the following: Under Focus: at risk for impairment to skin integrity related to impaired mobility and history of skin breakdown;. Under Goal: Will have no skin breakdown with a revision date of 3/4/2019. The surveyor interviewed the Director of Nursing on 2/25/2020 at 11:30 a.m., stated that the care plan should have been updated. N.J.A.C. 8:39-11.2 (2)

COMPLAINT # NJ 2 Based on observation, interview, Medical Records (MR) review, and review of other pertinent facility documents on 9/30/2019, it was determined that the facility staff failed to provide appropriate pest control to prevent an accumulation of flies. This deficient practice was evidenced by the following: During a unit tour accompanied by the Unit Manager (UM) on 9/30/2019 at 9:19 a.m., a foul odor was noted in a resident's room and several flies were observed in the room and around the resident's leg dressings. The UM reported the odor is from noncompliance with hygiene and refusing showers. No fly strips were observed by the surveyor in the resident's room during the tour. During an interview on 9/30/2019 at 10:54 a.m., the Administrator (Admin) reported he was aware of the fly problem and it was related to the resident's hygiene. He/she refuses to take showers. He/she has poor hygiene. The Admin also reported housekeeping is cleaning the room [ROOM NUMBER] times a day and Pest control was here last week. During an interview on 9/30/2019 at 12:55 p.m., the Director of Maintenance (DM) reported: No one had told him the 3rd floor had flies. He also reported: The 3rd floor has a bug light in the hallway and one at the nursing station. They (the bug lights) have been there since I came here 4 months ago. They (the flies) are probably coming in on the first floor, that is why we are treating the first floor. In addition, the DM reported Pest Control comes in 2 times a week. They sprayed last Friday. However, the DM did not know what pest they sprayed for. On 9/30/2019 at 1:10 p.m., a tour was conducted on the 3rd floor accompanied by the DM. Two bug lights were observed; one at the nursing station and the other in the hallway. The MD reported the strip was changed last week however, it was covered with bugs and flies. During a tour on 9/30/2019 at 2:23 p.m., accompanied by the UM and LPN #1 the surveyor observed 5 flies on the walls of the resident's room and several on the resident's lower leg dressings. At this time, fly strips were observed on the windows and the door. The UM also reported: Maintenance had placed fly strips on the windows and the walls and there is a bug zapper in the hallway. Review of a facility document for Pest Management for the 3rd floor, showed no entry for flies from 8/28/2019 to 9/29/2019. However, it did show 2 entries for Flies on 9/29/2019 and 9/30/2019. Review of the facility document titled Consumer Information Notice dated 2019, showed documentation from the pest control company that actual application was completed on the following dates in (MONTH) 2019: 9/4, 9/6, 9/11, 9/13,18, 9/20, 9/23, 9/25, and 9/27, however, it did not indicate what type of pest treatments were applied. Review of the document provided by the facility post survey, titled Pest Management dated 10/29/2009, identified a service contract for ''weekly service for one year. Scope of Service included mice, rats, ants and roaches. No other document/contract was provided. There was no evidence that this service was provided for the current time frame. NJAC 8:39-31.5

COMPLAINT # NJ 2 Based on observation, interviews and review of Medical Records (MR), on 9/30/2019, it was determined that the facility staff failed to provide appropriate incontinence care, as well as personal hygiene care, for 1 of 3 residents (Resident # 1) sampled for incontinence. In addition, the facility staff failed to follow their policy titled Incontinence Care Protocol. This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was originally admitted to the facility in 2008 and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 9/2/2019, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating that Resident #1 was cognitively intact. The MDS also indicated Resident #1 was extensive assistance for Activities of Daily Living (ADLs) and was always incontinent of bowel and bladder. Review of the Care Plan for Resident #1 with an admission date of [DATE], included the following Problems .actual impairment to skin integrity r/t (related to) sacral wound. Under Interventions Keep skin clean and dry. During a care tour on 9/30/2019 at 9:40 a.m., accompanied by the Unit Manager (UM), a wound observation was completed on Resident #1. A disposable diaper was in place and observed to be saturated with urine. The draw sheet was observed to be saturated with urine. Resident #1 reported he/she had not been changed since 5:00 a.m. During an interview on 9/30/2019 at 9:48 a.m., the UM reported: The resident is a heavy wetter. They should be changed frequently when a heavy wetter. Frequently is every 2 hours. I know she was not checked every 2 hours this morning. In addition, the UM added that the skin around the wound was macerated because the skin was wet. During an interview on 9/30/2019 at 10:12 a.m., Resident #1 reported: The care is good sometimes and sometimes not so good. No one came in this morning to check my diaper. During an interview on 9/30/2019 at 10:50 a.m., the Certified Nursing Assistant (CNA#1) reported: I was busy, so I did not get to him/her this morning. In addition, CNA #1 reported If a resident is not changed every 2 hours their skin will get bad. According to the Facility Policy titled Incontinence Care Protocol dated 11/11/17, under Goal included the following: To maintain skin integrity and prevent skin breakdown. Under Indication included the following: Skin in perineal areas at high risk for compromise due to exposure to body wastes. Proper perineal is essential in maintaining skin integrity, controlling odor and providing comfort and self-esteem for patient. Under Procedure section 10. Repeat procedure with each incontinent episode. N.[NAME][NAME]C. 8:39-27.2 (h)

Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan for 2 of 32 residents (Resident #38, and #102) reviewed for comprehensive care plans. This deficient practice was evidenced by the following: 1. On 6/19/19 12:14 PM, the surveyor observed Resident #38 in his/her room in a wheelchair. Resident #38 stated to the surveyor they were a diabetic, on a special diet for diabetes, and took medication (for diabetes). Resident #38 stated that they were on a blood thinner as well, to prevent blood clots. The surveyor reviewed the medical record for Resident #38, which revealed, an Admission Record that indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor then reviewed the physicians orders dated 1/06/19. The resident was prescribed Insulin [MEDICATION NAME] 10 units subcutaneously at bedtime (a medication used to treat diabetes mellitus). Also, on 9/2/18, the resident was prescribed Regular Insulin on a sliding scale, based on blood sugar reading to be given four times a day for treatment of [REDACTED]. The resident also had a physician's orders [REDACTED]. Further review of the medical record revealed that there was no comprehensive care plan for Resident #38 related to their risks associated with the chronic condition of DM, and the medications used for its treatment. Furthermore, there was no comprehensive care plan for the treatment and care associated with taking blood thinners to prevent the occurrence of [MEDICAL CONDITION]. On 6/25/19 at 12:46 PM, the surveyor interviewed Resident #38's Licensed Practical Nurse (LPN). The LPN stated that the resident was a diabetic and was taking insulin to control their blood sugar. The LPN stated that the resident had a history of [REDACTED]. Together with the LPN, the surveyor reviewed Resident #38's comprehensive care plans. The LPN acknowledged that Resident #38 did not have a care plan to reflect the resident's DM management and treatment and/or, a plan for the resident's risk for use of a blood thinning medication to prevent blood clots. The LPN further stated, it was the responsibility of the Unit Manager to update and initiate resident's care plans. On 6/25/19 at 12:49 PM, the surveyor interviewed the LPN/Unit Manager (LPN/UM). The LPN/UM confirmed she was responsible for creating and maintaining the resident's individualized care plans. The surveyor reviewed Resident #38's individualized care plan with the LPN/UM. The LPN/UM acknowledged that Resident #38 did not have a current care plan in place to address the resident's chronic condition of DM, the management and treatment of [REDACTED]. The LPN/UM further stated, the resident should have had current comprehensive care plan's in place to address the aforementioned care concerns. On 6/28/19 at 9:58 AM, the survey team met with the Administrator and the Director of Nursing (DON). The DON acknowledged that there was no care plan in place to address DM or anticoagulation therapy and that there should have been. 2. On 6/24/19 at 11:59 AM, the surveyor observed Resident #102 sitting in a wheelchair in the dayroom eating lunch. The resident was trying to get milk out of the container by using a spoon. Later that same day, the surveyor reviewed the medical record of Resident #102. The medical record contained an Admission Record that indicated the resident had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the Medication Administration Record [REDACTED] #102 which was dated (MONTH) 2019. The MAR indicated [REDACTED]. The surveyor reviewed Resident #102's Minimum Data Set (MDS-an assessment tool used by the facility) dated 5/2/19. The assessment recorded in section N0410 for medications received, was coded that the resident received an antipsychotic medication on seven days of the last seven days. The assessment recorded in section V, Care Area Assessment (CAA) Summary was coded for [MEDICAL CONDITION] drug use as a care area that triggered for care planning, and the decision was made to address this area in the resident's care plan. The surveyor then reviewed all of the resident's care plans. There was no care plan for the use of a [MEDICAL CONDITION] medication. On 6/28/19 at 11:32 AM, the Quality Assurance nurse stated that the facility care planned the resident's behavior and listed the medication as an intervention. She further stated, that the nurse forgot to list the medication as an intervention. On 6/28/19 at 11:55 AM, the surveyor reviewed the facility's policy and procedure titled, Care Planning, which had a revised date of 4/15/18, and read: under Policy: A comprehensive care plan is to be developed, by the IDC and resident, after the intake process and needs assessment have been completed. The needs assessment information and care plan are reported in PCC and should describe and prioritize the client's medical concerns, treatment adherence issues, mental health . and under Procedure 2 read: Comprehensive Care Plan; a. Identifying the Resident's issues, problems or concerns related to medical care, medication adherence and other issues, based upon the needs assessment. Priorities will be set to address the needs, e.g. making and keeping appointments, talking with doctors, following medication instructions, etc. and b. Identifying services that the Resident is already receiving. N.J.A.C. 8:39-11.2(e)2

Based on interview, and record review, it was determined that the facility failed to provide notice of the facility's bed hold policy. This was identified for Resident #77, 1 of 2 residents reviewed for hospitalization s. This deficient practice was evidenced by the following: On 6/27/19 at 11:00 AM, the surveyor reviewed the record of Resident #77. The record revealed that the resident was hosptalized on [DATE] for Low Hemoglobin and Hematocrit and elevated white blood cells. The resident was re-admitted to the facility on [DATE]. On 6/27/19 at 2:00 PM, the surveyor asked the Administrator if Resident # 77 and/or, the resident's representative were provided with written information about the facility's bed hold policy. The Administrator stated that the information was included in the facility's admission agreement and that he would find out if a notice was provided to the resident upon transfer to the hospital. On 6/28/19 at 10:54 AM, the Administrator informed the surveyor that he asked the Social Worker (SW) if she had provided notification to the resident and/or the resident's representative when the resident was transferred to the hospital on [DATE]. The SW remembered making a phone call to the resident's representative when Resident #77 was transferred to the hospital, but nothing was documented. The SW also informed the Administrator that she didn't give any written notification to the resident and/or, the residents representative upon readmission to the facility. N.J.A.C. 8:39-5.1 (a)

COMPLAINT# NJ 4 Based on observation, interview, and review of the medical record and other facility documentation, it was determined that the facility failed to properly inspect, identify, and implement interventions for residents' personal electronic devices according to facility policy. This deficient practice was observed by the surveyors for 3 of 3 sampled residents (Resident #1, #2, and #3) and 3 of 3 unsampled residents (Unsampled Resident #4, #5 and #6) and is evidenced by the following: All interviews, observations and record review occurred on the day of survey, 5/14/19, unless otherwise noted. 1.) According to the facility Admission Record, Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Sheet (MDS), an assessment tool, dated 4/2/19, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. On 5/14/2019 at 9:33 a.m., during a tour with the Licensed Practical Nurse Unit Manager (LPN UM), the surveyors entered the room of Resident #1. The surveyors observed an electrically powered radio in Resident #1's room. The surveyors asked the LPN UM to pick up the radio to visualize the all sides and external hardware of the radio. The LPN UM confirmed with the surveyors that the radio did not have any visual indications of inspection. The surveyors noted that the radio was off. The surveyors asked the LPN UM if the radio had been inspected by maintenance. The LPN UM was unsure of the process in which electrical items brought into the facility by a resident or family member were inspected. During an interview and observation of the resident at 12:50 p.m. by the surveyor, Resident #1 was awake and alert and was observed in his wheelchair in his room. Resident #1 confirmed he used his radio at times and was unaware of anyone checking the device. 2. According to the facility Admission Record, Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS, dated [DATE], revealed Resident #2 had a BIMS score of 15, which indicated intact cognition. During the tour with the LPN UM at 9:40 a.m., the surveyors entered Resident #2's room. Resident #2's Certified Nursing Assistant (CNA #1) was present in the room. The surveyors observed a small refrigerator in use and an electrically powered radio in Resident #2's room. The surveyors noted that the radio was off. The surveyors observed that the small refrigerator had an inspection sticker on the left side panel with a date written of 2/26 with no year indicated. The surveyors asked the LPN UM to pick up the radio to visualize all sides and external hardware, and the LPN UM confirmed with the surveyors that the radio had no indication of inspection. The surveyor asked CNA #1 who was to inspect the electronic devices in the room. CNA #1 indicated it was the responsibility of the maintenance staff to inspect such devices. During interview and observation of the resident at 10:40 a.m. by the surveyor, Resident #2 was awake and alert in wheelchair. Resident #2 stated he had the radio for a few months and was not aware of anyone checking it prior to the day of survey. 3.) According to the facility Admission Record, Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a MDS, dated [DATE], revealed a BIMS of 15, which indicated intact cognition. The surveyors continued the tour with the LPN UM into Resident #3's room at 9:50 a.m. The LPN UM explained that Resident #3 was no longer residing in the facility, as she had been out on pass since 4/2019 and was being discharged from the facility as of the date of this survey, 5/14/19. Upon entrance to Resident #3's room, the surveyors observed an electrically powered radio, fan, and humidifier located on the bedside table. The surveyors further noted that the radio was on, as it was plugged into an outlet and audibly playing music. The surveyors asked the LPN UM to pick up the radio and fan to visualize both devices and external hardware and confirmed that they both had no indication of inspection. The surveyors and LPN UM observed an inspection sticker on the humidifier base, with a date written of 1/1/19. During a tour with the Director of Maintenance (DOM) at approximately 10:10 a.m., the surveyors entered Resident #3's room, where the electrically powered radio, fan and humidifier were noted. The DOM examined the radio and the fan and confirmed with the surveyors that the radio had not been inspected. The DOM mentioned that when an electrical device is inspected, it would be checked for issues such as safe wiring and voltage requirements. The DOM further explained that an inspection sticker would be placed on the device with the date of inspection to identify it as cleared for use. 4.) At 10:00 a.m. the surveyors, accompanied by the DOM, entered Unsampled Resident #4's room and observed an electrically powered radio with speakers on the bedside table. The radio was not plugged into an outlet or other electrical source. The DOM examined the device and noted a crack in the plastic located in the upper right portion of the speaker. The DOM explained to the surveyors that he did not know Unsampled Resident #4 had a personal radio in his room. He further explained that this device would not have passed inspection due to the crack in the plastic. The DOM stated to the surveyors that he would remove the radio. This resident was unable to be interviewed by the surveyors. Review of a MDS, dated [DATE], revealed Unsampled Resident #4 had a BIMS score of 15, which indicated intact cognition. 5.) At 10:03 a.m., the surveyors, accompanied by the DOM observed a portable fan on the floor near the foot of Unsampled Resident #5's bed. The fan was not plugged into an outlet or other electrical source. The DOM examined the fan and confirmed with the surveyors that there was no inspection done on the device. Unsampled Resident #5 was unable to be interviewed by the surveyor. Review of a MDS, dated [DATE], revealed Unsampled Resident #5 had a BIMS score of 13, which indicated intact cognition. 6.) At 10:05 a.m. the surveyors, accompanied by the DOM observed an electrically powered radio on the bedside table of Unsampled Resident #6's room. Unsampled Resident #6 was not in his/her room. The radio was also examined by the DOM who confirmed that the radio had not been inspected. During an interview with the surveyor at approximately 10:40 a.m., the resident stated that he/she has had the radio for a year and no one has ever checked it. Review of a MDS, dated [DATE], revealed Unsampled Resident #6 had a BIMS score of 15, which indicated intact cognition. During an interview with the Director of Nursing (DON) at 10:50 a.m. the surveyors inquired about the process of residents bringing personal electronic devices into the facility. The DON explained that the resident and/or families were educated to inform nursing staff on the units about personal belongings, including electrically powered devices. Nursing staff were required to log new devices into the maintenance log on the units or inform the maintenance department at the daily morning meeting. The DON further explained that if an electrically powered device was found to not have been inspected, it would be removed until it was cleared with maintenance. During a follow up interview with the surveyor at 12:47 p.m., the DOM explained that each electrically powered device that was previously inspected needed to be re-inspected every thirty days to ensure proper functioning. The surveyor inquired as to the existence of a list of previously inspected devices with the dates they had been inspected, however, the DOM was unable to provide a list. The DOM was unable to identify how the maintenance staff logs, tracks, and reinspects previously inspected devices. During an interview at 9:58 a.m. with the surveyors, the DOM explained that residents' personal electronic devices brought in from outside of the facility were inspected by the maintenance staff upon arrival. The DOM explained that this would include items such as radios, refrigerators, humidifiers, fans, and other electrically powered devices not provided by the facility. The DOM explained that it was the responsibility of nursing staff to check for items daily and notify maintenance personnel if any personal electronic items needed to be inspected on the unit. The DOM explained that it was the facilities practice to have the family initially notify the nursing staff of any electrical devices brought in from outside of the facility. The nursing staff would then notify maintenance of the device to be inspected. The DOM explained that electronic devices were not permitted to be used until inspection occurs and that unit inspections are completed on a monthly basis to identify any items that need to be inspected. The DOM noted that each room is inspected during these monthly inspections. During an interview with the surveyor at approximately 9:40 a.m. the LPN UM stated she was unsure of the facility policy and procedure related to a resident's personal electronic equipment. During an interview with the surveyors at 1:10 p.m. in the presence of the Regional Administrator (RA), the Administrator explained that if there was a new electrically powered device brought into the facility by a resident or family member, maintenance would need to be made aware. The Administrator explained that upon admission, the resident and/or family member are given a welcome packet that includes information regarding the notification of staff of personal electronic equipment. The administrator explained that residents and/or family members would sign this document during admission. The surveyors requested documentation of the aforementioned signatures on this document for Resident #1, #2, #3 and Unsampled Resident #4, #5, and #6, however, they were not provided. He further explained that each unit had a maintenance log where staff could communicate the units' needs to maintenance. The Administrator further detailed that environmental rounds are done on a monthly basis and include an audit of 1 or 2 units a month. The surveyors requested documentation regarding the monthly environmental rounds, however, they were not provided. An undated facility document titled General Information, provided to the surveyors by the Administrator on the day of survey, revealed the following: .Although Alaris Health at Jersey City is not responsible for the loss or damage of personal equipment, small personal electronics like smart phones, personal music players or tablets with earphones are permitted for use in most resident rooms. Please check with your nurse before using any electronic devices .Any electrical equipment or item like a TV, radio, or computer has to be checked by maintenance staff before the item is used in the resident room . During an interview with the surveyors at 2:40 p.m., the Administrator stated he provided this document to all residents on admission. A facility policy titled Maintenance Review of Electrical Items, dated 11/17/2016, revealed the following: Policy: This facility will ensure that all electrical items are inspected for safety by the maintenance staff .The family of the resident, the resident, or the staff will advise maintenance staff that there is a new electrical item in the resident room .The item will be inspected by the maintenance staff for electrical integrity .the item cannot be used until it is inspected. Review of an undated facility policy titled Regional Maintenance Monthly Audit Form Policy, revealed the following: Procedure: A walkthrough of the facilities will be conducted every month by the regional maintenance director to ensure any issues that need attention are identified to make certain the facility is in good standing with state, federal, and local codes .The monthly audit form that has been given to each regional maintenance director must be filled out in its entirety .a copy of the completed form should also be left with the administrator of each facility. N.J.A.C. 8:39-31.4 (a)

Based on observation, interview and record review it was determined that the facility failed to maintain the health and safety of a resident at risk for aspiration for 1 of 5 sampled residents, (Resident #3). Resident #3 required a gastrostomy feeding tube for nutrition, due to dysphagia (swallowing disorder), and risk for aspiration (breathing in a foreign object, such as sucking food into the airway). Resident #3 was observed by the surveyor laying flat in bed with the nutritional feeding infusing via her gastrostomy tube (GT). The (Hospice) Home Health Aide (HHA) failed to follow a facility policy "Tube Feeding Administration" which stipulates "Elevate Head of Bed 45 degrees to reduce chance of aspiration" and by placing the resident flat in bed while tube feeding was infusing put the resident at risk for aspiration. This was identified as an immediate jeopardy to the health and safety of Resident #13. This deficient practice is evidenced by the following: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 7/29/14, documented that Resident #3's memory was severely impaired, and required extensive assistance with activities of daily living (ADL). The surveyor conducted a tour of Unit J on 9/22/14, with the Unit Manager (UM). The surveyor observed Resident #3 flat in bed with "[MEDICATION NAME] 1.2 cal" infusing at 75ml (unit of measure "milliliter") per hour via the gastrostomy tube. A Comprehensive Care Plan dated 1/8/14 and revised 4/18/14 contained a focus of "Resident requires tube feeding r/t (related to) Dysphasia and is at risk for aspiration." Interventions included but not limited to: "Resident needs the HOB (head of bed) elevated 45 degrees during and thirty minutes after tube feed. Monitor for signs and symptoms for aspiration, GI (gastrointestinal) distress and respiratory distress." Focus of "Resident is receiving hospice care services" initiated 5/12/14. Interventions included but not limited to: "Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met." A Physician order [REDACTED]. Hours per day: 17 hours or total volume 1275 ml. On at 4pm off at 9am. Another order dated: 8/18/14 contained orders for Diet: NPO (nothing by mouth), [DEVICE]. A review of the Enteral Protocol form dated 8/27/14 showed under the title of Placement: Elevate head of bed 45 degrees during feeding and 1 hour after. During an interview with the surveyor on 9/22/14 at 10:17am, the Unit Manger stated that she didn't know why Resident #3 was laying flat in bed with the [MEDICATION NAME] formula infusing, and responded, "no" when asked if the resident should be laying flat when formula is infusing. During an interview with the surveyor on 9/22/14 at 10:20am and 2:55pm, the HHA caring for Resident #3 stated,"I put the feeding on hold during care, I am not allowed to turn it off." The surveyor asked, why did you leave her flat in the bed? The HHA replied, "Because I was putting the garbage out when you (referring to the surveyor) came in. I was planning to put her up." At 2:55pm HHA stated that she started AM (morning ADL's) care at 10:00am and at that time put the feeding pump on hold then restarted the feeding when the surveyor walked in at 10:17am. When asked by the surveyor why she left Resident #3 flat in the bed the HHA responded, "I don't know why, I never do that." The surveyor then inquired if the HHA ever received any training on how to care for Resident #3, the HHA responded that the Hospice Registered Nurse (RN) Case Manager instructed her to wait 10 minutes after shutting off the pump before starting AM care and the head must always be elevated. During an interview with the Hospice RN Case Manager (Registered Nurse) on 9/22/14 at 12:15pm, the Hospice RN Case Manager stated that she instructed the HHA to not touch the feeding, she must let the nurse stop the feeding first and then must wait 30 minutes to prevent vomiting. When asked by the surveyor if the Hospice RN Case Manager ever monitored the HHA administering care to a resident with a GT, the Hospice RN Case Manager responded, "Yes, she was OK". The Hospice RN Case Manager also stated that she explains the job duties and makes a care plan for the HHA to follow. The surveyor requested a copy of the care plan for Resident #3 related to the feeding tube. The Hospice RN Case Manager was unable to locate a care plan, stating "The care plan is not in this chart." The Hospice RN Case Manager also stated that "I tell them to keep the head elevated and to watch for aspiration." The Hospice RN Case Manager stated that she was not sure if her agency had ever given the HHA any training on how to care for a resident with a GT. During an interview with the surveyor on 9/22/14 at 11:45am the Licensed Practical Nurse (LPN) responsible for the care of Resident #3 stated: "When a HHA is assigned to her unit she tells the HHA what to do with the resident, she observes her the first time to see how they care for the resident." When informed by the surveyor that Resident #3 was found laying flat with the feeding infusing, the LPN replied, "I didn't know she was there doing care." During an interview with the surveyor on 9/22/14 at 11:55am, the Administrator stated the outside agency staff are given an orientation and then the nurses go over what needs to be done. The Administrator failed to provide any documentation of the HHA having orientation given by the facility. During an interview with the surveyor on 9/22/14 at 12:05pm, the Quality Assurance Certified Nurse Assistant, responsible for giving out care assignments to the staff on J wing, stated: "We gave the HHA an inservice on how to care for Resident #3 and the nurse tells her what to do." During an interview with the surveyor on 9/22/14 at 12:40pm, the Regional Nurse stated that the facility doesn't have Certified Nurse Assistant (CNA) care plans "The CNA's use the same care plan that the nurse uses." A review of the facility Inservice dated 6/9/14, titled "Repositioning and Turning for CNA" documented as the summary of the presentation: "Included CNA with inservice to make nurse aware when doing care on [DEVICE] feeder to remove tube feeding prior to care." A review of the "Hospice Care Plan" dated 6/25/14 revealed no interventions for how to handle a GT during ADL's for Resident #3. A review of the Hospice "Orientation Checklist" of 2011, 2012 and 2013 demonstrated there was no specific training noted for the care of a resident with a GT. A review of the Hospice "Supplemental Interdisciplinary Progress Note" dated 4/29/14 stated: "Patient brought onto hospice care with [DIAGNOSES REDACTED]. Home Health Aide was instructed to keep head up 45 degrees at all times when feeding is in progress. When starting AM care instruct patient nurse to stop feeding and wait 30 minutes to start care. Do not put patients head down at any time when tube feeding is running via feeding pump. Keep head of bed up 20-30 minutes after feeding has been stopped by nurse to begin morning care." A review of the Hospice "Supplemental Interdisciplinary Progress Note" dated 5/6/14 stated: "Keep patient head of bed elevated when feeding is in progress. Home Health Aide verbalized understanding of care with safety and aspiration precaution." A review of the Hospice "Supplemental Interdisciplinary Progress Note" dated 5/13/14 stated: "Follow-up visit made with HHA with instruction on aspiration precautions as it relates to patients gastric tube. Keeping head up when feeding is in progress. Instruct staff nurse to stop feeding and disconnect tubing to start AM care. Wait 20-30 minutes before care." A review of the Hospice contract with the Facility dated 1/18/2013 revealed: 3.6 "The Hospice shall designate the RN Case Manager to be responsible for a Hospice Patient residing at the Facility. This designated member of the IDT (Interdisciplinary Team) is responsible for providing the overall coordination of the hospice care for the Hospice Patient with the Facility representatives and communication with the Facility representatives and other health care providers (Including the Hospice Medical Director, the resident's attending physician and other physician's involved in the care) participating in the provision of care for the terminal illness and related illness and related conditions and other conditions to ensure quality of care for the patient and family." 6.6 Experience and Competence, "It and its (sic) employees and personnel providing services pursuant to the Agreement are (i) familiar with the administrative and patient care needs associated with hospice patients, (ii) competent in the care of terminally-ill persons and in record keeping, and (iii) otherwise fully capable of performing its and their obligations hereunder in accordance with generally recognized professional standards of care." The Immediate Jeopardy (IJ) to Resident #3's health and safety which began on 9/22/14, was identified by the surveyor and relayed to the facility Administrator, Director of Nursing (DON), Vice President of Operations and the Regional Nurse on 9/22/14 at 3:00 PM, and was lifted on the same day, 9/22/14 at 4:00 PM when the facility implemented an acceptable plan of correction (POC). The POC stated: 1. Feeding was stopped and head of bed elevated immediately for resident (resident initials). Hospice aide that was taking care of (resident initials) did not call the nurse to turn off the feeding while doing care and head of bed was not elevated as per facility policy. The hospice aide was given an in-service regarding facility policy on tube feeding administration and importance of elevating head of bed at least 45 degrees during feeding. 2. All tube feeding residents in house has the potential to be affected by this deficient practice. All tube feeding residents were reassessed today to ensure compliance of the facility policy regarding tube feeding administration is in place. All were found to be in compliance. All C.N.A.'s were educated regarding calling the nurse to turn off feeding prior to care and notification to a nurse once care is completed. 3. Ongoing in-service for current staff, new hires, outside agency and hospice staff as well as daily rounds done by DON/designee and shift supervisor. Competencies will be done on in-house staff, outside agency and hospice staff every 6 months. Daily tube feeding audit will be completed every shift by nursing supervisor/delegate. 4. The DON will review the daily audits using a Quality assurance tool checklist for compliance with our tube feeding administration policy. Corrective actions will be enforced immediately along with the necessary staff in-services. Results of daily audit will be discussed with the team at our Quarterly Quality Assurance meeting. 5. Completion date was 9/22/14. This deficient practice continued as F309 at a lower scope and severity (D) level as follows: Based on observation, interview and record review it was determined that the facility failed to provide the necessary care and services to maintain the highest physical well being for 1of 5 sampled residents, (Resident #2). Resident #2 required gastrostomy feeding tubes for nutrition. According to the Hospital Triage Notes, dated 8/16/14, it was reported that Basic Life Support (BLS) found Resident #2 lying flat with continuous tube feeding infusing, resulting in the admission of Resident #2 on 8/16/14 to the hospital with a [DIAGNOSES REDACTED]. This deficient practice is evidenced by the following: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 7/14/14, documented that Resident #2's memory was severely impaired, and required extensive assistance with activities of daily living. A Comprehensive Care Plan initiated 10/15/13, revised 2/20/14, contained a focus of "Resident is npo and requires tube feeding r/t (related to [MEDICAL CONDITION] Dysphasia) placing him at risk for aspiration." Interventions included but not limited to: Resident needs the HOB (Head of bed) elevated 45 degrees during and thirty minutes after tube feed. Hold feeding 1 hour prior to ADLs." A review of the Physician order [REDACTED]." A Review of the POS [REDACTED]." A review of the facility "Progress Notes" dated 8/16/14 at 3:15am showed: "Resident seen with respiratory distress and wheezing on bilateral lungs. VS (vital signs) Temperature 99 Respirations 30 Pulse 90 Blood Pressure 141/70 SpO2 (Oxygen saturation) 87% with O2 2LPM (Liters per minute) via N/C. Neb (nebulizer) treatment given, Supervisor notified. At 3:30am Resident reassessed. wheezing present on bilateral lungs R28 SpO2 87% with O2 2LPM via N/C. Supervisor notified. Called 911 for transfer. MD called. still waiting for call back. Son called and left message. At 3:40am Resident escorted by four paramedics to (hospital name)." A review of the facility "Enteral Protocol" form dated 8/12/14 showed: Section titled, Placement: "Elevate head of bed 45 degrees during feeding and 1 hr after." A review of the facility "Admission History & Physical Examination" for Resident #2 revealed: Section titled "History of Present Illness," [AGE] year old male, transferred from (hospital name) to hospice care, my service, per request of Dr. (physician name). Known [MEDICAL CONDITION], admitted on ,[DATE] to (hospital name) for acute [MEDICAL CONDITION], on ventilator for 1 week. Localized pleural effusion was tapped. A review of the facility "Interdisciplinary Progress Note" dated 8/26/14 showed: " Resident is readmitted from (hospital name) with [DIAGNOSES REDACTED]. He has the stage 2 on sacrum, he has swelling of both hands and swelling of both lower extremities, swelling of pubic area including the penis. He returned with a Foley catheter and is on continuous Oxygen 3l/min. Resident is placed on Hospice at this time." A review of an undated facility policy titled "Tube Feeding Administration," showed: 5." Elevate head of bed 45 degrees to reduce the chance of aspiration." A review of (hospital name) Emergency Department Triage notes dated 8/16/2014 documented: "Pt aphasic (baseline) via Basic Life Support (BLS) from (name of nursing home) brought in for difficulty breathing. Upon BLS arrival patient was found laying flat while on continuous tube feed"..."After the evaluation in the Emergency Department, my clinical impression is [MEDICAL CONDITION] infection likely secondary to aspiration, dyspnea" Resident #2 was admitted . NJAC 8:39 - 27.1 (a)

Complaint #: NJ Based on interviews and review of medical records and other facility documentation, it was determined that the facility failed to follow their own policies and assure that 2 of 6 sampled residents (Resident #1) who had a known history of being at risk for wandering and elopement was accurately assessed for elopement risk on admission, supervised and/or monitored adequately to prevent elopement. Resident #1, who was cognitively impaired, independent with ambulation and had been admitted to the facility 16 days prior, exited the facility on 11/5/2013 and was found approximately 4 hours later at a facility he previously resided in which was approximately 2.5 miles away. In addition, facility staff did not consider Resident #1's unknown whereabouts on 11/5/2013 an elopement. The facility's failure to accurately assess and supervise, placed all newly admitted residents, who were at risk for elopement in an immediate jeopardy situation. The Immediate Jeopardy (IJ) to residents' health and safety began on 10/19/2013 was identified by the surveyor and relayed to the facility Administrator and Director of Nursing (DON) on 11/20/2013 at 4:40pm, and was lifted on the same day, 11/20/2013 at 5PM when the facility implemented an acceptable plan of correction (POC). This deficient practice is evidenced by the following; Interviews, observations and review of the medical records and other facility documention was conducted on 11/20/2013 unless otherwise noted. 1. According to the facility Face Sheet, Resident #1 was admitted to the facility in 10/2013 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 10/25/2013 showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of "6" which indicated severe cognitive impairment. The MDS showed Resident #1 needed limited assistance with ambulation and activities of daily living (ADLs). A Physician order [REDACTED]. Review of Resident #1's medical record (MR) showed a "New Jersey Universal Transfer Form" (TF), dated 10/19/2013, which indicated Resident #1 was transferred to the current facility from another facility on 10/19/2013. The TF confirmed the [DIAGNOSES REDACTED].#1 had "AT RISK ALERTS" for "Wanders" and "Elopement" and had periods of agitation. Located behind the TF in the MR was other documentation from the sending facility which was faxed to the current facility on 10/10/2013. The documentation included but was not limited to; history and physical, medication administration record (MAR) and progress notes (PN). Review of the sending facility's PNs dated 10/5 and 10/6/2013 showed that Resident #1 had worn a Wanderguard (WG) on his wrist. An Interdisciplinary Care Plan (CP), dated 10/19/2013 showed a focus for physical and occupational therapy and nutrition. There was no documentation related to a risk of wandering until 11/6/2013, the day after Resident #1 eloped, when the CP was updated to include a "history of agitation and anxiety as reported by the family" with interventions which included but were not limited to; monitor/record occurrence for target behavior symptoms and specify pacing, wandering, disrobing ...and document per facility protocol. There was no CP initiated for elopement. The CP cover sheet did not indicate Resident #1 was at risk for wandering and/or elopement. A facility "Admission Clinical Assessment" Form completed/signed by the current facility's Assistant Director of Nursing (ADON) and dated 10/19/2013, the date of admission to the facility, showed Resident #1 was independent in ambulation. Under a "Cognitive Assessment", the ADON indicated Resident #1 was "oriented to person" but not oriented to "place and time" and had no "Hx (history) of Wandering". The admission assessment included an interim CP which included a problem of "...Intermittent confusion" related to (r/t) use of psychotropic medications with interventions which included but were not limited to; anticipate needs. An "Elopement Risk" assessment, completed/signed by the ADON and dated 10/19/2013 included 4 sections with questions which were answered by checking off a "yes" or "no". a. The first section included but was not limited to the following questions; - Is there a history of wandering/elopement and/or does the resident verbalize a strong desire to leave? "No" was checked off. A hand written note by the ADON, above the question showed; "As per family, patient wanders around". - "Yes" was checked off for a [DIAGNOSES REDACTED]. b. The second section asked if, within the last 2 quarters have there been; "staff reported/documented episodes of elopement and/or attempts to elope and demonstrated impaired judgement...that would place him/her at risk in the community?" and both were checked off as "no". c. The third section asked; "Has the resident's representative (Health Care POA (Power of Attorney) family, guardian) requested that the resident be monitored on the Elopement Protocol? If YES, document this request on the Care Plan cover sheet, and place the resident on the Elopement Risk Protocol." "Yes" was checked. d. The fourth section noted; "A combined score of five (5) or more triggers possible elopement risk..." Checked as "yes" was (1) "Spends time in the First Floor/Lobby, or wanders between floors without supervision" (Score=1), (2) "Has the physical ability (able to walk with/without an assistive device) to leave the building" (Score=1), and (3) Becomes easily agitated, confused and/or disoriented or shows consistently poor judgement (i.e. would not be able to safely care for him/her outside the facility)" (Score=2) which totaled a score of 4. The fourth section showed that a score of 0-4 reflected the resident was not at risk for elopement. Review of Resident #1's CP cover sheet did not indicate any risk of elopement and/or wandering as indicated by the Elopement Risk Assessment protocol or that the elopement protocol was to be initiated. During an interview with the surveyor at 1:10PM in the presence of the UM, the ADON confirmed that she had completed the Admission Assessment, including the "Elopement Risk" Assessment for Resident #1. She confirmed that she spoke with the family member (FM) at the time of the assessments, who requested Resident #1 be placed on elopement protocol as Resident #1 wanders. The surveyor asked the ADON what the "elopement protocol" involved and she stated that Resident #1 was put on every 15 minute checks which would be documented on monitoring sheets which were kept on each unit. The surveyor also questioned why Resident #1 was assessed as "not at risk" for elopement since the TF noted a risk of wandering and elopement. The ADON stated she was not aware of any history of an elopement and "we give the benefit of the doubt" to the residents, "it takes a while to know the residents...and we want to monitor them...". The ADON stated she did not remember if she noted that "wandering and elopement" were noted on the TF. She confirmed that elopement and/or wandering risk and every (q) 15 minute monitoring was not added to the CP nor did she place a WG on Resident #1. During an interview with the surveyor at approximately 1:30PM, the UM and surveyor reviewed a monitoring book on the unit Resident #1 had resided and were unable to locate any documentation for monitoring. The UM stated there was no documentation of monitoring because Resident #1 was never put on monitoring because he was not considered at risk for elopement. The UM confirmed that Resident #1 did not have a WG bracelet placed on him. During an interview with the surveyor at approximately 1:50PM, the ADON verified that she could not locate any (q 15 minute) monitoring documentation for Resident #1. During an interview with the surveyor in the presence of the UM at approximately 1:45PM, the assigned 7AM-3PM shift Certified Nurses Aide (CNA #1) for Resident #1 stated he had taken care of the resident since admission and was unaware that Resident #1 was on any monitoring or was at risk for wandering and/or elopement. Review of Interdisciplinary Progress Notes (IPN) from 10/19/2013 through 11/4/2013 showed 4 times Resident #1 went OOP and returned with a FM. On 11/5/2013 at 4:26PM, the IPN showed; "Resident transferred from (present unit) to a (locked unit) accompanied by staff. Ambulatory with steady gait, alert and confused, verbally responsive. all due needs rendered...closely monitored q (every) 15 mins. Denied pain..." There was no indication in the IPN that Resident #1 had eloped from the facility on 11/5/2013. An "Interdisciplinary Quarterly Progress Note", dated 10/25/2013 showed Resident #1 was "able to make basic needs known but very forgetful...no behavioral issues". A Psychoactive Monitoring Form, dated 10/2013 showed; "Target Behavior" for Resident #1 was "pacing until exhausted" and showed on 10/20/13, "wandering into other residents room", 10/21/2013 at 8AM; "ambulating 'I want to go outside', ambulated with CNA (certified nurses aide) until calmed, Resident was angry and agitated", and on 10/21/2013 for the 11PM -7AM shift; "wandering in hallway". There were no further behaviors r/t pacing documented by the staff for 10/2013 through 11/5/2013. During an interview with the Administrator at 11:20AM, the surveyor asked if the facility had any resident elopements in the last 2 months. The Administrator stated they had no elopements but one resident (Resident #1) did leave the facility a week or 2 prior, for a few hours but Resident #1 knew where he wanted to go, so she (Administrator) did not consider it an elopement. The Administrator added that a FM visited regularly and took Resident #1 OOP however, when the FM did not show up at the facility, Resident #1 left without signing out or telling a staff member he was leaving the facility. The Administrator stated she was notified by the UM at approximately 1PM, that Resident #1 was unable to be located on the unit and immediately had employees search the inside and outside perimeter of the facility and when unable to locate Resident #1, the police were notified. The family of Resident #1 was called and returned the call and stated that Resident #1 may have gone to the FMs house and also made the facility aware that Resident #1 had been given money by the family. The Administrator stated that approximately 3-4 hours later, a previous facility, where Resident #1 had resided called and alerted the Administrator that Resident #1 was there and a facility staff member was sent to bring Resident #1 back to the facility. Additionally, the surveyor asked the Administrator, why, when the facility was unable to locate Resident #1 and he was missing for approximately 4 hours, they did not consider it an elopement and report this to the NJ Department of Health. The Administrator stated that Resident #1 knew where he wanted to go, to his FM's house, he had a destination in mind so they did not consider it an elopement. She also added that later in the day on 11/5/2013, approximately 2-3 hours after Resident #1 was noted as missing, Resident #1's roommate informed a staff member that Resident #1 told him he was going to visit a FM. During an interview with the surveyor at 12:30PM the DON confirmed that if the TF had documentation r/t a risk of elopement, the staff would conduct an assessment, "perhaps put a wanderguard on or put on a (locked unit)..., use 1:1 staff... and refer to the Interdisciplinary Team (IDT) to determine if interventions are needed". She confirmed Resident #1 was not referred to the IDT for an evaluation as he was not considered at risk for elopement on admission. Additionally, during an interview with the surveyor at 2PM, the DON stated that the facility protocol to determine a resident's elopement risk is the "Elopement Risk" Assessment. She stated that even though the FM had requested "Elopement Protocol" the facility would not institute it, as "we would do our own assessment" and monitor the resident and Resident #1 was assessed as not at risk. The DON added "We don't want to put a label on a resident". The DON confirmed that an IR was not completed as this was "not a fall or a bruise" and IRs are done for falls and bruises only. After surveyor review of a facility policy titled "Missing Resident", during an interview with the DON at approximately 2PM, the surveyor asked for a missing "Resident Checklist" form. The DON stated that the only documentation she had regarding Resident #1 absence on 11/5/2013 was her hand written note. She confirmed that there were no staff statements or witness statements obtained. Review of a handwritten note, dated 11/5/2013 and signed by the DON given to the surveyor at 2PM on 11/20/2013, showed that at 1PM on 11/5/2013, the DON was "notified by the nsg. (nursing) staff that (Resident #1) was not on the unit, all resident areas and entire ...unit checked (with) no results". The note also showed that a FM was called and did return the call and informed the facility that Resident #1 "knows the neighborhood...knows where (FM) lives...has money on him...". The police were notified of the existence of money which the facility felt could "broaden his whereabouts or travel via public transportation". The note did not include the time or who had last seen Resident #1 in the facility, what he was wearing, the time he returned, or any vital signs on return to the facility. During an interview with the surveyor at approximately 1:45PM, the assigned 7AM-3PM shift CNA (#1) for Resident #1 stated he had worked on 11/5/2013 and remembered that he last saw Resident #1 at approximately 10:30AM and was unaware that the resident had left the facility that day. Review of a "Police Department Investigation Report" faxed to the NJ DOH showed on 11/5/2013 at approximately 4:11PM the police responded to a report of a missing person (Resident #1) who "had left the nursing home for a walk and never returned...he was wearing a ..hat...jacket and ...pants.. when last seen at approximately 1PM". In addition, the report noted that Resident #1 was found at a previous facility he had resided, was in good condition and "stated that he got lost". At approximately 4:45PM a staff member from the current facility arrived and returned Resident #1 to the facility. During an interview with the surveyor at 3:30PM, the Facility Regional Nurse stated that if a resident has a history of wandering and/or elopement or if the family requested the elopement protocol, the Interdisciplinary Team should meet and discuss the issue at the morning meeting. If the outcome at that time is determined not to be at risk, the family should be notified. The resident should have a WG applied if a family requested it and it should be documented on the CP. When asked if Resident #1 eloped from the facility the Facility Regional Nurse stated "the Resident (#1) did not run away from the facility, he had a destination of where he wanted to go. He did not sign out to let us know. He did not just take off ...". Review of a faxed note from the Administrator to the NJ DOH, dated 11/21/2013, related to (r/t) Resident #1 showed; "Information received from the transferring facility noted the patient (Resident #1) was utilizing a (WG) but had no documented attempts of trying to leave the building. On the contrary, the notes document patients (Resident 1's) full cooperation with (OOP) process while at the facility. Upon admission the facility completed a current elopement risk assessment in which (Resident #1) was deemed not at risk for elopement. (FM) was present ...and did comment on elopement protocol, however (another FM) (POA) who is very close with the resident came in later that evening did not express the need for this during care discussion with the nurses...During the first 72 hours of admission (Resident #1) made one statement regarding wanting to go home, when asked what home he said my other room, he was making no attempt, only commenting...As with all new residents there was noted confusion with surroundings, this is expected... and not considered to be a negative behavior....At approximately 3:15 (PM) we received a call from another facility where (Resident #1) had been prior....staff picked up..." Additionally, the note showed; " When asked what happened (on return to the facility) (Resident #1) stated his (FM) did not come so he was going to visit him...I see other residents going out on their own why is this an issue (?) It was explained ...that a specific order is needed for independent OOP, his order was only for OOP with family. He (Resident #1) expressed an understanding...Following this event a pendant device (WG) was placed on the resident and his room was moved to the (locked unit) for safety until further assessment could be completed. (Resident #1) did not intend to elope from the facility...He (Resident #1) never intended to leave and not return." The Administrator also noted that the facility does obtain a current elopement assessment and review prior facility records but these are not always accurate or based on the (resident's) current status. "....If a new admission is identified as a risk for elopement the (facility) does have systems in place (elopement protocol) to provide a safe living environment through the use of pendant alarm system (WG) and a secured (locked) unit..." Resident #1 was moved to the secured (locked) unit until further monitoring/assessment could be completed by the center team per the elopement protocol. Review of the MR for Resident #1 showed no further assessments r/t elopement and/or wandering after the initial risk assessment completed on admission. Review of an undated facility policy titled "Elopement Protocol" showed "The facility has a formal elopement protocol in place for the safety and well being of our residents who based on assessment score 5 or higher on center Elopement Assessment. Procedure: Elopement Risk Assessment (is) completed upon admission for all new residents (and) completed quarterly and with any change in condition or mental status. Interventions: Resident will be given a pendant alarms (wanderguard) which are checked daily for placement and weekly for function...Resident will be care planned for elopement risk..." Review of a facility policy dated 2/2006 and titled; "Missing Resident" showed; a resident is determined to be "missing" when: The resident is not physically present during half-hour rounds. The resident leaves the facility without permission or a pass, discharge order ... A check by staff indicates that the resident is not in the facility. Procedure: Notify charge nurse/supervisor of residents absence...initiate a search...The Nursing Supervisor will initiate missing resident checklist noting the time each step was completed and initial each step..." The Nursing Supervisor will notify the police after 1 hour of search and the Administrator/DON will notify the NJ Department of Health and Senior Services... Review of the "Missing Resident Checklist" included but was not limited to; Interview staff, residents neighbors or friends to determine if missing resident has informed anyone of his/her intentions to leave and obtain written statements..." Review of a facility policy, dated 11/10/2010 and titled "Accident/Incident Report" (IR) showed; An (IR) is completed for ...all accidents or incidents where there is injury or the potential to result in injury..." Procedure; An IR must be completed on the shift in which the incident/accident occurred. Licensed personnel are responsible for the initiation and completion of the IR. The physician and/or Responsible Party are notified. Documention in the MR must include an accurate description of the accident/incident, results of range of motion, body assessment, vital sign check, notification of Physician and Family, remedial measures and /or treatment and any interventions initiated....All statements must be obtained from all witnesses on the shift it occurred..." The Immediate Jeopardy to the resident health and safety was identified and corrected on 11/20/2013 as evidenced by the following; 1. Resident #1 was placed on a locked unit on 11/5/2013 for safety and monitoring. 2. Any resident presenting a risk for elopement based on their elopement assessment and/or history of elopement are at risk. All residents admitted following 10/19/2013 were reviewed and assessed for accuracy. 3. All Nursing staff, initiated 11/20/2013 will be re-educated on accurate completion of elopement assessment, elopement protocol, care planning and history of wandering/elopement at prior locations which included hospital, nursing home or private residence. Elopement assessments and CP will be reviewed by the IDC team at the first clinical meeting following admission to assure accuracy of assessment for any potential adjustment needs. 4. Random audits of all new admission will be completed monthly by the DON or designee for accuracy and following through per policy and findings reported to the center quality improvement committee quarterly. NJAC 8:39-27.1 (a)