Every finding on record at Allaire Rehab & Nursing

Based on observation, interview, and policy review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 05/21/2026 from 09:47 AM until 11:00 AM, the surveyor observed the following in the kitchen in the presence of the Food Service Director (FSD):1. In the walk-in refrigerator three opened containers of chicken base were observed to have no opened or use-by date. The FSD indicated that the date observed on the item was the received date and further stated they should have an opened-on date as well.2. In the walk-in refrigerator a metal container with a plastic cling wrap cover with ketchup written on the plastic. On the plastic wrap was a sticker label with a use-by date of 4/25/26. The FSD indicated that the item was improperly labeled. 3. In the walk-in refrigerator a clear plastic container with a plastic lid labeled as Tuna was labeled to be used by 5/16/26. The FSD stated the item was tuna salad and confirmed the item was past its use-by date. The FSD removed the item from the refrigerator. 4. In the walk-in refrigerator a clear plastic container with a plastic lid labeled as Egg was labeled to be used by 5/15/26. The FSD stated the item was egg salad and confirmed the item was past its use-by date. The FSD removed the item from the refrigerator.5. In the walk-in refrigerator a metal container with a plastic cling wrap cover containing cookies with a use-by date of 5/18/26.6. On a shelf at the food preparation station, an opened bag of barley wrapped in clear plastic wrap with no opened-on or use-by date. The FSD confirmed the item should have an opened date on it. 7. On a shelf at the food preparation station, an opened bag of dry pasta wrapped in clear plastic wrap was observed to have no opened-on or use-by date. The FSD confirmed the item should have an opened-on date. 8. On a shelf at the food preparation station, an opened bag of confectioner's sugar wrapped in clear plastic wrap was observed to have a use-by date of 5/10/26. The FSD indicated that the item was mislabeled. 9. In the dry storage room several boxes containing food items were observed stacked directly on the floor. The FSD stated they were from a recent delivery. 10. In the dry storage room an opened unlabeled bag of dry cereal was observed with no opened-on or use-by date. The FSD stated that the item was used during the morning's breakfast and confirmed the items should have an opened-on date. 11. On the clean/ready to use dishware rack a plastic container containing clear tulip dessert cups were observed to have brown spots on five of the tulip cups observed from the top of the container. The FSD removed the items from the rack. 12. A male facility staff member was observed pushing a cart from the loading dock through the kitchen with no beard or hair net. The FSD indicated that the maintenance elevator was down and that the staff member was retrieving items from the delivery. 13. A female facility staff member was observed pushing a cart with boxes from the loading dock through the kitchen with no hair net. On 05/21/2026 at 11:35 AM, during initial tour of the facility a personal refrigerator in room [ROOM NUMBER] was observed to have no thermometer.On 05/27/2026 at 1:10 PM, during an interview the Licensed Nursing Home Administrator (LNHA) when asked if staff retrieving deliveries through the kitchen should have worn hair and/or beard nets responded yes. The LNHA further responded that it was necessary for infection prevention purposes. On 05/28/2026 at 9:22 AM, when asked if all resident personal refrigerators should have a thermometer the Director of Nursing (DON) responded yes. A review of the facility provided policy titled Labeling and Dating Food Items revealed under policy statement, All food items opened or removed from their original packaging with have a 'use by' date.A review of the facility provided policy titled Food Storage: Dry Goods, under procedures, number 4, All items will be stored on shelves at least 6 inches above the floor. The policy further stated under number 6, Storage areas will be neat, arranged for easy identification and date marked as appropriate.A review of the facility provided policy titled Food Storage: Cold Foods, under procedures, number 5, all foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.A review of the facility provided policy titled Resident Personal Refrigerators revealed under procedure, number 4, Refrigerators will contain a manual thermometer. NJAC 8:39-17.2(g)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the facility designated garbage area free of trash and debris and failed to have a closed cover over the opening of 1 of 2 garbage containers. This deficient practice was evidenced by:On 05/21/2026 at 10:53 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the facility's outdoor trash disposal area. The surveyor observed two garbage containers (GC) situated side by side outside of the facility. The surveyor observed one GC with an open lid which contained cardboard boxes exposed to the elements. On the same day and time, when asked if the lids should be open on the GC, the FSD responded that they should be closed and further indicated that an employee was probably coming back to load more and that was why it was not closed. The surveyor did not observe any additional employees in the outside trash disposal area at that time. On 05/27/2026 at 1:10 PM, when asked about proper garbage/refuse disposal, the Licensed Nursing Home Administrator (LNHA) stated, both lids on the GC should be closed. The LNHA further responded that this was necessary for infection prevention purposes. Review of the facility provided policy titled, Dispose of Garbage and Refuse revealed under procedures, Appropriate lids are provided for all containers NJAC 8:39-19.3(c)

Based on interview and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set assessment in a timely manner for 6 residents. This deficient practice was identified for 6 of 8 Residents (Residents #45,81,139,141,142 and #148) reviewed for Resident Assessment and was evidenced by the following:Resident #45 was admitted with diagnoses that included but were not limited to nontraumatic subarachnoid hemorrhage. On 05/28/2026, the surveyor reviewed the electronic medical record (EMR) for resident #45. The Quarterly Minimum Data Set (QMDS), an assessment tool completed every 3 months, revealed an Assessment Reference Date (ARD), a date used as the last day of a look-back period, of 04/3/2026. The EMR revealed that the QMDS for Resident #45 had been completed on 04/25/2026, 8 days late.Resident #81 was admitted with diagnoses that included but was not limited to quadriplegia (a condition that causes partial or total loss of all 4 limbs and the torso). On 05/28/2026, the surveyor reviewed the EMR for Resident #81. The QMDS revealed an ARD of 04/05/2026. The EMR revealed that the QMDS for Resident #81 had been completed on 04/25/2026, 6 days late. Resident #139 was admitted with diagnoses that included but was not limited to spastic quadriplegic cerebral palsy (a condition that affects muscles and movement due to increased muscle tone and stiffness). On 05/28/2026, the surveyor reviewed the EMR for Resident #139. The QMDS revealed an ARD of 04/05/2026. The EMR revealed that the QMDS for Resident #139 had been completed on 04/25/2026, 6 days late. Resident #141 was admitted with diagnoses that included but was not limited to intracranial injury (brain injury). On 05/28/2026, the surveyor reviewed the EMR for Resident #141. The QMDS revealed an ARD of 04/03/2026. The EMR revealed that the QMDS for Resident #141 had been completed on 04/25/2026, 8 days late. Resident #142 was admitted with diagnoses that included but was not limited to traumatic subdural hemorrhage (bleeding in the brain). On 05/28/2026, the surveyor reviewed the EMR for Resident #142. The QMDS revealed an ARD of 04/02/2026. The EMR revealed that the QMDS for Resident #142 had been completed on 04/25/2026, 9 days late. Resident #148 was admitted with diagnoses that included but was not limited to traumatic subdural hemorrhage (bleeding in the brain). On 05/28/2026, the surveyor reviewed the EMR for Resident #148. The QMDS revealed an ARD of 04/04/2026. The EMR revealed that the QMDS for Resident #148 had been completed on 04/25/2026, 7 days late. During an interview with the surveyor on 05/28/2026 at 10:59AM, the MDS Coordinator acknowledged that the QMDS's for Residents #45,81,139,141,142 and #148 were completed late. She stated it is important to have the MDS completed on time to be sure the residents are being assessed according to regulation and care plans are updated properly.Review of the facility provided policy titled Resident assessment Instrument/ MDS revealed that, The MDS Coordinator is responsible for ensuring timely resident assessments and review. NJAC 8:39-11.1

Based on observation, interview and record review, it was determined that the facility failed to administer medication with an error rate of less than 5%. The surveyor observed 3 nurses administer medications for 5 residents, errors were observed for 2 of 5 residents (Resident #37 and Resident #109). There were 25 opportunities for error with 11 errors observed resulting in an error rate of 44% as evidenced by the following: During the medication pass observation on 5/22/26 from 10:01 AM until 10:24 AM, the surveyor observed the following:At 10:01 AM, the surveyor observed Licensed Practical Nurse #1 (LPN #1) prepare 10 medications for Resident #109, they were as follows:Vascepa 1GM (gram) capsule, give two capsules by mouth two times a day; scheduled for 8:00 AM and 5:00 PM.Keppra 1000 mg (milligram) tablet, give one tablet by mouth two times a day; scheduled for 8:00 AM and 5:00 PM.Metformin 500 mg tablet, give one tablet by mouth one time a day administer with meals; scheduled for 8:00 AM.Metoprolol tartrate 25 mg tablet, give 0.5 tablet (12.5 mg) by mouth two times a day, give with meals; scheduled for 8:00 AM and 5:00 PM.Aspirin 81 mg oral tablet chewable, give one tablet by mouth in the morning; scheduled for 9:00 AM.Cholecalciferol 1000 unit tablet, give one tablet by mouth one time a day; scheduled for 9:00 AM.Colace 100 mg capsule, give two capsules by mouth in the morning; scheduled for 9:00 AM.Cyanocobalamin 1000 mcg tablet, give one tablet by mouth one time a day; scheduled 9:00 AM.Escitalopram 10 mg tablet, give one tablet by mouth in the morning; scheduled for 9:00 AM.Furosemide 40 mg tablet, give one tablet by mouth in the morning; scheduled for 9:00 AM.A review of the Medication Admin Audit Report for 5/22/2026 revealed the ten medications were given later than their scheduled administration time. The administration times were as follows:Vascepa 1GM (gram) capsule, give two capsules by mouth two times a day; scheduled for 8:00 AM and administered at 11:31 AM.Keppra 1000 mg (milligram) tablet, give one tablet by mouth two times a day; scheduled for 8:00 AM and administered at 11:31 AM.Metformin 500 mg tablet, give one tablet by mouth one time a day administer with meals; scheduled for 8:00 AM and administered at 11:31 AM.Metoprolol tartrate 25 mg tablet, give 0.5 tablet (12.5 mg) by mouth two times a day, give with meals; scheduled for 8:00 AM and administered at 11:31 AM.Aspirin 81 mg oral tablet chewable, give one tablet by mouth in the morning; scheduled for 9:00 AM and administered at 11:31 AM.Cholecalciferol 1000 unit tablet, give one tablet by mouth one time a day; scheduled for 9:00 AM and administered at 11:31 AM.Colace 100 mg capsule, give two capsules by mouth in the morning; scheduled for 9:00 AM and administered at 11:31 AM.Cyanocobalamin 1000 mcg tablet, give one tablet by mouth one time a day; scheduled 9:00 AM and administered at 11:31 AM.Escitalopram 10 mg tablet, give one tablet by mouth in the morning; scheduled for 9:00 AM and administered at 11:31 AM.Furosemide 40 mg tablet, give one tablet by mouth in the morning; scheduled for 9:00 AM and administered at 11:31 AM.On 5/22/2026 at 10:24 AM, the surveyor interviewed LPN #1 who acknowledged she should have followed the physician's order and administered the medications that needed to be given with food as directed. She further confirmed the medications were given late and stated she had an allowable time of up to one hour before and one hour after the scheduled administration time to give the medication.On 5/22/26 at 10:53 AM, the surveyor interviewed the Director of Nursing (DON) who stated LPN #1 should have followed the physician's orders and given the medications that required it with food. The DON further acknowledged the medications for Resident #109 had been administered late, more than one hour past the administration time.During the medication pass observation on 5/26/26 from 10:44 AM until 11:00 AM, the surveyor observed the following:At 10:57 AM, the surveyor observed LPN #2 prepare medications for Resident #37, they were as follows: Calcium and Vitamin D 500 mg/200 unit tablet, give one tablet orally two times a day. Scheduled for 8:00 AM and 5:00 PM. (unavailable).Sertraline 50 mg tablet, give one tablet by mouth in the morning; scheduled for 9:00 AM.Vitamin D 50 mcg (microgram) capsule, give one capsule by mouth one time a day; scheduled for 9:00 AM.A review of the Medication Admin Audit Report for 5/26/2026 revealed the two medications were given later than their scheduled administration time. The administration times were as follows:Sertraline 50 mg tablet, give one tablet by mouth in the morning; scheduled for 9:00 AM and administered at 10:56 AM.Vitamin D 50 mcg (microgram) capsule, give one capsule by mouth one time a day; scheduled for 9:00 AM and administered at 10:57 AM.On 5/26/26 at 10:57 AM, LPN #2 acknowledged the two medications were given late.On 5/28/2026 at 10:16 AM the surveyor reinterviewed the DON who stated medications should be given at their scheduled time and are given an allowance to administer medications one hour before and one hour after the scheduled time. A review of the facility's Administering Medication policy reviewed/revised 12/2025 included Medications must be administered in accordance with the orders, including any required time frames. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).NJAC 8:39-29.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provided a safe, clean, and homelike environment for 1 of 4 floors and 1 of 1 resident (Resident # 119) reviewed under the Environmental Task. The deficient practice was evidenced by the following: On 05/21/2026 at 10:28 AM during the initial tour, the surveyor observed Resident # 119 in bed in his/her room. At that time, the surveyor observed an emptied, needleless, saline syringe left on top of his/her blanket. On 05/21/2026 at 10:38 AM during the initial tour, the surveyor observed a plastic drawer outside of room [ROOM NUMBER]. At that time, the surveyor observed a soiled paper towel inside the top drawer that contained personal protective gowns. On 05/28/2026 at 1:09 PM during an interview with the surveyor, the Licensed Nursing Home Administrator replied, No when asked if saline syringes should be left in the bed of a resident. A review of the facility policy titled, Quality of Life - Homelike Environment revised 01/2026 revealed under Policy Interpretation and Implementation that, 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment . N.J.A.C. S 8:39-31.4 (a)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility did not ensure a residents medication regimen was free from unnecessary psychotropic medications. Specifically, a psychotropic medication ordered for an extended duration lacked a documented clinical rationale in the resident's record. The deficient practice was identified for 1 of 5 residents (Resident #1) reviewed for unnecessary medications.This deficient practice was evidenced by the following:05/21/2026 at 9:50 AM, the surveyor observed Resident #1 speaking loudly and appearing upset regarding his/her breakfast tray. Staff intervened immediately. The surveyor reviewed Resident #1's medical record which reflected that the resident had diagnoses which included anxiety and depression. The admission Minimum Data Set, an assessment tool, dated 12/19/2025 reflected that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated that the resident was cognitively intact. A review of the physician orders for Resident # 1 reflected orders dated 12/01/2025, 03/04/2026, and 03/12/2026 for the resident to receive alprazolam (an antianxiety) 0.5 milligrams as needed for anxiety. The surveyor did not observe a stop date or a duration for the alprazolam. Further review of Resident #1's electronic medical record (EMR) did not reveal any documented rationale for ordering alprazolam as needed with no duration specified.On 05/27/2026 at 1:29 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that as needed psychoactive medications should be scheduled for 14 or 30 days. She furthered that there should be documentation in the resident's chart regarding the duration. On 05/28/2026 at 9:20 AM, during an interview with the surveyor, the DON stated that the provider did not place a note in Resident # 1's chart regarding the duration of the alprazolam. A review of the facility policy titled, Psychoactive Drug Reduction revised 10/25 reflected that PRN orders for psychotropic medications are limited to 14 days, must be deemed medically necessary, and require documentation in the medication record for indication of use. N.J.A.C. 8:39-27.1(a)

Based on interview, record review, and review of other facility documentation it was determined that the facility failed to notify the Long-Term Care Ombudsman when a resident was transferred to an acute care hospital. The deficient practice was identified for 1 of 1 (resident # 161) resident reviewed for hospitalization. The deficient practice was evidenced by the following: A review of Resident # 161's diagnoses located in the medical record revealed diagnosis of but not limited to neurofibromatosis (a group of genetic disorders that cause benign (non-cancerous) tumors to grow on nerves throughout the body) and moderate protein calorie malnutrition. A review of the progress notes located in the medical record revealed that on 04/02/2026 Resident # 161 complained of abdominal pain. He/She refused all vitals and all as-needed medications. The provider was notified and did not prescribed any new orders. Resident # 161 called 911 themselves and was transferred approximately 8:45 AM. A review of the Minimum Data Set (MDS; an assessment tool) located in the electronic medical record was updated with a discharge MDS on 4/2/2026 with return anticipated. On 05/26/2026 at 10:30 AM, the surveyor requested from the facility evidence that the Long-Term Care Ombudsman (LTCO) was notified of Resident # 161's transfer to the hospital and discharge. On 05/27/2026 10:50 AM, During an interview with the surveyor, the Senior Regional Nurse of Clinical Compliance informed the surveyor that the facility did not complete the notification to the LTCO. On 05/27/2026 at 1:09 PM, the surveyor asked that when a resident is discharged to the hospital under a medical emergency and is since discharged , does the Long-Term Care Ombudsman have to be notified. The Licensed Nursing Home Administrator replied, Yes. A review of the facility policy titled, Transfer or Discharge Notice revised 1/2026 revealed that, 4. Notification of unplanned discharges will be sent to the Office of the State Long-Term Care Ombudsman, in the format preferred by the Ombudsman. N.J.A.C. S 8:39-4.1

Based on interview and record review, it was determined that the facility failed to complete the Annual Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 8 residents (Residents #91) reviewed for timing of assessments and was evidenced by the following: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicates that at a minimum, facilities are required to complete a comprehensive assessment for each resident not less than once every 12 months while a resident, where 12 months refers to a period within 366 days.This deficient practice was evidenced by the following:Resident #91 was admitted with diagnoses that included but were not limited to injury to the thoracic spinal cord. On 05/28/2026, the surveyor reviewed the electronic medical record (EMR) for resident # 91. The Annual Minimum Data Set (AMDS), an assessment tool completed every 12 months, revealed an Assessment Reference Date (ARD), a date used as the last day of a look-back period, of 04/2/2026. The EMR revealed that the AMDS for Resident #91 had been completed on 04/25/2026, 8 days late.During an interview with the surveyor on 05/28/2026 at 10:59AM, the MDS Coordinator acknowledged that the AMDS's for Resident #91 was completed late. She stated it was important to have the MDS completed on time to be sure the residents were being assessed according to regulation and care plans were updated properly.Review of the facility provided policy titled Resident assessment Instrument/ MDS revealed that, The MDS Coordinator is responsible for ensuring timely resident assessments and review. NJAC 8:39-11.2 (e)

Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care plan to address an anticoagulant (a blood thinner) medication for 1 of 32 residents (Resident #1) reviewed. The deficient practice was evidenced by the following: On 05/21/2026 at 9:50 AM, the surveyor observed Resident #1 speaking loudly and appearing upset regarding his/her breakfast tray. Staff intervened immediately. The surveyor reviewed Resident #1's medical record which reflected that the resident had a diagnosis which included atrial fibrillation. A review of the physician orders for Resident #1 reflected an order dated 12/01/2025 for the resident to receive Eliquis (an anticoagulant). The admission Minimum Data Set, an assessment tool, dated 12/19/2025 reflected that Resident #1 received an anticoagulant daily. The surveyor reviewed the resident's care plans which revealed there was no care plan developed to address the anticoagulant medication which was initiated on 12/01/2025. On 5/27/2026 at 1:29 PM, the surveyor interviewed the Director of Nursing who said the anticoagulant medication should be included in the care plan. A review of facility provided policy titled, Care Plans-Comprehensive, Person Centered , with a revised date of 02/2026 reflected a comprehensive person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan to include indwelling urinary catheter. This deficient practice was identified for 1 of 29 residents reviewed for resident-centered care plans (Resident #124), and was evidenced by the following: On 05/21/2026 at 11:35 AM, during initial tour, Resident #124 was observed lying in his/her bed while family visited. At this time Resident #124's family stated that the resident recently had an indwelling catheter placed. On 05/26/2026 at 9:38 AM, during follow up with Resident #124 the surveyor was informed by the Assistant Director of Nursing (ADON) that the resident had been admitted to the hospital with diagnoses that included urinary tract infection (UTI).A review of Resident #124's Electronic Medical Record (EMR) revealed that Resident #124 was admitted with diagnosis of but not limited to; acute cystitis (a sudden bladder infection causing pain and frequent urination), retention of urine (inability to empty bladder fully), and neuromuscular dysfunction of bladder (nerve and muscle issues causing bladder control problems). A review of Resident #124 EMR under physician's orders revealed orders that included insert indwelling catheter now with an order date of 5/10/2026 and 16F indwelling catheter for urinary retention with an order date of 05/11/2026.A review of Resident #124 resident-centered care plan reflected that this resident had an external catheter at times related to assistance with personal needs. Use of an indwelling urinary catheter was not reflected in Resident #124's resident-centered care plan. On 05/27/2026 at 1:10 PM, during an interview with the surveyor, the Director of Nursing (DON) revealed that a resident's care plan should be updated with any change and during care plan meetings. The DON further confirmed that residents with indwelling urinary catheters should be care planned for an indwelling urinary catheter. The DON further revealed that this was necessary to ensure continuation of care to make sure documentation was up to date. A review of the facility provided policy titled Care Plans, Comprehensive, Person-Centered revealed under Policy Interpretation and Implementation, under number 13., Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. NJAC 8:39-11.2

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to follow the recommendation identified by the Consultant Pharmacist. This deficient practice was identified for 1 of 5 Residents (Resident #1) reviewed for unnecessary medications, psychotropic medications, and medication regimen review and was evidenced by the following: 05/21/2026 9:50 AM, the surveyor observed Resident #1 speaking loudly and appearing upset regarding his/her breakfast tray. Staff intervened immediately. The surveyor reviewed Resident #1's medical record which reflected that the resident had diagnoses which included anxiety and depression. The admission Minimum Data Set, an assessment tool, dated 12/19/2025 reflected that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated that the resident was cognitively intact. A review of the Consultant Pharmacist's Monthly Report dated 02/01/2026 and 03/03/2026, indicated that a duration must be specified for as needed psychoactive medications. The first order is limited to only 14 days, but if rationale documented by prescriber to continue order, then next duration maybe for longer, ie 30,60, or 90 days. Please update order for alprazolam per Center for Medicare and Medicaid Services regulations. A review of the physician orders for Resident # 1 reflected orders dated 12/01/2025, 03/04/2026, and 03/12/2026 for the resident to receive alprazolam (an antianxiety) 0.5 milligrams as needed for anxiety. The surveyor did not observe a stop date or a duration for the alprazolam. Further review of Resident #1's EMR did not reveal any documented rationale for ordering alprazolam as needed with no duration specified. On 05/28/2026 at 9:20 AM, the Director of Nursing (DON) stated that the monthly pharmacist recommendations should have been completed within one to two weeks. She furthered that the nurses could not get ahold of the providers. A review of the facility provided policy titled, Pharmacy Consultant Policy and Procedure, revised on 10/2025 reflected that the pharmacist will report any irregularities to the attending physician and the DON and these reports must be acted upon in a timely manner. NJAC 8:39 - 29.3

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to a.) ensure residents were free from unnecessary medications and b.) medications were administered in accordance with a physician's orders. This deficient practice was identified for 1 of 5 residents (Resident #7) reviewed for unnecessary medication use.On 5/21/2026 at 11:51 AM, the surveyor observed Resident #7 in their room, with the lights off and resting.The surveyor reviewed the medical record for Resident #7.A review of the admission Record face sheet reflected the resident was admitted to the facility in April of 2025 with diagnoses which included paraplegia (the partial or complete paralysis of the lower half of the body), major depressive disorder, and hypotension (low blood pressure). A review of the Medication Review report dated on or after 4/1/2026 included the following order: Midodrine 5 mg (milligram) tablet, give one tablet by mouth two times a day (8:00 AM and 5:00 PM) for hypotension. Hold for SBP (systolic blood pressure) greater than 90. A review of the corresponding Medication Administration Record (MAR) for May 2026 revealed the medication was administered outside the Hold parameters on 16 out of 49 scheduled administration times. The dates and times were as follows: 5/1/2026 5:00 PM; BP 91/545/2/2026 8:00 AM; 97/605/3/2026 5:00 PM; 101/685/4/2026 8:00 AM; 112/645/6/2026 8:00 AM; 101/685/7/2026 5:00 PM; 118/725/8/2026 8:00 AM; 123/72 and 5:00 PM; 121/795/10/2026 5:00 PM; 100/665/11/2026 8:00 AM; 123/655/12/2026 8:00 AM; 112/78 and 5:00 PM; 118/785/13/2026 8:00 AM; 107/67 5/14/2026 8:00 AM; 116/575/20/2026 5:00 PM; 118/685/24/2026 5:00 PM; 118/70 On 5/27/2026 at 1:34 PM, the surveyor interviewed the Director of Nursing (DON) who stated the nurses should be following the physician's orders including the parameters for holding the medications. A review of the facility's Administering Medications policy dated reviewed/revised 9/2025 included The following information must be checked/verified for each resident prior to administering medications: Vital signs, if necessary, per physician's order. NJAC 8:39-29.2(d)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to ensure medication carts were kept clean, orderly, and free of loose medications. The deficient practice was identified for 2 of 4 medication carts reviewed under the Medication Storage task. The deficient practice was evidenced by the following: On 05/21/2026 at 11:54 AM, while inspecting the 1 South medication cart, the surveyor found 13 loose, unidentified tablets and pills located in the drawers. The surveyor also observed a card containing medication located behind the drawers out of reach. On 05/27/2026 at 10:24 AM while inspecting the Annex medication cart, the surveyor observed that the bottom drawer contained prescription inhalants, pain-relief patches, and cartons of nutritional formula amongst one another and not organized and separated by administration route. The surveyor also observed that the top drawer handle was broken exposing jagged plastic. On 05/27/2026 at 1:09 PM, the surveyor informed the Licensed Nursing Home Administrator of the medication cart findings. A review of the facility policy titled, Storage of Medications revealed that It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. and that, 3. External Products: Disinfectants and drugs for external use are stored separately from internal and injectable medications. The policy also revealed that, 4. Internal Products: Medications to be administered by mouth are stored separately from other formulations (i.e., eye drops, ear drops, injectable). N.J.A.C. S 8:39-29.4 (h)

Based on observations, interviews, record review and other pertinent facility documents, it was determined that the facility failed to use appropriate infection control a.) respiratory device tubing, masks, and mouthpiece were stored in protective coverings between uses identified for 1 of 2 residents (Resident #108) reviewed for respiratory care, b.) perform central line dressing changes, identified for 1 of 1 residents (Resident #119) reviewed for antibiotic use. This deficient practice was evidenced by the following:On 5/21/2026 at 12:27 PM, during initial tour, the surveyor observed Resident #108's nebulizer on the bedside table. At that time the surveyor observed the tubing to the nebulizer leading behind the bedside table.A review of Resident #108's Electronic Medical Record (EMR) revealed diagnosis of but not limited to; Chronic Respiratory Failure with hypoxia (Long-term lung inability to provide enough oxygen, causing low oxygen levels), Pneumonia (an infection in the lungs that can cause difficulty breathing) and encounter for attention to tracheostomy (a surgical opening in the neck to provide an airway to breathe).A review of Resident #108's EMR under physician's orders revealed an order to change nebulizer set weekly on Wednesday night shift initiated on 04/15/2026.On 05/21/2026 a 12:40 PM, in the presence of the surveyor, the Assistant Director of Nursing (ADON) retrieved Resident #108's nebulizer administration T piece from behind the resident's bedside table. When asked if that was how a nebulizer should be stored, the ADON responded that the T piece should be stored in a dated plastic bag when not in use. On 5/21/2026 at 12:27 PM, during initial tour, Resident #119 was observed lying in bed receiving intravenous antibiotics. At that time Resident #119 told the surveyor that the dressing to their Peripherally Inserted Central Catheter (PICC) had not been changed since the resident had returned from the hospital. On the same day at 12:40 PM, the surveyor asked the Assistant Director of Nursing (ADON) if she could verify the date on Resident #119's PICC dressing. The ADON revealed the dressing was dated 04/29/2026. The ADON responded absolutely when asked if Resident #119's dressing should have been changed. A review of Resident #119's EMR revealed diagnosis which included but not limited to; carrier of carbapenem-resistant Acinetobacter baumanni (a bacteria resistant to most antibiotics), pressure ulcer of the sacral region (skin breakdown from prolonged pressure on lower back area) and sepsis (Severe body response to infection causing organ dysfunction).A review of Resident #119's EMR revealed under physician orders, an order for Vancomycin HCl Intravenous Solution 1250MG/250ML (Vancomycin HCl), use 1250 mg intravenously every 12 hours for osteomyelitis (an infection of the bone) with a start date of 05/07/2026, Monitor PICC site every shift for infection, line fracture, breakage, dislodgement, pain or swelling every shift for monitoring with a start date of 04/30/2026 and Biopatch Protective Disk/CHG External Miscellaneous(Chlorhexidine Gluconate) Apply to PICC line dressing topically every day shift every Fri for PICC line care Change PICC line dressing every 7 days. Label dressing with date, time, and nurse's initials with a start date of 05/15/2026.A review of Resident #119's quarterly Minimum Data Set (MDS; an assessment tool) revealed that Resident #119 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating Resident #119 was cognitively intact. Further review of the MDS revealed under Section O that Resident #119 was receiving intravenous medications and that Resident #119 had intravenous access. On 05/27/2026 at 12:34 PM, during an interview with the surveyor the Infection Preventionist (IP) responded every 7 days, when asked how often central line, including PICC dressings should be changed. The IP confirmed that Resident #119's dressing should have been changed. The IP further stated this was necessary because it was best practice for infection control. A review of Resident #119's resident-centered care plan revealed that Resident #119 had a focus of Potential for complications at IV insertion site: right upper arm PICC revised on 05/11/2026 with an intervention to change IV site dressing per physician order and as need if soiled or wet initiated on 01/30/2026.A review of the facility provided policy titled Nebulizer Administration under General Guidelines number 18, section a. Date and place supplies in a treatment bag.A review of the facility provided policy titled Midline/Central Line Dressing Changes under General Guidelines number 1, change midline catheter dressing 24 hours after insertion, every 5-7 days or if it is wet, dirty, not intact, or compromised in any way. N.J.A.C. 8:39-19.4(a)

Based on observation and interview, it was determined that the facility failed to maintain the physical environment in a safe condition by failing to ensure that a corridor handrail was firmly secured to the wall. The deficient practice was identified for 1 of 4 floors. The deficient practice was evidenced by the following: On 05/21/2026 at 10:43 AM, during the initial tour while on the first floor, the surveyor observed a portion of the wall adjacent to the elevator missing a handrail. The surveyor observed dry-wall exposed where a previous handrail may have been secured. On 05/27/2026 at 1:09 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the finding. The LNHA said that the handrail became dislodged and maintenance was working to install it. A review of the facility provided policy titled, Maintenance Services Policy revealed that, a. Maintaining the building in compliance with current federal, state, & local laws, regulations, and guidelines. N.J.A.C. S 8:39-31.2 (e)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 10/30/25 at 11:30 AM, during a tour of the first floor, with the Unit Manager (UM), the nourishment room was noted to be in disrepair. The cabinet doors were askew. The UM stated this had not been reported to Maintenance. [NAME] stains were noted on the grates of the ice maker, the UM stated that it was not always like this. The paper towel dispenser was empty, and the roll of paper towels were sitting on top of the refrigerator. The microwave had brown debris on the bottom. The UM stated she was not sure how often the microwave was cleaned, and the CNA or nurse cleans it if there was a mess. Paint chips and peeling paint noted around the soap dispenser. The surveyor brought the Director of Nursing (DON) to the pantry, and she stated the microwave needed to be cleaned, the paper towels should be in a dispenser and the cabinet doors should close. The surveyor interviewed the Director of Housekeeping, who stated the nourishment room is cleaned once a month by the porter and as needed if informed by the staff of a need. He also stated the grates on the ice maker are supposed to be cleaned when the room is cleaned. He further stated the room was cleaned at the beginning of the month. The DON also stated that the microwave was nobody's responsibility, but rather if it's dirty, clean it.Review of the Nourishment Room Cleaning Log, provided by the facility, revealed that the first-floor nourishment room was signed as being cleaned on 10/1/25. A review of the undated policy, [NAME] Cleaning Guidelines and Protocols, included:Nourishment rooms, to be cleaned in the first week of every month. Fill out audit sheet.N.J.A.C. 18:39-17.2(g)

Complaint # 2582137 Refer to F610 and F835Based on observations, interviews, and review of pertinent facility documentation on 08/05/2025, 08/06/2025, and 08/07/2025, it was determined that the facility failed to implement their abuse policy to ensure a.) residents were protected from abuse after an allegation of abuse was made on 08/05/2025, by the local police regarding Resident #8 and their caregiver, Resident Representative (RR #1). This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #8). During an interview with the Licensed Nursing Home Administrator (LNHA) on 08/06/2025, revealed that on 08/05/2025, he observed the local police at the facility, and overheard the police officer tell the facility's Receptionist that Resident #8 was being mistreated by RR #1, who was caring for the resident. The LNHA acknowledged that mistreated could be considered abuse, but at the time of the allegation, Resident #8 was on the facility's premises out on pass. The LNHA stated that the facility did not conduct an investigation including completing an incident report because Resident #8 was cognitively intact and when the LNHA asked the resident if they were okay, the resident stated they were okay, it was family drama.The facility's failure to implement their abuse policy including investigating all allegations of abuse and protecting all residents from abuse during the investigation, placed Resident #8, as well as all residents at risk for abuse. This posed the likelihood of serious physical and emotional harm or injury which resulted in an Immediate Jeopardy (IJ) situation.The IJ began on 08/05/2025, after the police notified the facility. The facility's Administrator was notified of the IJ on 08/07/2025 at 5:59 P.M. The facility submitted an acceptable Removal Plan (RP) on 08/11/2025 at 10:24 A.M. The surveyor verified the implementation of the RP on-site on 08/12/2025 at 12:45 P.M.The facility further failed to b.) protect a resident (Resident #1) from sexual and physical abuse when Resident #2 entered Resident #1's room and attempted to kiss them on their mouth and Resident #1 bit Resident #2's tongue which resulted in bleeding. In response, Resident #2 hit Resident #1 who sustained bruises to the face. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #1). The evidence was as follows:Part A A review of the facility policy with a revision date of 01/2025, titled Abuse Prevention Program whose policy statement includes .promotes an environment that does all to prevent resident abuse, neglect, misappropriation of property through the following components: screening and training of employees, prevention, identification, investigation, protection and reporting, Under section V Investigation: an investigation is initiated for all allegations of suspected abuse, neglect or misappropriation. Further in #4 of Investigation it states that the Abuse Investigator will complete a thorough investigation inclusive of interviewing the resident, alleged abuser and any witnesses. In section VII Reporting: it states that The Abuse Investigator will be responsible to make all reports regarding abuse investigations and indicates the agencies to report to. According to the admission Record (AR), Resident #8 was admitted to the facility with the diagnoses which include but were not limited to; amyotrophic lateral sclerosis (ALS-a progressive neurodegenerative disease affecting the brain and spinal cord leading to muscle weakness and atrophy), hypertension (high blood pressure), mood disorder, and anxiety disorder. According to the Minimum Data Set (MDS), an assessment tool dated 05/27/2025, Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating that the resident was cognitively intact.A review of Resident #8's Care Plan (CP) include a focus area dated 05/03/2024, for depression and anxiety and that the resident refused to meet with psychiatry. Interventions included to monitor for depression, and to discuss concerns with [resident name's] family.On 08/06/2025 at 1:45 P.M., during an interview with the Unit Manager (UM #1), she stated that morning (08/06/2025), she became aware of an allegation of abuse involving Resident #8 and their caregiver (RR #1). UM #1 stated that the Social Worker (SW) received a call from a [community name redacted] organization regarding an allegation of abuse, and the SW spoke to Resident #8 about it. UM #1 stated that she assumed the SW investigated the allegation. UM #1 stated that RR #1 helped with Resident #8's care since the resident could be difficult with staff.On 08/06/2025, at 1:59 P.M., the surveyor observed Resident #8's bedroom door closed. The surveyor knocked on the door and RR #1 opened the door. The surveyor noted that Resident #8 was lying in bed eating lunch. There was no facility staff in the room with the resident at that time. On 08/06/2025 at 2:20 P.M., during an interview with the Licensed Practical Nurse (LPN #1), she confirmed that she was aware of the allegation of abuse. LPN #1 stated that she had not seen RR #1 abuse the resident. On 08/06/2025 at 2:34 P.M., during an interview with the SW, she confirmed that a [community name redacted] organization notified her that Resident #8's RR #2 called them and reported that the RR #1 was abusing the resident. The SW stated that she spoke with the resident who denied the allegation that RR #1 was abusing them. The surveyor continued to review Resident #8's medical record.A review of Resident #8's Progress Notes (PN) did not include documentation of the alleged abuse. The PN also did not include documentation from the SW that she received a phone call from a [community name redacted] organization alleging Resident #8 was abused.A review of the medical record also did not include any documentation that a skin assessment was conducted after the allegation of abuse was made.On 08/06/2025, at 4:33 P.M., during an interview with the LNHA, he stated that he was aware of the police being at the facility yesterday, and he overheard them telling the Receptionist at that time that Resident #8 was being mistreated by RR #1 who was caring for them. When asked if mistreated could be considered abuse, the LNHA agreed. The LNHA further stated that it was presented as a third-party claim of abuse, and added; I went outside and spoke to them right away. When the surveyor asked about what should be done when there was an allegation of abuse of a resident, the LNHA responded, First, make sure they are not hurt. The LNHA further stated that if the abuser is a visitor it's technically the same as staff and they need to be separated. The LNHA also that at the time, the resident was on the property premises, Out on Pass, and that the alleged perpetrator (RR #1) was on the other side of the facility parking lot. The LNHA stated that he wrote a statement about the claim and did not write an incident report since the resident had a BIMS of 15, and that the resident denied RR #1 was abusing them. When asked if an incident report should have been filed, the LNHA replied, I would have to check our abuse policy.On 08/07/2025, at 9:30 A.M., the surveyor observed RR #1 in the facility' s elevator headed up towards the resident's room.On 08/07/2025 at 10:40 A.M., during a follow-up interview with UM #1, she stated that she was not asked to provide a statement regarding the allegation or instructed to collect any statements from any potential witnesses. UM #1 acknowledged that there was no skin assessment conducted for Resident #8, and that she would try to complete one. UM #1 also stated that RR #1 was in the facility that morning when she arrived at work on 08/07/2025.On 08/07/2025, at 11:29 A.M., during a follow-up interview with the LNHA, he re-stated that the police were at the Receptionist's area when he walked into the lobby. Per the LNHA, the police acknowledged his presence but continued to talk with the Receptionist. The LNHA confirmed that he did not inquire from the police specific details regarding the allegation because he assumed that the police were unable to substantiate the allegation. The LNHA also stated that RR #1 (the perpetrator) was not separated from Resident #8 because he ruled out abuse as resident is alert and verbal. The LNHA stated I feel like if we were doing an assessment, all these measures would need to be taken into account. I was able to rule out abuse instantaneously. At that time, the LNHA stated The thought process was these measures are typically taken to rule out abuse, they had a BIMS of 15. I thought once ruled out the other steps weren't necessary. When the surveyor asked if that was the facility's policy, the LNHA responded, Per the policy all these steps are part of an investigation and should have been done. The LNHA further confirmed that nursing staff did not perform a body check on the resident to check for injuries. The LNHA also confirmed that there were no staff interviews conducted. The LNHA stated that he felt that he initiated an investigation by talking with Resident #8 because the resident was alert and oriented and stated they felt safe. When questioned about protection for Resident #8 from the alleged abuser, the LNHA stated that the aggressor (RR #1) was not separated from the resident because he felt that he ruled out abuse since the resident was alert and verbal and had a BIMS of 15. The LNHA acknowledged that an assessment should have been done.On 08/07/2025 at 2:24 P.M., during a follow-up interview with the SW, she stated, Administrator or myself is responsible for initiating an investigation when there is an allegation of abuse.On 08/07/2025 at 2:27 P.M., during an interview with the Certified Nursing Assistant (CNA #1), she stated that when RR #1 (alleged perpetrator) was at the facility, they do not want to be bothered. CNA #1 stated that the resident and RR #1 kept the door shut and she had to wait for them to ring.On 08/07/2025, at 3:37 P.M., during an interview with the Director of Nursing (DON), she stated that when notified of an allegation of abuse, the alleged victim and perpetrator must be immediately separated, the investigation begins and then call the police.An acceptable Removal Plan (RP) was received on 08/11/2025 at 10:27 A.M., indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: on 08/05/2026 and 08/06/2025, Resident #8's skin was attempted to be assessed and the resident refused. On 08/05/2025 and 08/06/2025, Resident #8 was interviewed, and they stated that they felt safe and no abuse was occurring, that they wanted RR #1 to continue visiting that it was family drama. Resident #8 was provided a trauma screen, the facility requested a psychology consultation, and Resident #8 was provided emotional support. On 08/06/2025, the LNHA educated the nursing supervisor/manager to complete 30-minute checks on Resident #8 to ensure no threat until completion of investigation. The LNHA and SW were reeducated by the Regional DON on proper reporting of abuse allegations, the Receptionist was educated on proper procedures when law enforcement presents allegations, and on 08/07/2025, all staff began education on abuse identification and reporting.The survey team verified the implementation of the RP on-site on 08/12/2025 at 12:45 P.M. Part B A review of the facility policy dated revised 01/2025, titled Abuse Prevention Program whose policy statement is .promotes an environment that does all to prevent resident abuse, neglect, misappropriation of property through the following components: screening and training of employees, prevention, identification, investigation, protection and reporting. The purpose of the policy states Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion by an individual . A review of the Facility Reported Event (FRE) submitted to the New Jersey Department of Health (NJDOH) dated 07/28/2025, indicated that Resident #1 informed facility staff that Resident #2 had made contact' with them. The FRE indicated that the police were called to the facility, and that both residents were sent to the local hospital for treatment. Both residents returned to the facility the same day, and Resident #2 was placed on one-to-one (1:1) monitoring. A review of the facility's Incident Report (IR) revealed that on the date of the incident, Resident #1's Certified Nursing Assistant (CNA #2) entered the resident's room and observed Resident #2 on the floor. When CNA #2 asked Resident #1 what happened, the resident stated that Resident #2 hit them in the face. It also indicated that Resident #1 was observed with a hematoma (bruise) to the left cheek and Resident #2 was bleeding from the tongue and that both residents were sent to the local hospital for treatment. Further review of the IR indicated that facility placed Resident #2 on 1:1 monitoring. According to the statement from CNA #3, who was assigned as a companion for Resident #2, CNA #3 stated that he was distracted by an aide Who came to speak to me for a moment. I looked back; I didn't see them. A few minutes later an aide came and told me that Resident #2 was in Resident #1's room.According to the admission Record (AR), Resident #1 was admitted to the facility with the diagnoses which include but were not limited to: cerebral vascular accident (CVA; stroke), diabetes mellitus-type 2, and Moyamoya disease (a rare cerebrovascular condition where the carotid arteries in the brain are narrowed, leading to reduced blood flow and increased risk of stroke).According to the Minimum Data Set (MDS), an assessment tool dated 05/12/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicating that the resident was cognitively intact. According to the AR, Resident #2 was admitted to the facility with the diagnoses which included but were not limited to: Parkinson's disease, psychotic disorder with hallucinations, depression, and dementia.According to the MDS dated [DATE], Resident #2 had a BIMS score of 15/15, indicating that the resident was cognitively intact.A review of the Resident #2's Physician Order Sheet (POS) included an order for a wander guard (alarmed security bracelet) dated 02/13/2025, to the back of the wheelchair and to check placement every shift. A Care Plan (CP) report for Resident #2 included a Focus of the potential to be physically aggressive and combative at times related to Parkinson's disease, dementia, and mood disorder. According to the CP, Resident #2 had an altercation with another resident after becoming agitated on 4/06/2024. The Intervention/task dated 4/06/2024 was that the resident given a room change and moved to the second floor. On 08/05/2025 at 9:42 A.M., the surveyor observed Resident #1 in their room washed and dressed. The surveyor observed a bruise to the left corner of the resident's mouth's that spread down to the neck. There was also a small bruise observed to the resident's left eye. The resident was wearing sunglasses and did not want to remove them. When interviewed, the resident told the surveyor that Resident #2 tried to kiss them and that they bit Resident #2, and that Resident #2 then hit them in the face. Resident #2 was not in the facility at the time of survey. On 08/05/2025 at 12:19 P.M., the surveyor interviewed UM #1, who stated that she was made aware of the incident between the two residents that night. When the surveyor asked how Resident #2 was able to go to another floor (since Resident #2 wore a wander gaurd), UM #1 stated that Resident #2 often went to their unit for activities. UM #1 continued that due to Resident #2 having an increased fall risk, she requested the companion to accompany the resident. During an interview with the LNHA on 08/05/2025 at 2:55 P.M., the LNHA stated that each floor had companions, 1-2 per floor. The LNHA stated that the purpose of the companion was to accompany any resident who might wander or had a fall risk. The LNHA stated that a companion did not usually have a care assignment, but they could be asked to perform other tasks when the resident was not going off the floor. The LNHA further stated that he wouldn't consider this 1:1. It wasn't related to behavior, was related to falls and when residents leave the unit for visual contact of the resident.During an interview on 08/06/2025 at 10:20 A.M., with UM #2 for the floor where Resident #2 resided, she stated that someone was supposed to be with Resident #2, but not as 1:1. Their job was just watch the resident.During an interview with the DON on 08/06/2025 at 11:15 A.M., she stated that the role of the companion was to go with the resident and keep them safe, to supervise. The DON further stated that while some of the staff consider it 1:1, it was really a companion. The DON stated that Resident #2 liked to go outside for exercises, and to use the vending machines and to attend activities on another floor. The DON stated that she did not feel a companion should be care planned. The DON stated that it was not the type of 1:1 that required a physician's order. The DON did not provide further information for how both Residents #1 and Resident #2 were not protected from physical harm on the day of the incident.NJAC 8:39-4.1(a)(5)

Complaint # 2582137Based on interviews and review of other pertinent facility documentation on 08/05/2025, 08/06/2025, and 08/07/2025, it was determined that the facility failed to implement their abuse policy by thoroughly investigating an allegation of abuse to a resident (Resident #8) that the police officer reported the allegation on 08/05/2025. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #8).During an interview with the Licensed Nursing Home Administrator (LNHA) on 08/06/2025, revealed that on 08/05/2025, he observed the local police at the facility, and heard the police officer tell the facility's Receptionist that Resident #8 was being mistreated by the Resident Representative (RR #1), who was caring for the resident. The LNHA acknowledged that mistreated could be considered abuse, but at the time of the allegation, Resident #8 was on the facility's premises out on pass. The LNHA stated that the facility did not conduct an investigation including completing an incident report because Resident #8 was cognitively intact and when he asked the resident if they were okay, the resident stated that they were okay; it was family drama.The facility's failure to implement their abuse policy by investigating all allegations of abuse placed Resident #8, as well as all resident at risk for abuse. This posed the likelihood of serious physical and emotional harm or injury which resulted in an Immediate Jeopardy (IJ) situation.The IJ began on 08/05/2025, after the police notified the facility of the allegation. The facility's Administrator was notified of the IJ on 08/07/2025 at 5:59 P.M. The facility submitted an acceptable Removal Plan (RP) on 08/11/2025 at 10:24 A.M. The surveyor verified the implementation of the RP on 08/12/2025 at 12:45 P.M. The evidence was as follows:Refer F 600, F 835 A review of the facility policy dated revised 01/2025, titled Abuse Prevention Program whose policy statement is .promotes an environment that does all to prevent resident abuse, neglect, misappropriation of property through the following components: screening and training of employees, prevention, identification, investigation, protection and reporting, Under section V Investigation: an investigation is initiated for all allegations of suspected abuse, neglect or misappropriation. Further in #4 of Investigation it states that the Abuse Investigator will complete a thorough investigation inclusive of interviewing the resident, alleged abuser and any witnesses. In section VII Reporting: it states that The Abuse Investigator will be responsible to make all reports regarding abuse investigations and indicates the agencies to report to.According to the admission Record (AR), Resident #8 was admitted to the facility with the diagnoses which include but were not limited to; amyotrophic lateral sclerosis (ALS-a progressive neurodegenerative disease affecting the brain and spinal cord leading to muscle weakness and atrophy), hypertension (high blood pressure), mood disorder, and anxiety disorder. According to the Minimum Data Set (MDS), an assessment tool dated 05/27/2025, Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating that the resident was cognitively intact.A review of Resident #8's Care Plan (CP) include a focus area dated 05/03/2024, for depression and anxiety and that the resident refused to meet with psychiatry. Interventions include to monitor for depression, and to discuss concerns with [resident name's] family.On 08/06/2025 at 1:45 P.M., during an interview with the Unit Manager (UM #1), she stated that morning (08/06/2025), she became aware of an allegation of abuse involving Resident #8 and their caregiver (RR #1). UM #1 stated that the Social Worker (SW) received a call from a [community name redacted] organization regarding an allegation of abuse, and the SW spoke to Resident #8 about it. UM #1 stated that she assumed the SW investigated the allegation. UM #1 stated that RR #1 helped with Resident #8's care since the resident could be difficult with staff.On 08/06/2025, at 1:59 P.M., the surveyor observed Resident #8's bedroom door closed. The surveyor knocked on the door and RR #1 opened the door. The surveyor noted that Resident #8 was lying in bed eating lunch. There was no facility staff in the room with the resident at that time. On 08/06/2025 at 2:20 P.M., during an interview with the Licensed Practical Nurse (LPN #1), she confirmed that she was aware of the allegation of abuse. LPN #1 stated that she had not seen RR #1 abuse the resident. On 08/06/2025 at 2:34 P.M., during an interview with the SW, she confirmed that a [community name redacted] organization notified her that Resident #8's RR #2 called them and reported that the RR #1 was abusing the resident. The SW stated that she spoke with the resident who denied the allegations. The survey continued to review Resident #8's medical record.A review of Resident #8's Progress Notes (PN) did not include documentation of the alleged abuse. The PN also did not include documentation from the SW that she received a phone call from a [community name redacted] organization alleging Resident #8 was abused.A review of the medical record also did not include any documentation that a skin assessment was conducted after the allegation of abuse was made.On 08/06/2025, at 4:33 P.M., during an interview with the LNHA, he stated that he was aware of the police being at the facility yesterday, and he overheard them telling the Receptionist at that time that Resident #8 was being mistreated by RR #1 who was caring for them. When asked if mistreated could be considered abuse, the LNHA agreed. The LNHA further stated that it was presented as a third-party claim of abuse and added; I went outside and spoke to them right away. When the surveyor asked about what should be done when there was an allegation of abuse of a resident, the LNHA responded First, make sure they are not hurt. The LNHA further stated that if the abuser is a visitor, it's technically the same as staff and they need to be separated. The LNHA also that at the time, the resident was on the property premises, Out on Pass, and that the alleged perpetrator (RR #1) was on the other side of the facility parking lot. The LNHA stated that he wrote a statement about the claim and did not write an incident report since the resident had a BIMS of 15, and that the resident denied the abuse. When asked if an incident report should have been filed, the LNHA replied, I would have to check our abuse policy.On 08/07/2025 at 10:40 A.M. during a follow-up interview with UM #1, she stated that she was not asked to provide a statement regarding the allegation or instructed to collect any statements from any potential witnesses. UM #1 acknowledged that there was no skin assessment conducted for Resident #8, and that she would try to complete one. UM #1 also stated that RR #1 was in the facility that morning when she arrived at work on 08/07/2025.On 08/07/2025, at 11:29 A.M., during a follow-up interview with the LNHA, he re-stated that the police were at the Receptionist's area when he walked into the lobby. Per the LNHA, the police acknowledged his presence but continued to talk with the Receptionist. The LNHA confirmed that he did not inquire from the police specific details regarding the allegation because he assumed that the police were unable to substantiate the allegation. The LNHA also stated that RR #1 (the perpetrator) was not separated from Resident #8 because he ruled out abuse as resident is alert and verbal. The LNHA stated I feel like if we were doing an assessment, all these measures would need to be taken into account. I was able to rule out abuse instantaneously.At that time, the LNHA stated The thought process was these measures are typically taken to rule out abuse, they had a BIMS of 15. I thought once ruled out the other steps weren't necessary. When the surveyor asked if that was the facility's policy, the LNHA responded, Per the policy all these steps are part of an investigation and should have been done. The LNHA further confirmed that nursing staff did not perform a body check on the resident to check for injuries. The LNHA also confirmed that there were no staff interviews conducted. The LNHA stated that he felt that he initiated an investigation by talking with Resident #8 because the resident was alert and oriented and stated they felt safe. When questioned about protection for Resident #8 from the alleged abuser, the LNHA stated that the aggressor (RR #1) was not separated from the resident because he felt that he ruled out abuse since the resident was alert and verbal and had a BIMS of 15. The LNHA acknowledged that an assessment should have been done.On 08/07/2025 at 2:24 P.M., during a follow-up interview with the SW, she stated, Administrator or myself is responsible for initiating an investigation when there is an allegation of abuse. The SW stated that an investigation required obtaining statements from staff, and the nurses wrote the Incident Report because the of the skin integrity and the nurse was responsible for notifying the physician. The SW stated that the facility was technically still investigating and there was no summary or conclusion at that time.On 08/07/2025, at 3:37 P.M., during an interview with the Director of Nursing (DON), she stated that when notified of an allegation of abuse, the alleged victim and perpetrator must be immediately separated, the investigation begins and then call the police. The DON verified that an investigation should have been started when the police made the facility aware of the allegation of abuse. The DON stated that in her absence, the staff should have known what to do.An acceptable Removal Plan (RP) was received on 08/11/2025 at 10:27 A.M., indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: on 08/05/2025, the LNHA after hearing the allegation from the police officers, interviewed Resident #8 who stated they felt safe and there was no abuse occurring. Resident #8 stated they wanted to continue having RR #1 visit them and it was family drama, and Resident #8 was provided emotional support. On 08/06/2025, the SW interviewed Resident #8, and a skin assessment was attempted but the resident refused. On 08/06/2025 and 08/07/2025, statements were collected from the staff. The staff collected a statement from RR #1, who denied hitting or abusing the resident. The LNHA, SW, and DON were immediately re-educated on the investigative process of alleged abuse. On 08/07/2025, the LNHA and DON revised the facility's abuse policy to clarify that any allegation, regardless of source or resident's perception, triggers an immediate investigation. On 08/07/2025, training on the Investigation of Abuse was started for all staff by the DON.The survey team verified the implementation of the Removal Plan on-site on 08/12/2025 at 12:45 P.M.NJAC8:39-4.1(a)(5)

Complaint # 2582137Based on interviews and review of other pertinent facility documentation on 08/05/2025, 08/06/2025, and 08/07/2025, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure himself, as well as staff, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) protecting a resident from an alleged perpetrator pending a thorough investigation and b.) thoroughly investigating an allegation of abuse.The Licensed Nursing Home Administrator (LNHA) was interviewed by the surveyor on 08/06/2025. The LNHA stated that on 08/05/2025 he observed the local police at the facility and overheard the police officer tell the facility's Receptionist that Resident #8 was being mistreated by the Resident Representative (RR #1), who was caring for the resident. The LNHA acknowledged that mistreated could be considered abuse, but at the time of the allegation, Resident #8 was on the facility's premises out on pass. The LNHA stated that the facility did not conduct an investigation including completing an incident report because Resident #8 was cognitively intact and when he asked the resident if they were okay, the resident stated they were okay; it was family drama.The facility's failure to ensure the LNHA, as well as all staff, implemented their facility policies to ensure all residents were free from abuse by not protecting a resident from abuse and not investigating an allegation of abuse posed the likelihood for serious physical or emotional harm or injury. This resulted in an Immediate Jeopardy (IJ) situation.The IJ began on 08/05/2025, after the police notified the facility of the allegation. The facility's Administrator was notified of the IJ on 08/07/2025 at 5:59 P.M. The facility submitted an acceptable Removal Plan (RP) on 08/11/2025 at 10:24 A.M. The surveyor verified the implementation of the RP on 08/12/2025 at 12:45 P.M. The evidence was as follows:Refer F 600, F 610 A review of the undated Administrator - Job Description provided by the facility included the following:Position Summary: this position is responsible to establish and maintain systems that are effective to operate the nursing home in a manner to safely meet residents' needs in accordance with federal, state, and local regulations.Essential Requirements, Duties, and Responsibilities.develop, maintain and implement operational policies and procedures to meet residents' need compliance with federal, state and local requirements.develop and enforce a monitoring program to assure compliance with federal, state, and local requirements.establish systems to enforce the facility policies and procedures.establish systems to ensure compliance with federal, state, and local regulations.observe all facility policies and procedures.A review of the facility policy that was revised on 01/2025, titled Abuse Prevention Program included policy statement .promotes an environment that does all to prevent resident abuse, neglect, misappropriation of property through the following components: screening and training of employees, prevention, identification, investigation, protection and reporting, Under section V Investigation: an investigation is initiated for all allegations of suspected abuse, neglect or misappropriation. Further in #4 of Investigation it states that the Abuse Investigator will complete a thorough investigation inclusive of interviewing the resident, alleged abuser and any witnesses. In section VII Reporting: it states that The Abuse Investigator will be responsible to make all reports regarding abuse investigations and indicates the agencies to report to.On 08/06/2025 at 1:45 P.M., during an interview with the Unit Manager (UM #1), she stated that morning (08/06/2025), she became aware of an allegation of abuse involving Resident #8 and their caregiver (RR #1). UM #1 stated that the Social Worker (SW) received a call from a [community name redacted] organization regarding an allegation of abuse, and the SW spoke to Resident #8 about it. UM #1 stated that she assumed the SW investigated the allegation. UM #1 stated that RR #1 helped with Resident #8's care since the resident could be difficult with staff.On 08/06/2025, at 1:59 P.M., the surveyor observed Resident #8's bedroom door closed. The surveyor knocked on the door and RR #1 opened the door. The surveyor noted that Resident #8 was lying in bed eating lunch. There was no facility staff in the room with the resident at that time. On 08/06/2025 at 2:34 P.M., during an interview with the SW, she confirmed that a [community name redacted] organization notified her that Resident #8's RR #2 called them and reported that the RR #1 was abusing the resident. The SW stated that she spoke with the resident who denied the allegations. On 08/06/2025, at 4:33 P.M., during an interview with the LNHA, he stated that he was aware of the police being at the facility yesterday, and he overheard them telling the Receptionist at that time that Resident #8 was being mistreated by RR #1 who was caring for them. When asked if mistreated could be considered abuse, the LNHA agreed. The LNHA further stated that it was presented as a third-party claim of abuse and added; I went outside and spoke to them right away. When the surveyor asked about what should be done when there was an allegation of abuse of a resident, the LNHA responded First, make sure they are not hurt. The LNHA further stated that if the abuser is a visitor it's technically the same as staff and they need to be separated. The LNHA also that at the time, the resident was on the property premises, Out on Pass, and that the alleged perpetrator (RR #1) was on the other side of the facility parking lot. The LNHA stated that he wrote a statement about the claim and did not write an incident report since the resident had a BIMS of 15, and that the resident denied the abuse. When asked if an incident report should have been filed, the LNHA replied, I would have to check our abuse policy.On 08/07/2025 at 10:40 A.M., during a follow-up interview with UM #1, she stated that she was not asked to provide a statement regarding the allegation or instructed to collect any statements from any potential witnesses. UM #1 acknowledged that there was no skin assessment conducted for Resident #8, and that she would try to complete one. UM #1 also stated that RR #1 was in the facility that morning when she arrived at work on 08/07/2025.On 08/07/2025, at 11:29 A.M., during a follow-up interview with the LNHA, he re-stated that the police were at the Receptionist's area when he walked into the lobby. Per the LNHA, the police acknowledged his presence but continued to talk with the Receptionist. The LNHA confirmed that he did not inquire from the police specific details regarding the allegation because he assumed that the police were unable to substantiate the allegation. The LNHA also stated that RR #1 (the perpetrator) was not separated from Resident #8 because he ruled out abuse as resident is alert and verbal. The LNHA stated I feel like if we were doing an assessment, all these measures would need to be taken into account. I was able to rule out abuse instantaneously. At that time, the LNHA stated The thought process was these measures are typically taken to rule out abuse, they had a BIMS of 15. I thought once ruled out the other steps weren't necessary. When the surveyor asked if that was the facility's policy, the LNHA responded, Per the policy all these steps are part of an investigation and should have been done. The LNHA further confirmed that nursing staff did not perform a body check on the resident to check for injuries. The LNHA also confirmed that there were no staff interviews conducted. The LNHA stated that he felt that he initiated an investigation by talking with Resident #8 because the resident was alert and oriented and stated they felt safe. When questioned about protection for Resident #8 from the alleged abuser, the LNHA stated that the aggressor (RR #1) was not separated from the resident because he felt that he ruled out abuse since the resident was alert and verbal and had a BIMS of 15. The LNHA acknowledged that an assessment should have been done.An acceptable Removal Plan (RP) was received on 08/11/2025 at 10:27 A.M., indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: the Administration attempted to restrict RR #1 from the premise pending an investigation, but Resident #8 did not agree. The LNHA educated the nursing supervisor/manager to check Resident #8 every 30-minutes to ensure no threat while the investigation was being concluded. The LNHA received education from the Regional Director of Nursing (RDON) about abuse prevention oversight, reporting, and compliance timelines. The facility's abuse prevention program was reviewed and revised to reflect appropriate reporting timeframes in addition to the requirement of mandatory reporting and proper investigation. The LNHA was additionally educated by the RDON regarding regulatory requirements for F 600 and F 610.The survey team verified the implementation of the Removal Plan on-site on 08/12/2025 at 12:45 P.M. NJAC 8:39-9.2(a)NJAC 8:39-9.3(a)NJAC 8:39-27.1(a)

Complaint # 2582137Census: 137Sample:12Based on observations, interviews, medical record review and review of other pertinent facility documentation on 08/05/2025, 08/06/2025 and 08/07/2025 it was determined that the facility failed to administer medications according to the acceptable practice for 1 of 4 residents (Resident #8). The facility failed to follow their policy titled Administering Medications.The deficient practice was evidenced by the following:Reference: New Jersey Statues Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means the identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen within the scope of practice of the registered professional nurse. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human responses mean those signs, symptoms, and processes which denote the individual's health need or reaction to an actual or potential health problem.The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.According to the admission Record (AR), Resident #8 was admitted to the facility with the diagnoses which include but is not limited to: Amyotrophic Lateral Sclerosis (ALS-a progressive neurodegenerative disease affecting the brain and spinal cord leading to muscle weakness and atrophy), Hypertension, Mood disorder, anxiety disorder. Review of the Minimum data Set (MDS) an assessment tool dated 05/27/2025, indicated that Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating that the resident is cognitively intact.A review of the Order Summary Report (OSR) Active as of 085/06/2025 included the following Physician Orders. (PO's):Calcium Oral Tablet 500 mg by mouth two times a day.Multiple Vitamin-Minerals Tablet give one tablet by mouth daily.Cholecalciferol Tablet 1000 Unit give one tablet twice daily.Rilutek Oral tablet 50 mg give 1 tablet by mouth two times a day for neuromuscular agent give on an empty stomach. Give one hour prior to meal or two hours after.The surveyor observed Resident #8 on 08/06/2025 at 1:59 P.M., who was lying in bed while the caretaker fed the resident lunch. The surveyor observed six pills in a medicine cup at the resident's bedside.On 08/06/2025 at 2:00P.M., the surveyor informed the Unit Manager (UM) of the medication in the cup. On 085/06/2025 at 2:04 P.M., the surveyor observed the UM remove the medication cup from the resident's bedside table and notified the Licensed Practical Nurse (LPN#1) assigned to the resident. The surveyor then interviewed the caretaker about the medication, and asked her if the medication was left for her to medicate the resident. The caretaker replied that she doesn't administer medications to Resident #8 and the resident also shook their indicating that the caretaker did not administer medications. The caretaker stated that the nurse was waiting for pudding to use in administering the medication. The survey interviewed the UM on 08/06/2024 at 2:07 P.M., and she identified the pills in the cup. When asked if it is policy to leave medications at residents' bedside, she replied, No, absolutely not. On 08/06/2025 at 2:20 P.M., the surveyor interviewed LPN #1 who confirmed that she left the medication at the resident's bedside, and stated she knows she should not have, It is not the policy. She further stated that she does not normally do that, but the resident's caretaker wanted the medications to be given in pudding so she left the medications to wait for pudding.During an interview with the Director of Nursing (DON) on 08/06/5025 at 4 2:51 P.M., she stated that it was not the policy for nurses to leave medication at bedside. The expectation would be if they do not take the medication then mark them as refused.Review of the facility policy dated 01/2025 indicated; Administering Medications under the Policy Statement, Medications shall be administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation, 3. Medications must be administered in accordance with the orders, including any required time frame. 4.Medicaitons must be administered within one (1) hour of their prescribed time, unless otherwise specified. 18. If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall indicate such on the MAR.NJAC 8:39-29.2 [d]

Based on interview, record review, and review of facility policy, it was determined that the facility failed to protect the residents' rights to be treated with respect and dignity when the facility searched all 136 residents' rooms for drugs, including marijuana without properly obtaining informed consent for 2 of 31 residents reviewed for resident rights (Resident #65 and Resident #105) . Review of documentation provided by the Licensed Nursing Home Administrator (LNHA) revealed that on 10/07/24, all the resident rooms in the facility were searched. On 10/14/24, four resident rooms were searched, and on 10/21/24, an additional four resident rooms were searched. On 10/29/24 at 1:21 PM, the surveyor interviewed Resident #105 who stated that the facility had drug dogs come and search the facility every week. Resident #105 stated that they felt harassed by being searched. On 10/30/24 at 11:30 AM, the surveyor interviewed the LNHA who stated when the searches were conducted, staff knocked on the resident's door before entering, and if the canine picked up on a scent, they asked the resident to open the drawer, closet, or wherever the canine was indicating. Further interview with the LNHA revealed that if drugs were found during the search, it was thrown away and if hard drugs were found he called the police. There was no documented evidence that the police were notified when illegal substances were found. The facility developed a blanket policy which indicated that the facility could search resident rooms based on what they determined to be suspicion and probable cause. The facility contracted with a private agency for a drug canine to come into the facility. There was no law enforcement present during the searches nor was law enforcement called. The facility's failure to ensure that the residents were allowed to exercise their rights as a resident of the facility and their rights to be treated with respect and dignity placed all residents at risk of serious psychosocial harm due to causing the residents to feel degraded or harassed. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 10/07/24, when all the resident rooms in the facility were illegally searched. The facility's Administration was notified of the IJ on 10/30/24 at 6:10 PM. The facility submitted an acceptable removal plan (RP) on 10/31/24 at 5:37 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 11/01/24 at 1:45 PM. Findings include: Review of the facility's policy titled, Resident Rights, dated 08/15/24, included employees shall treat all residents [ .] with kindness, respect, and dignity; federal and state laws guarantee certain basic rights to all residents of this facility. These rights include: the resident's right to a dignified existence; be treated with respect, kindness, and dignity .exercise his or her rights as a resident of the facility and as a resident or citizen of the United States . Review of the facility's undated policy titled, Forbidden Items Policy, included For the safety of our residents, all weapons or items that can be used as such are banned from the facility at all times. In addition, alcohol, federally classified illegal drugs (including marijuana and THC products) and other contraband are strictly forbidden. Visitors who violate any of our rules will immediately lose their visiting privileges. Residents who violate any of our rules will cause discharge proceedings to be initiated on their behalf. In addition, violators will be reported to the police. We strongly encourage our residents and their families not to bring any of their own medications to the facility. If a resident insists on having their own medication, it must first be approved on an individual basis by nursing administration. The policy contained areas for the resident and/or Relative/Responsible Party names and signatures. There was no space for a witness or facility staff signature. Review of the undated policy titled, Possession of Drugs, Taking of Drugs, or Possession With Intent To Sell, included As a resident at [facility name] I [blank] agree that during my stay at the facility, I will NOT bring in drugs of any kind, I will NOT take any drugs that are not prescribed by my Physician and I will NOT give or sell drugs of any kind to any other resident, visitor or staff member. I understand and agree that if I am found in possession of drugs or observed taking or selling drugs of any kind, I may be discharged from the facility and not permitted readmission. If suspected of bringing federally classified illegal drugs (including marijuana and THC-based products) into the facility I agree to be searched/have my room searched. My Physician, as well as the local Police department will be notified promptly. If suspected, but not observed taking illegal drugs, I agree to urine and blood drug screening ordered by my Physician. My signature indicates my acceptance and agreement with this Policy. The form contained blanks for the signature of the resident and a witness. Review of a document titled, 3DK9 Deployment Report, dated 10/07/24, and provided by the Administrator revealed, .K9 [canine; police dog trained to do tasks such as drug searches] team met with [two] designated people and began a search of every room in the facility. Approximately all 136 rooms were searched along with [two] individuals who showed a huge change in behavior once the K9 was seen. See below for a complete list of items found . [room number withheld] .multiple pills . The Security Suggestions revealed, Increase frequency of searches and utilize a second K9. During an interview on 10/30/24 at 11:30 AM, with the LNHA and Social Services Director (SSD), the LNHA stated that the facility had been conducting searches for a few years due to the facility's population. The LNHA stated that the facility had been conducting the searches quarterly because the facility wanted to have a safe environment for the residents who were not alert and oriented. The LNHA stated they had ramped up the searches over the last month because there was a resident (Resident #125) who went to the hospital and was found with a bottle of pills. The LNHA stated that the facility decided to do searches with a canine for a month and then go back to quarterly if nothing else was found. The LNHA stated that when the quarterly searches were done, they searched anyone who had a repeated offense or there was a reason to suspect drug use. The LNHA stated that if someone was acting off or staff noticed something, then those residents' rooms were searched. The LNHA stated after the resident was found with the bottle of pills, the facility searched every single room as a baseline on 10/07/24, and depending on the findings, that was who the facility went back to for subsequent searches. The surveyor asked if all 136 residents gave consent for the room searches on 10/7/24, and the LNHA stated that staff knocked on the door before entering, and if the canine picked up on a scent, they asked the resident to open the drawer, closet, or wherever the canine was indicating. The LNHA stated, We do have a Forbidden Item Policy, part of what they (the residents) agree to is searches. The LNHA stated, If they say no, we aren't going to go into their pocket unwilling. The SSD stated the signed copies of the policies were kept with the social services documentation and that the signatures were obtained upon admission to the facility. The LNHA reported that the facility had an outside private company come in with a canine and a handler to conduct the searches, and the facility's security officer, who was also a smoking monitor, accompanied the handler, and they tried to have two staff members present. On 10/30/24 at 12:47 PM, the LNHA stated he was not keeping a log of what rooms were searched, but provided information from the outside company conducting the searches. The LNHA stated that if something was found during the search, it was thrown away. The LNHA stated that non-drug items went to the smoke monitor, and if it were drugs, the facility usually threw them out. The LNHA reported that he had a conversation with the police department, and they informed him that if hard drugs were found, to call them and they would do an investigation. During an interview on 10/30/24 at 2:32 PM, the LNHA stated the reason for the full facility search on 10/07/24, was because Resident #125 was sent to the hospital and had a bottle of pills with another resident's name on it. The LNHA identified the other resident as Resident #103, who was still residing at the facility. 1. During an interview on 10/29/24 at 1:21 PM, Resident #105 stated the facility had drug dogs come and search the facility every week. Resident #105 stated that they felt like they were being harassed. Resident #105 also stated that they told the facility once that it was okay because the resident did not have anything to hide. Resident #105 stated that they were tired of it, and the searches gave them flashbacks of living on the street. Resident #105 stated every room in the facility had been searched the first time, and even the police tell you why they wanted to search you. On 10/29/24 at 1:30 PM, the surveyor reviewed the medical record for Resident #105. A review of the Admission Record face sheet (an admission summary) reflected Resident #105 was admitted to the facility with diagnoses that included; amyotrophic lateral sclerosis (ALS), anxiety disorder, unspecified mood disorder, and problem related to unspecified psychosocial circumstances. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 09/01/24, reflected that Resident #105 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A further review of the MDS revealed that the resident had bilateral upper and lower extremity range of motion impairments. A review of the Forbidden Items Policy and Possession of Drugs, Taking of Drugs, or Possession With Intent To Sell policy both provided by the SSD, were not signed by Resident #105. The policies were dated as signed on 04/02/24, and handwritten by the SSD that Resident #105 verbally agrees. 2. During an interview on 10/29/24 at 11:04 AM, Resident #65 was asked if they were treated with respect and dignity by the staff at the facility, and the resident stated, Up until recently, they (the facility) were coming in with drug sniffing dogs. They have rifled through my dresser three times. The surveyor asked why the facility was performing these searches, and Resident #65 stated, I guess they are looking for drugs and such. The surveyor asked if the resident had consented to the searches, and Resident#65 stated, I did not sign anything, the intake contract stated it was a random search. My understanding was that these searches are a weekly thing and it's done before families come to visit, so they are not aware of it. On 10/29/24 at 11:04 AM, the surveyor reviewed the medical record for Resident #65. A review of the Admission Record face sheet revealed Resident #65 was admitted to the facility with diagnoses which included; alcohol induced disorder, chronic pain, bipolar, tobacco use, and anxiety disorder. A review of the quarterly MDS dated [DATE], indicated Resident #65 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. A review of the facility's Forbidden Items Policy, provided by the SSD, dated 04/05/24, included a notation that Resident #65 refused to sign it and it was verbally reviewed with the resident. The policy did not indicate who verbally reviewed it with the resident. A review of the facility's Possession of Drugs, Taking of Drugs, or Possession with Intent to Sell document provided by the SSD, the resident's signature was blank and dated 4/5/24. The SSD signed the document as the witness on 4/8/24, and there was a notation documenting that the resident refused to sign and the policy was verbally reviewed. A review of a document related to Resident #65 titled, 3DK9 Deployment Report dated 10/21/24, and provided by the LNHA included . [room number withheld] weed vapes [marijuana] and contraband . During an interview on 10/30/24 at 10:07 AM, the LNHA was asked why Resident #65 was searched if the resident had not signed (gave consent) the facility's Forbidden Items Policy. The LNHA stated, [Resident #65] consented when we approached them and when the canine came to Resident #65, they did not refuse the search. The LNHA stated multiple pills, marijuana vapes, and other contraband were found. During a follow-up interview on 10/30/24 at 11:28 AM, when the LNHA and SSD were asked about the facility's decision to do the weekly canine searches, the LNHA stated, It was ongoing when I started here about three to four years ago. When the LNHA was asked who was searched, he stated, Anyone who we found or who we had reason to suspect with pills. They were pocketing pills, marijuana, alcohol, etc we just get feedback from staff or if a team member has a feeling a resident might be using, but it's usually someone with a history. When asked how the consent to search Resident #65's room was obtained, the LNHA stated, We knocked on the door, if the dog picked up a scent, then we asked them to open the drawers. We have a Forbidden Items Policy, and they have agreed to the search. The SSD stated, If they said no to the search, we would then review the policy with them, and if they deny us again, we will begin the 30-day discharge. When the SSD was asked if these policies were provided to Resident #65 upon admission, the SSD stated, No, they were not in the admission packet. The acceptable Removal Plan on 10/31/24 at 5:37 PM, indicated the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: room searches will not be conducted for any resident without suspicion or probable cause; when probable cause was found the following must be done: the resident must be assessed, the care plan updated to reflect the findings of the assessment, and a written consent must be obtained from the resident; if the resident/representative does not consent, a room search cannot be completed; and all staff were educated on the updated facility's drug policy. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 11/01/24. On 11/01/24, the facility provided documentation of a resident questionnaire. The question was: Have you experiences [sic] psych social [psychosocial] harm related to the canine searches. It was documented that there were four residents [Resident #59, Resident #63, Resident #69, and Resident #83] who answered, Yes. NJAC 8:39-4.1(a)(12)(15)(16)(34)

Complaint # NJ00176157 Based on observation, interview, record review, and review of pertinent facility documents on 8/15/24, it was determined that the facility failed to ensure that 1 of 1 Justice Involved Individual (JII) Resident #6 was afforded the autonomy to participate in group activities, community dining, serving meals in a dignified manner, freely communicate with visitors, leave rooms at will and be free from physical restraints. The failure to treat Resident #6 respectfully and in a dignified manner had the likelihood to cause serious injury and psychological harm. This was cited as an isolated incident that immediately jeopardizes the health and safety of the JII that resided in the facility which resulted in an immediate jeopardy(IJ) situation. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL, indicated Resident Rights SNFs and NFs, as residential environments, must permit residents to have autonomy and choice, to the maximum extent practicable regarding how they wish to live their everyday lives and receive care. Federal statutes and regulations establish an array of individual rights and safeguards. Nursing homes cannot impose conditions or restrictions that undermine resident rights and protections required by federal law. Facilities cannot require prospective residents to give up their rights as a requirement for admission . The Immediate Jeopardy (IJ) began on 05/21/24, the date that Resident #6 was admitted to the facility and based on staff interviewed noted below, that upon admission has been secluded each day by correction officers (COs) of the Middlesex County Correctional Facility (MCCF). The IJ was identified on 08/15/24, when Resident #6 was observed by Surveyors being secluded to their room, guarded by COs, and was not permitted to participate in group activities and community dining. Further observation revealed the JII was not allowed to intermingle with other residents or visitors and were restricted from leaving the room at will. The Surveyors reviewed the following in the Electronic Medical Record (EMR). According to the Admission Record, Resident #6 was admitted to the facility with diagnoses which included but not limited to Cerebrovascular disease and Abnormalities of Gait and Mobility. The Minimum Data Set (MDS), an assessment tool, dated 05/28/24, indicated that Resident #6 had a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. The MDS also indicated Resident #6 had no behaviors and utilized no physical or chemical restraints. The facility's Licensed Nursing Home Administrator (LNHA) was informed on 08/15/24 at 7:51 p.m., that an Immediate Jeopardy situation existed. An acceptable removal plan was electronically mailed to the Surveyors on 8/15/24 at 10:15 p.m., indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: The JII was discharged from the facility as of 8/15/24 at 9:05 p.m. The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care. The Surveyors verified the removal plan on-site on 8/19/24 and determined the IJ was removed as of 8/15/2024. The Director of Clinical Operations (DCO) provided the Surveyors with multiple facility policies including, RESIDENT RIGHTS, reviewed and revised on 01/2024, indicated under Policy Statement Employees shall treat all residents with kindness, respect, and dignity .1. Federal and state laws guarantee certain and basic rights to all residents of this facility. These rights include resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property and exploitation; d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; e. self-determination; f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights .cc. access to a telephone, mail, and email; dd. Communicate in person and by mail, email, and telephone with privacy The facility policy titled, ABUSE PREVENTION PROGRAM reviewed and revised on 01/2024, under Policy Statement Our residents have the right to be free from abuse, neglect .This includes but is not limited to freedom from corporal punishment, involuntary seclusion .Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone .3 .implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents . The facility policy titled Dining Room Services, dated 5/2024, under Purpose: The purpose of this policy is to ensure that all residents receive safe, nutritious, and enjoyable dining experiences in a respectful and dignified environment. This policy outlines the standards and procedures for meal service, dietary accommodations, and dining room conduct. Scope: This policy applies to all residents .Accessibility: The dining room should be easily accessible to all residents .Resident Rights Choice and Independence: Residents have the right to make choices about their meals and dining experience .Dignity and Respect: All residents should be treated with dignity and respect during mealtimes . The facility policy titled Activities, reviewed and revised on 3/2024, under Purpose: The purpose of this policy is to ensure that all residents have access to a variety of meaningful, engaging, and age-appropriate activities that promote physical, emotional, and social well-being .Scope: This policy applies to all residents .Resident Rights: Residents have the right to choose which activities they participate in and to decline participation without consequence . The facility also failed to comply with the policies titled Resident Rights, Abuse Prevention Program, Dining Room Services, and ''Activities were implemented. During an interview with the Surveyors on 8/15/24 at 9:17 a.m., in the presence of the Assistant Administrator, Director of Nursing (DON), Assistant DON (ADON), Director of Social Services (DSS), Clinical Director of Operation (CDO), and Assistant Concierge (AC), the Administrator stated that the MCCF Administrator, DON, and Medical Director had an agreement that upon admission, the JII would have COs that would stay in the room throughout the day. The visits would have to be scheduled to coincide with the MCCF schedule. The Administrator explained that the MCCF administration instructed the facility to have visitors one day a week and then the receptionist will send the inmate visitor upstairs to check with the COs. The DON stated that anything that was brought to Resident #6's room had to be checked by the COs. The DON also added that the activities for the JII had to be given to the COs for approval, before giving them to the JII, and that the Resident was not allowed to participate in activities outside the room as instructed by the MCCF. During the tour of the unit on 8/15/24 from 11:17 a.m. to 12:30 p.m., the surveyors observed Resident #6 lying in bed, watching television. The resident's ankles were shackled and two COs were sitting inside the room. The Surveyors further observed Resident #6's cell phone was out of reach. During mealtime, Resident #6 was observed sitting on the side of the bed with ankles shackled together. Resident #6's meal was served on disposable plate and utensils. On 8/15/2024 at 11:17 a.m., the Surveyors interviewed Resident #6. The resident stated that they were not allowed to go out of the room to attend activities or go to the dining room with other residents. The resident also stated that the cell phone can only be used after approval from the COs. Resident #6 revealed that meals were served with disposable plate and utensils without knife (plastic or silver) to cut the food. Resident #6 explained that in order to eat the meal, the resident picked up the food and used their hands to break the meat into pieces. The resident stated that they felt like dirt. During the interview with the Surveyors on 8/15/2024 at 11:48 a.m., the COs stated that they were following the Middlesex County Correctional Facility (MCCF) policy for Resident #6, by not allowing the resident to leave the room except for Physical Therapy and Occupational Therapy (PT/OT), showers, and other pre-approved medical necessary. A review of Resident #6's Care Plan (CP), initiated on 5/26/24 and revised on 8/15/2024 revealed My leisure time will be under direct supervision. I may need solo leisure materials. Interventions included but not limited, Recreation Staff will have minimal and supervised interactions with [Resident #6] .Any mail or packages must be handed directly to the [CO] .Recreation Staff, as requested and as approved by the guards, will drop off solo leisure supplies such as a deck of playing cards, jigsaw puzzle, word puzzle book, notebook, reading materials, safe writing or coloring implements, etc. Upon request and approval of CO .We are not permitted to give [Resident #6] any electronics. All items must be handed to the CO on duty. We are not permitted to provide shopping service for [Resident #6]. We are not able to provide salon services for [Resident #6]; without the approval of the correctional institution's warden and resident is able to fund the service. During the interview with the Surveyors on 8/15/2024 at 11:59 a.m., the Licensed Practical Nurse (LPN #1), assigned nurse for Resident #6 stated that the JII stayed in their room all day except when going for a shower or PT/OT. LPN #1 further stated that the JII does not go into the main dining area to attend activities and eat outside the room. During the interview with the Surveyors on 8/15/2024 at 12:16 p.m., the assigned Certified Nursing Assistant (CNA #1) stated that the JII was served their meals on disposable plates with plastic utensils, and the COs would check the tray and remove the knife. The CNA further stated the JII took showers on scheduled days and the COs would stay in the shower room with the JII. During a follow up interview with the Surveyors on 8/15/24 at 2:30 p.m. with the LNHA and DON, the LNHA stated he was not aware and never paid attention that the Resident #6 was being shackled since Resident #6 was under the jurisdiction of the [MCCF]. The DON stated that she was aware that Resident #6 was being shackled, since this was the protocol of the county. The DON stated the only rights the resident had were to have a Bible, medical care, food, and nutrition. The resident can't go out to activities with other residents because of inmate status. It's a security issue, like if [he/she] attacks someone. I don't consider it restraining , [he/she] is the property of the jail and we are an extension of the jail. The Administrator and DON stated that they do not consider the Resident #3 a resident. According to DON and Administrator, Resident #6's rights weren't being followed because the facility was following the MCCF regulations for inmates. During the interview with the Surveyors on 8/15/2024 at 4:01p.m, the DSS confirmed that Resident #6 was not provided an admission agreement. The DSS further confirmed that Resident #6's resident rights (RR) were explained, however, the RR were not being implemented because the facility was following the MCCF protocol. NJAC 8:39-4.1(a) 11

Complaint # NJ00176157 Based on observation, interview, record review, and review of pertinent facility documents on 8/15/2024, it was determined that the facility failed to ensure that 1 of 1 Justice Involved Individual (JII) Resident #6 was afforded the right to retain personal possessions and to have a homelike environment. This failure to treat Resident #6 respectfully and in a dignified manner had the likelihood to cause serious injury and psychological harm. This was cited as an isolated incident that immediately jeopardizes the health and safety of the JII which resulted in an immediate jeopardy ( IJ) situation. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL. Under .Resident Rights SNFs and NFs, as residential environments, must permit residents to have autonomy and choice, to the maximum extent practicable regarding how they wish to live their everyday lives and receive care. Federal statutes and regulations establish an array of individual rights and Page 7- State Survey Agency Directors safeguards. Nursing homes cannot impose conditions or restrictions that undermine resident rights and protections required by federal law. Facilities cannot require prospective residents to give up their rights as a requirement for admission. Resident rights in the nursing home include, but are not limited to the right to: Be free from physical or chemical restraints imposed for discipline or convenience, and not for treatment of a resident's medical condition; 9 Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care [and] interact with members of the community both inside and outside the facility; 10 Personal privacy and confidentiality of his or her personal and clinical records; 11 Immediate access to any resident by the following: subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident; 12 Be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 13 Also, nursing home residents must not only be able to exercise their rights as residents of the facility and as citizens of the United States, but also have the right to be free of interference, coercion, discrimination, or reprisal from the facility in exercising those rights . The Immediate Jeopardy (IJ) began on 05/21/24, the date that Resident #6 was admitted to the facility and based on staff interviewed noted below, that upon admission has been secluded each day by correction officers (COs) of the Middlesex County Correctional Facility (MCCF). The IJ situation was identified on 08/15/24, when Residents #6 was observed being secluded to their room guarded by CO, and not permitted to participate in group activities, community dining, and being served meals in a dignified manner. The JII was not allowed intermingling with other residents, communicating with visitors, and leaving the room at will. The Surveyors reviewed the following in the Electronic Medical Record (EMR). Review of the Admission Record (AR), Resident #6 was admitted to the facility with diagnoses which included but was not limited; Disease of Pericardium, Auditory Hallucinations, Hypertension, Anemia, Personal Muscle Weakness, Shortness of Breath, Need for Assistance with Personal Care. The Minimum Data Set (MDS), an assessment tool dated 5/28/2024, indicated that Resident #6's BIMS was 15, showing intact cognition, and required assistance from staff in Activities of Daily Living (ADL). The MDS further indicated under Section F- Preferences for Customary Routine and Activities .F0400. Interview for Daily and Activity Preferences revealed that while Resident was in the facility, the Resident was interviewed and stated that it is Important, but can't do or no choice, 1)to choose what clothes to wear; 2.) to take care of your personal belongings or things; 3.) to choose between a tub bath, shower, bed bath, or sponge bath; 4.) to be able to use the phone in private . Review of the Resident's Care Plans (CP) initiated on dated 05/26/24 and revised on 8/15/2024. The CP indicated My leisure time will be under direct supervision. I may need solo leisure materials. The CP interventions included but were not limited to .Recreation Staff will have minimal and supervised interactions with [Resident #6] .Any mail or packages must be handed directly to the guards .Recreation Staff, as requested and as approved by the guards, will drop off solo leisure supplies such as; deck of playing cards, jigsaw puzzle, word puzzle book, notebook, reading materials, safe writing or coloring implements, etc. Upon request and approval of [correction officer]; We are not permitted to give [Resident #6] any electronics. Any and all items must be handed to the CO on duty. We are not permitted to provide shopping service for [Resident #6]. We are not able to provide salon services for [Resident #6] without the approval of the correctional institution's warden . initiated on 05/26/2024, created on 05/26/2024, and revised on 08/15/2024. The facility Licensed Nursing Home Administrator (LNHA) was informed on 08/15/24 at 7:51 p.m., that an Immediate Jeopardy situation existed. An acceptable removal plan was electronically mailed to the surveyors on 8/15/2024 at 10:15 p.m., indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice, the JII was discharged from the facility as of 8/15/24. The facility provided education to all administrative facility personnel on CMS guidance in reference to federal requirements for providing services to JIIs' and to ensure that the rights of JIIs can be respected if the individuals is admitted into the facility care. The Surveyors verified the removal plan on-site on 8/19/24 and determined the IJ was removed as of 8/15/2024. The Director of Clinical Operations (DCO) provided the Surveyors with multiple facility policies including, a policy titled Resident Rights dated 02/2024, included under Policy Explanation and Compliance Guidelines that prior to or upon admission, the social service designee, or another designated staff member, will inform the resident of the resident's rights and responsibilities. 2. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. 5. Respect and Dignity. The resident has a right to be treated with respect and dignity including the right to be free of any physical or chemical restraint . 6. Self-determination. The resident has the right to, and the facility must promote and facilitate residents' self-determination through support of resident's choice, including but not limited to the right to choose activities, make choices about aspect of his or her life, right to interact with members of the community both inside and outside the facility, and the right to receive visitors. 7. Information and communication. The resident has the right to be informed of his or her rights and of all the rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. 8. Privacy and confidentially. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment written and telephone communication, personal care, visits, and meetings of family and resident groups. During an interview with the Surveyors on 8/15/2024 at 9:17 a.m., in the presence of Clinical Director of Operation (CDO) LNHA, Director of Nursing (DON), Assistant DON (ADON), Director of Social Services (DSS), Assistant Concierge (AC), the LNHA stated that there was one JII in the facility that was being supervised by two correctional officers (COs) upon admission. The LNHA further stated Resident #6 was not provided an admission agreement (AA) because they were a JII. However, the DSS stated that the JII's resident rights were explained. According to the LNHA, the facility has been following the correctional agreement with MCCF, and that MCCF had the jurisdiction of the JII and the facility needed to follow the correctional guidance which included but not limited to everything you bring in the room, the CO needs to check before giving to the JII. During the tour of the 2nd floor on 8/15/2024 at 11:17 a.m., Resident #6 and 2 COs were inside Resident #6's room. Resident #6 was lying on their bed with hospital gown and the lower extremities were shackled with metal cuff. The cell phone was observed by the window out of the resident's reach. During the interview with the Surveyors on 8/15/2024 at 11:17 a.m., Resident #6 stated that they could only use the cell phone to call their loved ones after the COs approval and was not allowed to have any items brought from the outside. Resident #6 stated that approval is needed from the COs before being allowed to do anything. NJAC 8:39-4.1

Complaint # NJ00176157 Based on observation, interview, record review, and review of pertinent facility documents on 8/15/24, it was determined that the facility failed to ensure that 1 of 1 Justice Involved Individual (JII) Resident #6 was afforded the right to make own choices regarding aspects of life and care; participate in activities and interact with other residents inside of the facility. The failure to treat Resident #6 respectfully and in a dignified manner had the likelihood to cause psychological harm. This was cited as an isolated incident that immediately jeopardizes the health and safety of the JII that resided in the facility which resulted in an IJ situation. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL, indicated Resident Rights SNFs and NFs, as residential environments, must permit residents to have autonomy and choice, to the maximum extent practicable regarding how they wish to live their everyday lives and receive care. Federal statutes and regulations establish an array of individual rights and safeguards. Nursing homes cannot impose conditions or restrictions that undermine resident rights and protections required by federal law. Facilities cannot require prospective residents to give up their rights as a requirement for admission . The Immediate Jeopardy (IJ) began on 05/21/24, the date that Resident #6 was admitted to the facility and based on staff interviewed noted below, that upon admission has been secluded each day by correction officers (COs) of the Middlesex County Correctional Facility (MCCF). The IJ was identified on 08/15/24, when Resident #6 was observed by the Surveyors being secluded in their room, guarded by COs, and was not permitted to participate in group activities and community dining. Further observation revealed the JII was not allowed to intermingle with other residents or visitors and were restricted from leaving their room at will. The Surveyors reviewed the following in the Electronic Medical Record (EMR). According to the Admission Record, Resident #6 was admitted to the facility with diagnoses which included but not limited to Cerebrovascular disease and Abnormalities of Gait and Mobility. The Minimum Data Set (MDS), an assessment tool, dated 05/28/24, indicated that Resident #6 had a Brief Interview for Mental Status (BIMS) of 15 which indicated the Resident was cognitively intact. The MDS also indicated Resident #6 had no behaviors and utilized no physical or chemical restraints. A review of Resident #6's Care Plan (CP), initiated on 5/26/24 and revised on 8/15/2024 revealed My leisure time will be under direct supervision. I may need solo leisure materials. Interventions included but not limited, Recreation Staff will have minimal and supervised interactions with [Resident #6] .Any mail or packages must be handed directly to the [CO] .Recreation Staff, as requested and as approved by the guards, will drop off solo leisure supplies such as deck of playing cards, jigsaw puzzle, word puzzle book, notebook, reading materials, safe writing or coloring implements, etc. Upon request and approval of CO .We are not permitted to give [Resident #6] any electronics. Any and all items must be handed to the CO on duty. We are not permitted to provide shopping service for [Resident #6]. We are not able to provide salon services for [Resident #6]; without the approval of the correctional institution's warden and JII's ability to fund the service. The facility Licensed Nursing Home Administrator (LNHA) was informed on 08/15/24 at 7:51 p.m., that an Immediate Jeopardy situation existed. An acceptable removal plan was electronically mailed to the Surveyors on 8/15/24 at 10:15 pm, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: The JII was discharged from the facility as of 8/15/24 at 9:05 p.m. The facility's referral team will review all future JII referrals to ensure that the rights can be fully respected if the individual is admitted into the facility's care. The Surveyors verified the removal plan on-site on 8/19/24 and determined the IJ was removed as of 8/15/2024. The Director of Clinical Operations (DCO) provided the Surveyors with multiple facility policies including, titled, RESIDENT RIGHTS, reviewed and revised on 01/2024, indicated under Policy Statement Employees shall treat all residents with kindness, respect, and dignity .1. Federal and state laws guarantee certain and basic rights to all residents of this facility. These rights include resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property and exploitation; d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; e. self-determination; f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights .cc. access to a telephone, mail, and email; dd. Communicate in person and by mail, email, and telephone with privacy The facility policy titled, ABUSE PREVENTION PROGRAM, reviewed and revised on 01/2024, under Policy Statement Our residents have the right to be free from abuse, neglect .This includes but is not limited to freedom from corporal punishment, involuntary seclusion .Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone .3 .implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents . The facility policy titled Dining Room Services, dated 5/2024, under Purpose: The purpose of this policy is to ensure that all residents receive safe, nutritious, and enjoyable dining experiences in a respectful and dignified environment. This policy outlines the standards and procedures for meal service, dietary accommodations, and dining room conduct. Scope: This policy applies to all residents .Accessibility: The dining room should be easily accessible to all residents .Resident Rights Choice and Independence: Residents have the right to make choices about their meals and dining experience .Dignity and Respect: All residents should be treated with dignity and respect during mealtimes . The facility policy titled Activities, reviewed and revised on 3/2024, under Purpose: The purpose of this policy is to ensure that all residents have access to a variety of meaningful, engaging, and age-appropriate activities that promote physical, emotional, and social well-being .Scope: This policy applies to all residents .Resident Rights: Residents have the right to choose which activities they participate in and to decline participation without consequence . The facility also failed to ensure that the facility policies titled RESIDENT RIGHTS, ABUSE PREVENTION PROGRAM Dining Room Services and ''Activities were implemented During an interview with the Surveyors on 8/15/24 at 9:17 a.m., in the presence of the LNHA, Director of Nursing (DON), Assistant DON (ADON), Director of Social Services (DSS), Clinical Director of Operation (CDO), and Assistant Concierge (AC), the LNHA stated that the MCCF Administrator, DON, and Medical Director had an agreement that upon admission, that the JII would have COs that stayed in the room throughout the day, the visits have to be scheduled, and the visitor schedule was to be the same as MCCF schedule. The Administrator explained that the MCCF instructed the facility to have visitors once a day during the week. The receptionist will send the JII visitor upstairs to check in with the COs. The DON stated that anything that was brought to Resident #6's room had to be checked by the COs. The DON also added that the JII had approved leisure activities by the MCCF, the activities had to be given to the COs before giving them to the JII and that the Resident was not allowed to participate in activities outside the room as instructed by the MCCF. During the tour of the unit on 8/15/24, from 11:17 a.m. to 12:30 p.m., the Surveyors observed Resident #6 lying in bed, watching television, with their ankles shackled together, and two Correctional Officers (COs) were sitting inside the room. The Surveyors further observed Resident #6's cell phone was out of reach. During lunch time, the resident was observed sitting on the side of the bed with their ankles shackled. Resident #6's meal was served on a disposable plate with disposable utensils. During the interview with the Surveyors on 8/15/2024, at 11:17 a.m., Resident #6 stated that they were not allowed to go out of their room to attend activities or go to the dining room with other residents. They also stated that the cell phone can only be used after approval from the COs. Resident #6 revealed that they were served with disposable plates and utensils without knife (plastic or silver) to cut the food. Resident #6 explained that they picked up their food and used their hands to break the meat into pieces. The JII voiced that they felt like dirt. During the interview with the Surveyors on 8/15/2024 at 11:48 a.m., COs stated that they were following the Middlesex County Correctional Facility (MCCF) policy for Resident #6. The resident was not allowed to leave their room except for Physical Therapy and Occupational Therapy (PT/OT), showers, and other pre-approved medical necessities. During the interview with the Surveyors on 8/15/2024, at 11:59 a.m. the Licensed Practical Nurse (LPN #1), the assigned nurse for Resident #6 stated that the JII stayed in their room all day except when they received showers and PT/OT. LPN #1 further stated the JII does not go into the main dining area to attend activities and to receive meals. During the interview with the Surveyors on 8/15/2024, at 12:16 p.m., the assigned Certified Nursing Assistant (CNA #1) for Resident #6 stated that the resident was served meals with disposable plates, plastic utensils, and cups. The COs would check Resident #6's tray and remove the knife. The CNA further stated that the resident took showers on scheduled days, and the COs would stay in the shower room during that time. During the interview with the Surveyors on 8/15/2024 at 4:01p.m., the Director of Social Services (DSS) confirmed that Resident #6 was not provided an admission agreement. The DSS further confirmed that Resident #6's resident rights were explained on admission, however, the rights were not being implemented because the facility was following the MCCF protocol for inmates. NJAC 8:39-27.1(a)

Complaint # NJ00176157 Based on observation, interview, review of resident medical records and other pertinent facility documentation it was determined that the facility failed to ensure that 1 of 1 Justice Involved Individual (JII) (Resident #6) was free from involuntary seclusion. The JII was secluded from having autonomy and to make choices to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. The failure to allow JII autonomy posed the likelihood to cause psychological harm which resulted in an Immediate Jeopardy (IJ) situation. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL, documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. The Immediate Jeopardy (IJ) began on 05/21/24, the date that Resident #6 was admitted to the facility and based on staff interviewed noted below, that upon admission has been secluded each day by correction officers (COs) of the Middlesex County Correctional Facility (MCCF). The IJ was identified on 08/15/24, when Resident #6 was observed by the Surveyors being secluded to their room, guarded by COs, and was not permitted to participate in group activities and community dining. Further observation revealed the JII was not allowed to intermingle or communicate with other residents or visitors and were restricted from leaving the room at will. The Surveyors reviewed the following in the Electronic Medical Record (EMR). According to the Admission Record, Resident # 6 was admitted to the facility with diagnoses which included Cerebrovascular disease, Abnormalities of Gait and Mobility. According to the MDS dated [DATE], Resident #6 had a BIMS of 15 and was assessed as having no behaviors and utilized no physical or chemical restraints. A review of the Individualized Care Plans revealed no care plans were initiated for seclusion. Review of the resident's Individualized Care Plans (CP) dated 05/21/24, did not address that the resident required constant supervision from the correction officers (CO) for all aspects of activities of daily living (ADLs). The CP did not address that the resident was not permitted to leave the room unless for showering and Physical and Occupational Therapies (PT/OT) accompanied by the COs. The facility Licensed Nursing Home Administrator (LNHA) was informed on 08/15/24 at 7:51 p.m., that an Immediate Jeopardy situation existed. An acceptable removal plan was electronically mailed to the Surveyors on 8/15/24 at 10:15 pm, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: The JII was discharged from the facility as of 8/15/24 at 9:05 p.m. The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care. The Surveyors verified the removal plan on-site on 8/19/24 and determined the IJ was removed as of 8/15/2024. The Director of Clinical Operations (DCO) provided the Surveyors with multiple facility policies including, the policy dated 01/2024 and titled, Resident Rights indicated that Federal and state laws guarantee certain and basic rights to all residents of this facility. These rights include resident's right to: a. dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property and exploitation; d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; e. self-determination; f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; .t. privacy and confidentiality; .aa. Visit and be visited by others from outside the community; .cc. access to a telephone, mail, and email; dd. Communicate in person and by mail, email, and telephone with privacy. The facility policy dated 3/2024 and titled, Activities indicated that, The purpose of this policy is to ensure that all residents have access to a variety of meaningful, engaging, and age-appropriate activities that promote physical, emotional, and social well-being. This policy outlines the standards and procedures for planning, implementing, and evaluating activity programs. Under the sub-heading Activity Program Development indicated that, Activities should be inclusive, allowing residents of all physical and cognitive abilities to participate. Under the sub-heading Resident Participation indicated that, Residents have the right to choose which activities they participate in and to decline participation without consequence. Their choices should be respected, and alternative options should be offered when possible. The facility also failed to comply with the policies titled Resident Rights, Abuse Prevention Program, Dining Room Services, and ''Activities were implemented. On 8/15/24 at 2:30 p.m., Surveyors interviewed the Administrator and the Director of Nursing (DON), who stated that she and the LNHA had a meeting with the Middlesex County Correctional Facility (MCCF) facility staff (DON, Medical Director, and Administrator) prior to accepting the inmate. They both stated that the MCCF administration staff stated that Resident #6 is under the jurisdiction of MCCF. The LNHA stated that collectively as a team the facility agreed to accept the inmate, and that the facility follows the guidelines of the jail. The DON and LNHA stated that the MCCF administration informed them that Resident #6 is not allowed to participate in activities outside of the room. They further stated that MCCF informed them that Resident #6 also has restricted visits. The visitors are only allowed two days a week. On 08/15/2024 at 11:59 a.m., the Surveyors interviewed Licensed Practical Nurse (LPN#1) who stated that she has worked for the facility for over a year and has been the full-time nurse on day shift for four months. LPN #1 stated that there was only one JII residing on the unit (Resident #6). She stated that there are officers always guarding the resident and that Resident #6 only comes out of their room for showers and PT/OT; and the officers are always with the resident. On 08/15/2024 at 11:17 a.m., the Surveyors interviewed Resident #6, who was observed being guarded by two Correctional Officers (COs) with shackles around both ankles. The COs stepped outside of the room to allow the Surveyors to speak with the resident. Resident #6 stated that officers never step outside the room to allow for privacy. The resident stated that they do not receive privacy when speaking on the phone and when the medical staff are communicating about their medical information. The Surveyors asked if the resident was always shackled. The resident stated that they were either shackled to the bed or just both ankles shackled together. The resident stated that it depends on the CO that is working that shift. Resident #6 also stated that unless they are going to PT/OT or to a shower, they must stay in the room. Resident #6 stated that COs remain at the door when taking a shower. On 08/15/2024 at 11:40 a.m., the Surveyors interviewed the COs that were guarding Resident #6. They stated that the resident is to wear metal ankle restraints, either directly shackled to the bed or the ankles are shackled together. The COs stated that the resident cannot attend facility activities and could not intermingle with other residents. They further stated that the resident could only leave the room with COs for showering or any other reason that was medically necessary. They stated the resident must eat in the room and could not eat in the main dining room with the other residents. The CO stated that visitation of anyone must be approved by MCCF. On 08/15/2024 at 12: 15 p.m., the Surveyors interviewed the Director of Activities (DOA) who stated that based on experience, they would only offer room-based activities. She stated that the resident was not offered to attend any activities out of the room. On 08/15/2024 at 12:16 p.m., the Surveyors interviewed the Certified Nursing Assistant (CNA #1), who stated that all meals were provided in the room, and the resident was never offered to eat in the main dining with the other residents. On 8/19/24 at 9:57a.m., the Surveyors interviewed Activity Aide #1, who stated that every day the activities staff would do morning room visits. She stated that if she offered anything besides coffee, it had to be approved by the COs. She said that if the resident asked for a coloring book or pen, everything had to be approved by the Correction Officers. On 08/15/24 at 4:01p.m., the Surveyors interviewed the Director of Social Services (DSS) who stated that she had been employed by the facility for about five years. She explained during the initial social services visit, that it's her protocol to review Resident's Rights (RR) and the Advanced Directives. She stated that RR are reviewed with all alert and oriented residents. She stated that when the JII was admitted to the facility, she explained to the resident rights and advanced directives. She stated that resident is being secluded, and that the interventions that are put into place by the COs and MCCF and not from the facility. NJAC 8:39-4.1 (a)

Complaint # NJ00176157 Based on observation, interview, review of resident medical records and other pertinent facility documentation it was determined the facility failed to ensure that 1 of 1 Justice Involved Individual (JII) (Resident #6) was free from physical restraints. The failure to treat residents respectfully and in a dignified manner had the likelihood to cause psychological harm, that resulted in an immediate jeopardy (IJ) situation. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL, documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. The Immediate Jeopardy (IJ) began on 05/21/24, the date that Resident #6 was admitted to the facility and based on staff interviewed noted below, that upon admission has been shackled by the ankles each day by correction officers (COs) of the Middlesex County Correctional Facility (MCCF). The IJ was identified on 08/15/24, when Resident #6 was observed by the Surveyors with both ankles shackled and guarded by correction officers (CO). The Surveyors reviewed the following in the Electronic Medical Record (EMR). According to the Admission Record, Resident # 6 was admitted to the facility with diagnoses which included Cerebrovascular disease, Abnormalities of Gait and Mobility. According to the MDS dated [DATE], Resident #6 had a BIMS of 15 and was assessed as having no behaviors and utilized no physical or chemical restraints, however Resident #6 was observed by the Surveyors on 08/15/24 at 11:17 a.m., wearing metal ankle shackles. A review of the Individualized Care Plans revealed no care plans were initiated for restraints. The CP did not address that the resident required constant supervision from the Correction Officers (CO) for all aspects of activities of daily living (ADLs). The CP did not address that the resident was not permitted to leave the room unless for showering and Physical and Occupational Therapies (PT/OT) accompanied by the COs. There were no consents for the use of metal ankle shackles. The facility LNHA was informed on 08/15/24 at 7:51 p.m., that an Immediate Jeopardy situation existed. An acceptable removal plan was electronically mailed to the Surveyors on 8/15/24 at 10:15 pm, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: The JII was discharged from the facility as of 8/15/24 at 9:05 p.m. The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care. The Surveyors verified the removal plan on-site on 8/19/24 and determined the IJ was removed as of 8/15/2024. The Director of Clinical Operations (DCO) provided the Surveyors with multiple facility policies including, the policy dated 01/2024 and titled, Resident Rights indicated that Federal and state laws guarantee certain and basic rights to all residents of this facility. These rights include resident's right to: a. dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property and exploitation; d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; e. self-determination; f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; .t. privacy and confidentiality; .aa. Visit and be visited by others from outside the community; .cc. access to a telephone, mail, and email; dd. Communicate in person and by mail, email, and telephone with privacy. The facility policy dated 02/2024 and titled, Use of Restraints indicated that restraints should only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. 6.) Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms. 9.) Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. specific reason for the restraint; b. how the restraint will be used to benefit the resident's medical symptom; and c. the type of restraint, and period of time for the use of the restraint. The facility also failed to comply with the policies titled Resident Rights, and Physical Restraints were implemented. On 8/15/24 at 2:30 p.m., the Surveyors interviewed the LNHA and the Director of Nursing (DON) who stated that she and the LNHA had meeting with the Middlesex County Correctional Facility staff (DON, Medical Director, and Administrator) prior to accepting the inmate. They both stated that the MCCF administrative staff indicated that Resident #6 is under the jurisdiction of MCCF and the use of restraints have been in use since admission. The Administrator stated that collectively as a team, they agreed to accept the inmate, and will follow the guidelines of the jail. On 08/15/2024 at 11:59 a.m., the Surveyors interviewed Licensed Practical Nurse (LPN#1) who stated that she has worked for the facility for over a year and has been the full-time nurse on day shift for four months. LPN #1 stated that there was only one JII residing on the unit (Resident #6). She stated that there are officers always guarding the resident. She stated that Resident #6 only comes out of the room for shower and PT/OT, and always with the officers. She stated that on the days she works, she sees that the resident is shackled, unless going to PT/OT or going for a shower. On 08/15/2024 at 11:17 a.m., the Surveyors interviewed Resident #6. The resident was observed to have shackles around both ankles. The COs stepped outside of the room to allow surveyors to speak with resident. Resident stated that officers never step outside the room to allow for privacy. The Surveyors asked if resident was always shackled. The resident stated that it depends on the CO, if they are ankles are shackled to the bed or just ankle shackled. On 08/15/2024 at 11:40 a.m., the Surveyors interviewed the COs that were guarding Resident #6. They stated that the JII is to wear the metal ankle restraints. The JII ankle restraints can be directly shackled to the bed or only the ankle restraints. NJAC 8:39-7.3(a)

Complaint # NJ 176157 Based on observation, interviews, and review of pertinent facility documents on 8/15/2024, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to a.) ensure the facility implemented policies and procedures for Resident Rights and Self Determination as well as policies and procedures to prevent physical restraints and seclusion; b.) ensure residents signed an Admission Agreements upon admission to the facility; c.) were afforded the autonomy to participate in group activities, community dining, serving meals in a dignified manner, freely communicate with visitors, and to leave rooms at will; and d.) ensure facility policies for Justice Involved Individual (JII) were in compliance with State and Federal regulations. This deficient practice was identified for 1 of 1 JII reviewed (Resident #6). The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL. Under .Resident Rights SNFs and NFs, as residential environments, must permit residents to have autonomy and choice, to the maximum extent practicable regarding how they wish to live their everyday lives and receive care. Federal statutes and regulations establish an array of individual rights and Page 7- State Survey Agency Directors safeguards. Nursing homes cannot impose conditions or restrictions that undermine resident rights and protections required by federal law. Facilities cannot require prospective residents to give up their rights as a requirement for admission. Resident rights in the nursing home include, but are not limited to the right to: Be free from physical or chemical restraints imposed for discipline or convenience, and not for treatment of a resident's medical condition; 9 Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care [and] interact with members of the community both inside and outside the facility; 10 Personal privacy and confidentiality of his or her personal and clinical records; 11 Immediate access to any resident by the following: subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident; 12 Be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 13 Also, nursing home residents must not only be able to exercise their rights as residents of the facility and as citizens of the United States, but also have the right to be free of interference, coercion, discrimination, or reprisal from the facility in exercising those rights . The Immediate Jeopardy (IJ) began on 05/21/24, the date that Resident #6 was admitted to the facility and based on staff interviewed noted below, that upon admission has been secluded each day by correction officers (COs) of the Middlesex County Correctional Facility (MCCF). The IJ situation was identified on 08/15/24, when Resident #6 was observed by the Surveyors being secluded and shackles on both ankles in the room guarded by Correction Officers (COs), secluded from participating in group activities, community dining, being served meals in a dignified manner, intermingling with other residents, communicating with visitors and leaving the room at will. The Surveyors reviewed the following in the Electronic Medical Record (EMR). According to the Admission Record, Resident #6 was admitted to the facility with diagnoses which included but not limited to Cerebrovascular disease and Abnormalities of Gait and Mobility. The Minimum Data Set (MDS), an assessment tool, dated 05/28/24, indicated that Resident #6 had a Brief Interview for Mental Status (BIMS) of 15 which indicated the Resident was cognitively intact. The MDS also indicated Resident #6 had no behaviors and utilized no physical or chemical restraints. A review of Resident #6's Care Plan (CP), initiated on 5/26/24 and revised on 8/15/2024 revealed My leisure time will be under direct supervision. I may need solo leisure materials. Interventions included but not limited, Recreation Staff will have minimal and supervised interactions with [Resident #6] .Any mail or packages must be handed directly to the [CO] .Recreation Staff, as requested and as approved by the guards, will drop off solo leisure supplies such as deck of playing cards, jigsaw puzzle, word puzzle book, notebook, reading materials, safe writing or coloring implements, etc. Upon request and approval of CO .We are not permitted to give [Resident #6] any electronics. Any and all items must be handed to the CO on duty. We are not permitted to provide shopping service for [Resident #6]. We are not able to provide salon services for [Resident #6]; without the approval of the correctional institution's warden and JII's ability to fund the service. A review of the Resident's Physician's orders did not reveal any orders for restraints. The orders did reveal a dietary order specifying that only plastic spoons are to be on the tray. The facility Licensed Nursing Home Administrator (LNHA) was informed on 08/15/24 at 7:51 p.m., that an Immediate Jeopardy situation existed. An acceptable removal plan was electronically mailed to the Surveyors on 8/15/24 at 10:15 p.m., indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: The JII was discharged from the facility as of 8/15/24 at 9:05 p.m. The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care. The facility will review, and update policies annually and as needed. The Surveyors verified the removal plan on-site on 8/19/24 and determined the IJ was removed as of 8/15/24. On 08/15/24, the Director of Clinical Operations (DCO) provided the surveyors with multiple facility policies including Dining Room Services and Activities. The Dining Room Services policy with a revised date of 3/ 2024, included under the purpose section, The purpose of this policy is to ensure that all residents receive safe, nutritious, and enjoyable dining experiences in a respectful and dignified environment. The facility policy dated 3/2024 titled Activities indicated that, The purpose of this policy is to ensure that all residents have access to a variety of meaningful, engaging, and age-appropriate activities that promote physical, emotional, and social well-being. This policy outlines the standards and procedures for planning, implementing, and evaluating activity programs. Under the sub-heading Activity Program Development indicated that, Activities should be inclusive, allowing residents of all physical and cognitive abilities to participate. Under the sub-heading Resident Participation indicated that, Residents have the right to choose which activities they participate in and to decline participation without consequence. Their choices should be respected, and alternative options should be offered when possible. A review of the facility policy titled Care Plans, Comprehensive, Person-Centered with a review date of 1/2024 revealed under, Policy Statement that, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs developed and implemented for each resident. A review of the undated facility's Job Description for Administrator document revealed that the duties of the Administrator included but not limited to: - Develop, maintain, and implement operational policies and procedures to meet residents' needs in compliance with federal, state, and local requirements. - Determine the personnel requirements of the facility and hire or arrange for sufficient staff to implement the facility policies and procedures. - Develop a monitoring system to assure compliance with federal, state, and local requirements. On 8/15/24 at 2:30 p.m., the Surveyors interviewed the LNHA and the Director of Nursing (DON) who stated that she and the LNHA had meeting with the Middlesex County Correctional Facility Administrative staff (DON, Medical Director, and Administrator) prior to accepting the inmate. They both stated that the MCCF Administrative staff indicated that Resident #6 is under the jurisdiction of MCCF and the use of restraints have been in use since admission. The Administrator stated that collectively as a team, they agreed to accept the inmate, and will follow the guidelines of the jail. On 08/15/2024 at 11:59 a.m., the Surveyors interviewed Licensed Practical Nurse (LPN#1) who stated that she has worked for the facility for over a year and has been the full-time nurse on day shift for four months. LPN #1 stated that there was only one JII residing on the unit (Resident #6). She stated that there are officers always guarding the resident. She stated that Resident #6 only comes out of the room for shower and PT/OT, and the officers are always present. On 08/15/2024 at 11:17 a.m., the Surveyors interviewed Resident #6, who was observed to be guarded by Correctional Officers (COs), and the resident's ankles were both shackled together. The COs stepped outside of the room to allow the Surveyors to speak with resident. Resident #6 stated that officers never step outside the room to allow for privacy. Resident #6 stated there is no privacy is permitted when speaking on the phone and when the medical staff are communicating medical information with the resident. The Surveyors asked if resident was always shackled and the resident stated that both ankles are shackled both together or attached to the bed. The resident stated that they only leave the room for Physical Therapy and Occupational Therapy ( PT /OT) and showers, and the COs are always present. On 08/15/2024 at 11:40 a.m., the Surveyors interviewed the Correctional Officers ( COs). The COs stated that the resident is to wear metal ankle restraints, either directly shackled to the bed or the ankles are to be shackled together. The COs stated that the resident cannot attend facility activities and could not intermingle with other residents, and that the resident could only leave the room for showers or any other reason that was medically necessary. The COs stated that Resident #6, could only eat in the room and not in the main dining room with the other residents. The COs stated that visitation of anyone must be approved by MCCF. On 08/15/2024 at 12:15 p.m., the Surveyors interviewed the Director of Activities (DOA) who stated that based on experience, they would only offer room-based activities. She stated that the resident was not offered to attend any activities outside of the room. On 08/15/24 at 4:01 p.m., the Surveyors interviewed the Director of Social Services (DSS), who stated that she had been employed by the facility for about five years. She explained that, during the initial Social Services visit on admission, that it's her protocol to review Resident's Rights (RR) and the Advanced Directives. She stated that RR are reviewed with all alert and oriented residents. She stated that when the JII was admitted to the facility, she explained to the Resident Rights and Advanced Directives. She stated that Resident #6 is being secluded and that the interventions that are put into place by the COs and MCCF and not from the facility. NJAC 8:39-4.1 NJAC 8:39-4.1 (6) NJAC 8:39-4.1 (a), 11 NJAC 8:39-7.3(a) NJAC 8:39-9.2(a) NJAC 8:39-27.1(a)

COMPLAINT: # NJ 7 Based on observations, interviews, Medical Record (MR) review, and review of other pertinent facility documentation on 01/08/21 and 1/13/21, it was determined that the facility failed to supervise, monitor and ensure the safety of a resident who had a history of wandering and exit seeking and had a physician order Resident is not allowed out on pass. On 12/19/20, Resident #3 was able to independently exit the facility unattended, without the staff's knowledge, and wandered off the facility grounds to a main road. While crossing the main road the resident was struck by an automobile and subsequently sustained multiple injuries including a fracture and was transported to the hospital for medical treatment of the injuries. The facility was unaware of the whereabouts of the resident until informed by the resident's sister that he/she was taken to the hospital with injuries. The facility staff also failed to follow their policies titled: Wandering/Elopement Policy, and Out on Pass Unaccompanied, for 1 of 4 residents (Resident #3) sampled. This deficient practice placed Resident #3 and all other residents who were at risk, who had a known history of wandering and/or exit seeking behavior, in an Immediate Jeopardy (IJ) situation. The IJ was identified on 01/08/21 at 5:26 p.m., when the Director of Nursing (DON) was notified of the IJ situation, which ran from 12/19/20 until 01/08/21 at 7:15 p.m., when the facility provided an acceptable Removal Plan to remove the Immediacy. This deficient practice was further evidenced by the following: 1. According to the Admission Record (AR), Resident #3 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: [CONDITION(S)], Lyme's Disease, Unspecified [CONDITION(S)] due to a Substance or Known Physiological Condition, [CONDITION(S)], Anxiety Disorder, [CONDITION(S)], and Traumatic [CONDITION(S)]. Review of the Minimum Data Set (MDS), an assessment tool dated 12/25/20, revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated that Resident #3 was cognitively intact. The MDS also indicated Resident #3 was independent for Activities of Daily Living (ADLs). Review of the Care Plan (CP) with an initiated date of 6/22/20, revealed Resident #3 had a Focus of: ADL self-care performance deficit related to impaired dynamic standing balance, impaired coordination and impaired problem solving. The CP also revealed a Focus of: wandering aimlessly, and significantly intrudes on others, takes personal property and makes inappropriate comments towards peers and staff, with an initiated date of 7/18/20. Interventions included; distract and redirect the resident from wandering by offering diversions The CP also revealed a Focus of: physical and aggressive behavior with poor impulse control and severe paranoia which was initiated on 7/29/20. Review of the facility document titled Wandering Risk Scale dated 10/5/20, revealed Resident #3 scored 9 of 23 possible points, which indicated that the resident was at risk to wander related to being ambulatory, medical diagnosis of dementia/cognitive impairment: diagnosis impacting gait/mobility or strength. During an observation, while on the elevator on 1/8/21 at 10:15 a.m., Resident #3 was observed in a wheelchair with the left leg elevated and a leg brace in place. The resident stated that he/she was hit by a car appropriately 3 weeks ago while walking to the store to get cigarettes. During an interview on 1/8/21 at 10:17 a.m., Resident #3 reported that on 12/19/20, during the daytime, he left the facility and was struck by an automobile. I was supposed to stay on the premises, but I left The light changed and one guy stopped in the first lane, the second lane the light changed to green and the women did not stop, and I got hit. It was my fault I was not supposed to leave here. In addition, Resident #3 stated that he did not inform anyone he was leaving the grounds. Review of Resident #3's MR revealed a progress note written on 12/19/20 at 2:25 p.m., by the Registered Nurse (RN), stating she received a call from the resident's sister who reported that the resident was at the hospital for an evaluation and treatment after a fall outside of the facility. Review of the MR revealed a progress note written on 12/19/20 at 8:25 p.m., by the Licensed Practical Nurse (LPN), reporting that Resident #3 returned from the hospital with a fractured wrist and sprained left ankle. Review of the Physician Orders verified that Resident #3's Physician wrote an order; Resident is not allowed out on pass. Resident may not sign himself in or out of (facility name), dated 9/17/20, and again on 10/12/20. The CP did not include this. During an interview on 01/08/21 at 10:30 a.m., the 3rd floor Unit Manager (UM) reported that Resident #3 was ambulatory and left the faciity on [DATE], and was hit by a car while walking across a main road and sustained multiple fractures. During an interview on 1/8/21 at 3:02 p.m., the 3rd floor UM reported that the physician put an order in place that Resident #3 could not go out on pass because he's/she's not safe to go out due to behaviors, aggressive behaviors. The UM also stated that the resident continued to go out unaccompanied because the Administrator (Admin) had informed the staff that since the resident is alert and oriented times 3 (to person, place and time) the staff could not impinge on the residents right to go out/leave. The UM stated that the physician was never notified that Resident #3 continued to go out despite his order. In addition, the UM stated that Resident #3 would go out to the smoking area and leave through an unlocked gate and the resident had done this several times. He/she would just leave so we weren't aware he/she left. The Smoke Monitor (SM) would not report it and never called the nursing staff to let us know the resident left. When the UM was asked if she ever spoke to the SM about notifying the staff that the resident left the grounds the UM stated: He knows that it's on the policy. Review of the facility document titled: Smoking Agreement, verified that Resident #3 signed a smoking contract on 7/23/20, that he/she was educated on the smoking regulations of the facility and failure to comply with these rules and regulations will result in the potential for loss of privilege to smoke, up to and including receipt of a 30 day discharge notice. Review of the MR failed to show any evidence to address a behavior plan and/or contract regarding Resident #3 leaving the facility against medical advice (AMA) and the facility staff was unable to provide one. Review of the Sign Out sheet located at the front receptionist desk verified that the Resident #3 signed out of the facility on the following dates: 9/16/20, 9/17/20, (twice) and once in October (undated) and again on 11/13/20. The Sign Out sheet did not show a signature/signed out for 12/19/20. During an interview on 1/8/21 at 12:10 p.m., the Social Worker (SW) reported that the procedure for a resident to go out on pass is determined by the team. They review the resident's cognitive and physical ability and the ability to use a cell phone. However, the SW was unable to provide any documentation or progress note to verify that the team did in fact meet to review Resident #3's ability to leave the facility unaccompanied. During an interview on 1/8/21 at 12:27 p.m., the DON stated that the IDT (Interdisciplinary) team needs to meet to determine if a resident is safe to go out on pass. Behavior, cognition and physical ability are all reviewed to determine if the resident is safe to go out on pass. We review everything before they can go out unaccompanied. The DON also stated that a physician order is needed for a resident to go out on pass. However, the DON was unable to verify if the IDT team did in fact meet to determine if Resident #3 was safe to go out on pass. During an interview on 1/8/21 at 4:10 p.m., the DON reported that she was aware there was a physician order in place that Resident #3 could not go out on pass but the order was not followed by the nursing staff because he/she doesn't listen, we can't keep him/her here. He/she gets violent and acts out. The DON also stated that Resident #3 was unsafe to himself and towards others due to his/her aggressive behaviors. Review of the facility document titled 30-Day Notice of Intent to Discharge/Transfer Resident, undated, revealed documentation by the staff that Resident #3 was to be discharged to another facility on 10/30/20, for the following reason: The move is necessary for your own welfare and your needs cannot be met within the nursing facility. and The safety and health of the individuals in the nursing facility would otherwise be endangered due to the clinical or behavioral status of the resident. During an interview on 1/8/21 at 1:24 p.m., the Admin stated that Resident #3 was given a 30 day notice/letter in October due to the drug use and his/her behaviors. However, the resident refused to sign the notice and the family rejected the move due to the distance to travel. The Admin further stated that 20 to 30 other facilities denied him/her. During an interview on 01/08/21 at 1:24 p.m., the Admin reported that Resident #3's physician put an order in place that the resident was not allowed out on pass because of outburst and behaviors which required sending him/her to crisis several times. The Admin also stated that they were not aware that Resident #3 was out of the building on 12/19/20, until the resident's sister called and reported that he/she was in an accident. According to the Admin he spoke several times to Resident #3 that the physician had an order in place that the resident was not to go out on pass, but the Admin could not provide documentation that the resident signed that he/she was informed. During an interview on 1/8/21 at 4:10 p.m., Resident #3 reported continuous pain in the left leg after the accident, my leg hurts all the time. The pain is 10/10 all the time. It never stops hurting, even after the pain medication. It's like taking a baby aspirin. No relief. Resident #3 also stated that he/she can not leave now since confined to a wheelchair. During an interview on 01/13/21 at 12:10 p.m., the Security/Smoke monitor (SM) reported that he saw Resident #3 leaving the smoking area on 12/19/20, by exiting the gate and informed the resident, that he/she was not supposed to leave the premises and it was not safe because there was ice on the ground. According to the SM the resident responded I can do whatever the (expletive) I want to do, and he/she continued out the gate. The SM stated that he did not report to anyone that Resident #3 left the facility grounds until about 15 minutes later when he went up to the third floor and informed a nurse at the desk that the resident had left, and stated that the nurse was the only one he informed. Review of the document titled New Jersey Police Crash Investigation Report, provided to the surveyor by the facility staff, listed the date of the accident as 12/19/20 at 1:43 p.m. Under Crash Description/Narrative: Driver of Vehicle #1 stated she was driving eastbound and had a green light. As she passed the intersection the pedestrian stepped off the curb into traffic. She attempted to stop but could not stop in time and struck the pedestrian. Minor damage to her front license plate and bracket of the car. The pedestrian (Resident #3) stated he/she was waiting to cross the street and thought the light had turned red and stepped off the curb into the traffic when he/she was struck by Vehicle #1. The pedestrian (Resident #3) stated it was his/her fault because the light was green and he/she thought it was red. Pedestrian complained of a possible broken left ankle. In addition, the Officer documented that there was no crosswalk where the pedestrian entered into traffic. A review of the facility's policy titled Wandering/Elopement Policy dated 9/18/2019, included the following under Policy; It is the objective of this facility to ensure the safety and protection of wandering residents by preventing their exit from the building. Under Policy Interpretation and Implementation, section 7. After locating the resident, an incident report must be completed and document incident in the nurse's notes. 7c. An appropriate Care Plan will be developed to prevent a reoccurrence of elopement. A review of the facility's policy titled Out on Pass Unaccompanied. dated 9/2020, included the following under Policy; It is the mission of (facility name) to maintain our residents' highest practicable level of independence, resident rights and safety with regards to leaving the facility unaccompanied. Under Purpose To facilitate residents' safety and respect for resident's rights. Under Procedure; Unless otherwise specified by a physician, a competent resident may exercise his or her right to leave the facility unaccompanied by staff This deficient practice placed Resident #3 and all other residents who were at risk, who had a known history of wandering and/or exit seeking behavior, in an Immediate Jeopardy (IJ) situation. The IJ was identified on 01/08/21 at 5:26 p.m., when the Director of Nursing was notified of the IJ situation, which ran from 12/19/20 until 01/08/21 at 7:15 p.m., when the facility provided an acceptable Removal Plan to remove the Immediacy, which included safety checks on Resident #3 every 15 minute, no out on pass, unescorted, and staff education on identifying elopement and wandering behaviors. The Removal Plan was verified on 1/13/21, the second day of the survey. N.A.C.P. 8:39-33.1(d)