Every finding on record at Atlas Healthcare at Seashore Gardens

Complaint #: 2710717, 2791836 Based on interviews, medical record reviews, and review of other pertinent facility documentation it was determined that the facility failed to update the care plan (CP) with interventions for a resident (Resident #2) who's family expressed preferences related to incontinence care. This deficient practice was identified in 1 of 5 residents reviewed for care plans and was evidenced by the following:According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses including but not limited to benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostrate that is not obstructing the urethra or irritating the bladder); muscle weakness; and cognitive communication deficit (communication difficulty caused by disrupted brain function). According to the Comprehensive Minimum Data Set (MDS), an assessment tool dated 01/29/2026, Resident #2 had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident's cognition was impaired. Further review of the MDS revealed that Resident #2 was frequently incontinent of urine and frequently incontinent of bowel. A facility GRIEVANCE/CONCERN FORM dated 02/06/2026, with DATE OF OCCURENCE 2/5/2026 and Resident #2's name and room number at the top was reviewed. The description of the concern revealed Residents [sic] family report resident is being placed in briefs. Further review of the facility form revealed under RESOLUTION/ACTION TAKEN TO RESOLVE GRIEVANCE/COMPLAINT: the facility form revealed that Resident #2's family was informed that the resident's MDS indicated that the resident was incontinent. The family was understanding but requested that Resident #2 only be placed in incontinent briefs at night. This section of the facility form further revealed Resident #2's CP was updated to reflect the use of briefs at night. A review of Resident #2's CP revealed no focus, goal, or interventions related to the family's preference that the resident wear briefs only at night. An interview was conducted with the Director of Nursing (DON) on 06/12/2026 at 4:03 PM. The DON stated that the purpose of CPs was for nurses and Certified Nursing Assistants to know the individual care needs of residents. The DON stated that CPs should be updated to reflect changes in residents' needs. The CP for Resident #2 was reviewed with the DON. The DON stated that Resident #2's CP should have been updated to reflect the family's preference for the use of briefs only at night, but it was not. The facility Comprehensive Care Plans policy with an implementation date of 04/01/2026 and a reviewed/revised date of 04/01/2026 was reviewed. Under Policy the policy revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under Policy Explanation and Compliance Guidelines: the facility policy revealed 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. This section of the facility policy further revealed 3. The comprehensive care plan will describe, at a minimum, the following: [.] f. Resident specific interventions that reflect the resident's needs and preferences. NJAC 8:39-11.2 (e) (1) (2)

Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's reach in refrigerator, ice machine, ice scoop holder, shelves, floor fan, rack, and the microwave ovens located in the pantry and snack rooms clean and sanitized. Additionally, the facility failed to ensure kitchen food preparation pans were dry when stored and failed to keep stored foods closed in the kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 139 residents who consumed food prepared from the facility's kitchen.Findings include: Review of the facility's policy titled, Sanitation dated 11/22 indicated, Policy Statement The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. All kitchens, kitchen area and dining areas shall be kept clean . 2. All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning . 7. Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical .10. Ice machines and ice storage containers are drained, cleaned, and sanitized per manufacturer's instructions . Review of the facility's policy titled, Food Receiving and Storage dated 11/22 indicated, Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices . Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated . 1. Observation during the initial kitchen inspection on 07/21/25 from 9:20 AM to 10:00 AM, with the Dietary Manager (DM) present, revealed the following unclean and wet food preparation and storage equipment: a. One of the kitchen's reach-in refrigerators was unclean with a black moldlike substance in its interior storage compartment that could be wiped away with a paper towel. b. The interior of the kitchen's ice scoop holder, which was stored on top of the ice machine with the scoop stored inside, was unclean with a black moldlike substance that could be wiped away with a paper towel. c. The kitchen's ice machine was unclean with a black moldlike substance on the machine's inner metal rim that could be wiped away with a paper towel. d. Two metal shelves under the kitchen's grill were rusted and unclean with a greasy residue that could be wiped away with a paper towel. e. A large floor fan that was operating in a food preparation area was unclean with heavy accumulation of black dust on the fan's grill and three fan blades. The unclean fan was positioned approximately six feet away from where a dietary employee was slicing meat on the kitchen's electric slicer and the fan was blowing air directly at the employee and the slicer. f. Five food preparation pans, which were ready for use, were stacked directly on top of each other and were stored wet. g. One of the kitchen's metal can storage rack was unclean with a dried brown and sticky substance on four of the metal racks where cans of food were stored in direct contact with the substance. During an interview with the DM, during the initial kitchen inspection on 07/21/25 from 9:20 AM to 10:00 AM, the DM confirmed the kitchen's reach in refrigerator, ice machine, ice scoop holder, two metal shelves, large floor fan and can storage rack were unclean and the five food preparation pans were stored stack together with moisture on them. The DM stated dietary staff were expected to follow the kitchen's cleaning schedule and keep all kitchen equipment clean, and to not stack pans together until they were dry. 2. Observation on 07/21/25 at 9:50 AM of food stored in a kitchen reach in refrigerator, during the initial kitchen inspection, revealed three bags of onion rings and one bag or French fries that were not closed. During an interview on 07/21/25 at 9:50 AM the DM confirmed the stored three bags onion rings, and one bag of French fries was not closed. The DM stated staff were expected to close food bags completely when stored. 3. Observation on 07/23/25 of the facility's unit pantries and snack rooms, for resident use, revealed the following: a. Observation on 07/23/25 at 8:50 AM of the facility's 200 hallway snack room revealed the microwave in this room was unclean with accumulated dried food substances and splatters in its inner cooking compartment. The DM and Registered Dietitian (RD)1 also viewed this microwave and confirmed that it was unclean. b. Observation on 07/23/25 at 9:00 AM of the facility's 200 hallway pantry revealed the microwave in this room was unclean with accumulated dried food substances and splatters in its inner cooking compartment. The DM and RD1 also viewed this microwave and confirmed that it was unclean. c. Observation on 07/23/25 at 9:10 AM of the facility's 100 hallway snack room revealed the microwave in this room was unclean with accumulated dried food substances and splatters in its inner cooking compartment. The DM and RD1 also viewed this microwave and confirmed that it was unclean. During an interview on 07/23/25 at 9:10 AM, the DM stated the kitchen staff were responsible for cleaning the microwave ovens in the facility's snack rooms and pantries. The DM explained the kitchen staff were expected to clean these microwave ovens first thing in the morning and when needed. NJAC 8:39-17.2(g)NJAC 8:39-19.7(d)

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 102) reviewed for choices and food preferences were honored, Specifically, 27 out of 28 residents residing in the secure dementia unit were not offered choices of food, beverages, and condiments at meals. This failure could lead to dissatisfaction with meals, weight loss, or malnutrition.Findings include:Review of R102's admission Record located under the Profile tab in his electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia, mood disorder, chronic kidney disease, and anemia.Review of R102's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of one out of 15 which indicated R102 had severely impaired cognition. The resident did not exhibit any mood or behavioral problems. The resident received a mechanically altered, therapeutic diet.During an interview on 07/21/25 at 11:54 AM, R102's Family Member (F1) stated the residents on the secure dementia unit were not offered choices of food or beverages at meals. F1 stated she provided information on the resident likes and dislikes, but added, I know they give him/her things he/she doesn't like, like today's tuna casserole. He/she doesn't like fish. I told them that. Review of R102's Care Plan dated 02/11/25 and located under the Care Plan tab of the EMR revealed, [R102] is at risk for malnutrition r/t [related to] Hx [history of] significant weight change, inadequate caloric intake with need of supplementation, need of therapeutic/mechanically altered diet, [and] PMHx: [past medical history of] Afib [atrial fibrillation], CKD [chronic kidney disease], Anemia, Dementia, HTN [hypertension], [and] HLD [high cholesterol]. The approaches included, Encourage H2O [water] intake at and between meals for hydration . [and] Honor food and fluid preferences to optimize PO [oral] intake, update PRN [as needed]. -Dislikes: fish, mushrooms.Review of R102's Dietary Assessment and Documentation dated 11/03/24 and located under the Assessments tab of the EMR revealed, Food preferences were reviewed and updated with the kitchen. Dislikes fish, mushrooms. Review of R102's meal tray card provided on paper from the kitchen revealed the dislikes of fish and mushrooms were included on the card. During observation of lunch in the secure dementia unit on 07/21/25 beginning at 11:58 AM, all residents but one (who received a grilled cheese sandwich) were served tuna casserole, tater tots, and green beans. There were no condiments, such as salt, pepper, or ketchup, available or offered to the residents. All residents received a glass of lemonade; there were no other beverages available or offered, though one resident requested and received a cup of coffee. No water was served with the meal. R102 was served tuna casserole, tater tots, green beans, and a glass of lemonade. The resident did not receive water with their meal as directed on the Care Plan. The resident was observed to only eat bites of their meal while being assisted by F1.During observation of lunch in the secure dementia unit on 07/24/25 beginning at 11:50 AM, all residents but one (who received a veggie burger) were served pasta and sauce, meatballs, and spinach. All residents were served a glass of strawberry-kiwi juice, there were no other beverages available or offered. Additionally, no condiments were available or offered. During an interview on 07/24/25 at 11:57 AM, Certified Nure Aide (CNA) 2 stated the kitchen typically sent one type of juice with each meal. She stated the residents were only given the juice that was sent, they were not offered a choice of beverage. During an interview on 07/24/25 at 12:04 PM, CNA7 stated the kitchen typically sent the main meal for all residents; their orders were not taken, and they were not offered choices at meals.During an interview on 07/24/25 at 12:05 PM, CNA1 stated all residents were served the main meal; however, they could ask for something different and it would be requested from the kitchen.During an interview on 07/24/25 at 1:26 PM, the Dietary Manager (DM) stated that since the residents in the secure dementia unit were cognitively impaired, the weekly menus were left out at the front desk for the family members to fill out with resident preferences. She stated there was no system in place to offer residents a choice of meals unless the family members were in the facility to fill out the menus each week. The DM stated residents' likes and dislikes were assessed upon admission, and the kitchen should serve something different if a food is listed as a dislike. The DM stated R102 did not like fish, so he/she should have received a substitute for the tuna casserole. The DM explained that in the facility's main dining room, there was a menu provided, and servers assisted the residents to choose their preferences at the beginning of each meal. The DM stated the staff should be offering a choice of beverages. She stated in the main dining room, different types of juice, different types of soda, water, coffee, tea, hot chocolate, and milk were offered.Review of the facility's policy titled, Food and Nutrition Services, dated October 2017 revealed, The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits . Reasonable efforts will be made to accommodate resident choices and preferences. NJAC 8:39-4.1(a)

Based on interviews, record review, document review and policy review, the facility failed to ensure concerns regarding food temperatures voiced by eight of eight residents who participated in the Resident Council meeting (R19, R34, R43, R89, R92, R105, R129, and R143) in a total sample of 36 residents were acted upon in a timely manner in an attempt to resolve the group's concerns. This failure had the potential to lead to resident dissatisfaction with the facility's Resident Council and grievance resolution processes.Findings include:Review of the facility's April 2024 through June 2025 Resident Council meeting minutes provided on paper revealed ongoing grievances regarding palatable food temperatures:June 2024: Residents stated the food/waffles are cold. There was no follow up to this concern documented in the June 2024 or July 2024 meeting minutes/resolutions.September 2024: The food could be a lot warmer. The response, Temp [temperature] logs checked.November 2024: Residents expressed food is cold when it is provided to them. The resolution was, In the process of ordering new pellet plates to help keep food warm.December 2024: Expressed irregular food temperatures when the trays are delivered. Some residents' food will be cold, and others will be warm. It was also stated that sometimes the food has to be sent back because of how cold it is and that the plate is cold to touch which caused to [sic]temperatures of the food to drop. The resolution, Manager will reeducated [sic] regarding placing food on cold plates.March 2025: Resident report food temperatures have been better, some who eat in their rooms state can still be cold at times. The resolution, Will continue to monitor temperature of the food.April 2025: Coffee is not always hot when given to them. The resolution, Will continue to monitor the temperature of the food/coffee.June 2025: Grill [sic] Cheese not hot enough. French toast not hot enough. The resolution, [Dietary Manager] will make sure those items are wrapped properly so they stay hot until tray gets to residents.During a group interview with eight members (Resident (R)19, R34, R43, R89, R92, R105, R129, R143) of the Resident Council on 07/23/25 at 11:28 AM revealed all eight residents agreed the food was served cold at most meals, especially if you had to wait for a room tray. All residents agreed the food temperatures had not improved. R129 stated, If it were hot, it would be good. R89 stated he/she would like the food hotter, and this was a complaint that had come repeatedly in Resident Council minutes. All residents agreed they did not know what the facility was doing to improve the service temperatures of the food. Review of R19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/25 and located under the MDS tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] and the Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. Review of R34's annual MDS with an ARD of 06/27/25 revealed he/she was admitted to the facility on [DATE] and the BIMS score was 14 out of 15 indicating intact cognition. Review of R43's quarterly MDS with an ARD of 05/07/25 revealed he/she was admitted to the facility on [DATE] and the BIMS score indicating intact cognition. Review of R89's quarterly MDS with an ARD of o4/29/25, revealed he/she was admitted to the facility on [DATE] and score 15 out of 15 on the BIMS score was 15 out of 15 indicating intact cognition. Review of R92's annual MDS with an ARD of 06/20/25 revealed he/she was admitted to the facility on [DATE] and the BIMS score of 12 out of 15 indicating moderately impaired cognition. Review of R105's quarterly MDS with an ARD of 07/10/25 revealed he/she was admitted to the facility on [DATE] and the BIMS score of nine out of 15 indicating moderately impaired cognition. Review of R129's quarterly MDS, with an ARD of 06/13/25 revealed he/she was admitted to the facility on [DATE] and the BIMS score of 15 out of 15 indicating intact cognition. Review of R143's annual MDS, with an ARD of 06/26/25 revealed he/she was admitted to the facility on [DATE] and the BIMS score of eight out of 15 indicating moderately impaired cognition.During the survey, the last resident breakfast tray was observed to be served on the 200 hallway on 07/23/25 at 8:24 AM. At this time, the food and beverages on the test tray were sampled in the presence of the Dietary Manager (DM) and Registered Dietitian (RD)1. The coffee, which was served from a carafe that was on the delivery cart, registered 119.8 degrees Fahrenheit and tasted barely warm. The DM and RD1 also tasted the coffee and confirmed the coffee was barely warm and needed to be hotter. (Refer to F804: Food Palatability). On 07/24/25, the facility provided an undated summary of efforts to address the residents' complaints of cold food on paper. The summary documented temperature audits were completed (on 04/15/25 - three temperatures were documented; on 05/05/25 - three temperatures were documented; on 05/19/25 - two temperatures were documented; on 06/02/25 - three temps documented; and on 06/09/25 - two temperatures were documented). Also, on 07/03/25, new coffee pots had been ordered and on 07/14/25, new insulated carts had been ordered. During an interview on 07/24/25 at 1:26 PM, the DM stated she was aware of residents' concerns regarding cold food and had been auding the temperature of the foods on the tray line prior to service. She stated audits of the temperature at the point of service on a test tray were not done frequently and had probably last been completed a few months ago. The DM stated there were no systemic changes made to address the repeated concerns until new coffee pots and insulated carts were ordered in July 2025. Review of the policy titled, Resident Council dated February 2021 revealed, The purpose of the resident council is to provide a forum form . discussion of concerns and suggestions for improvement. A Resident Council Response Form will be utilized to track issues and their resolution. Review of the policy titled, Resident and Family Grievances dated February 2021 revealed, The facility will make prompt efforts to resolve grievances. NJAC 8:39-4.1(a)NJAC 8:39-13.2(c)

Based on observation, interview, record review, document review, and facility policy review, the facility failed to serve food that was palatable and hot to three (Resident (R) 85, R158, and R159) of four residents reviewed for food palatability and eight of eight residents who participated in the Group meeting (R19, R34, R43, R89, R92, R105, R129, and R143) in a total sample of 36 residents.Findings include: Review of the facility's policy titled Food and Nutrition Services dated 10/17 indicated, Policy Statement, each resident is provided with a nourishing. Palatable, well-balanced diet that meets his or her daily nutritional and special dietary need, food likes, dislike, eating habit, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 1. Review of R85's electronic medical record (EMR) revealed an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/25 located under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident was cognitively intact. During an interview on 07/21/25 at 2:02 PM, R85 stated she ate her meals in her room and the food served at meals was warm and she would like her food to be hotter. R85 specified that the breakfast meal was the most problematic. During an interview on 07/22/25 at 3:24 PM, R85 stated her eggs and oatmeal were cold when served at breakfast this morning. 2. Review of R158's EMR revealed an admission MDS with an ARD of 07/24/25 located under the MDS tab indicated a BIMS score of 15 of 15, which indicated the resident was cognitively intact. During an interview on 07/21/2025 1:48 PM, R158 stated she ate her meals in her room and at the breakfast the coffee, eggs, and oatmeal were cold when served. During an interview on 07/23/25 at 8:15 AM, R158 stated the coffee served with her breakfast meal was only warm and she would like it to be served hotter. R158 stated she was not served eggs with her breakfast on this date. 3. Review of R159's EMR revealed an admission MDS with an ARD of 07/25/25 located under the MDS tab indicated a BIMS score of 13 of 15, which indicated the resident was cognitively intact. During an interview on 07/21/2025 at 1:15 PM, R159 stated he ate meals in his room and the food he received at meals was cold and bland. 4. Review of the monthly Resident Council meeting minutes dated 06/25, 03/25, 12/24, 11/24, and 06/24, provided by the facility, revealed residents voiced a concern regarding food being served cold at meals. 5. A group meeting on 07/23/25 at 11:30 AM, revealed that eight of eight residents (R19, R34, R43, R89, R92, R105, R129, and R143) voiced concerns regarding the food they were served at meals that was not always hot. During a group meeting all eight residents agreed the food was served cold at most meals, especially if you had to wait for a room tray. All residents agreed the food temperatures had not improved. R129 stated, If it were hot, it would be good. R89 stated she would like the food hotter, and this was a complaint that had come repeatedly in Resident Council minutes. All residents agreed they did not know what the facility was doing to improve the service temperatures of the food. Review of R19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/25 and located under the MDS tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and the Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. Review of R34's annual MDS with an ARD of 06/27/25 revealed he was admitted to the facility on [DATE] and the BIMS score was 14 out of 15 indicating intact cognition. Review of R43's quarterly MDS with an ARD of 05/07/25 revealed she was admitted to the facility on [DATE] and the BIMS score indicating intact cognition. Review of R89's quarterly MDS with an ARD of o4/29/25, revealed she was admitted to the facility on [DATE] and score 15 out of 15 on the BIMS score was 15 out of 15 indicating intact cognition. Review of R92's annual MDS with an ARD of 06/20/25 revealed she was admitted to the facility on [DATE] and the BIMS score of 12 out of 15 indicating moderately impaired cognition. Review of R105's quarterly MDS with an ARD of 07/10/25 revealed she was admitted to the facility on [DATE] and the BIMS score of nine out of 15 indicating moderately impaired cognition. Review of R129's quarterly MDS with an ARD of 06/13/25 revealed she was admitted to the facility on [DATE] and the BIMS score of 15 out of 15 indicating intact cognition. Review of R143's annual MDS with an ARD of 06/26/25 revealed she was admitted to the facility on [DATE] and the BIMS score of eight out of 15 indicating moderately impaired cognition. 6. In response to resident complaints about food, a test tray was requested to be sent to the facility's 200 hallway during the breakfast meal on 07/23/25. Observation revealed before the meal tray cart, which contained the test tray, left the kitchen at 8:00 AM, resident meals were observed being served in unheated bowls and food temperatures were at acceptable levels of 140 degrees Fahrenheit (F) and above on the kitchen tray line. The test tray and other resident meal trays were placed on an open and uncovered tray cart that had no heating element and were delivered to the 200 hallway at 8:02 AM. The last resident breakfast tray was observed to be served on the 200 hallway on 07/23/25 at 8:24 AM. At this time, the food and beverages on the test tray were sampled in the presence of the Dietary Manager (DM) and Registered Dietitian (RD)1. The DM utilized a calibrated facility thermometer to obtain temperatures of the food and beverages served on the test tray. The DM and RD1 also tasted the food served on the requested test tray. Temperature checks and tasting of the food served on the test tray revealed the following: a. The scrambled eggs served on the test tray registered 114.1 degrees Fahrenheit (F) and were barely warm when tasted. The DM and RD1 also tasted the scrambled eggs and confirmed the eggs tasted barely warm and needed to be hotter. b. The coffee, which was served from a carafe that was on the delivery cart, registered 119.8 degrees F and tasted barely warm. The DM and RD1 also tasted the coffee and confirmed the coffee was barely warm and needed to be hotter. NJAC 8:39-17.4(a)2,(e)

Based on record review, admission agreement review and interviews, the facility failed to explicitly inform residents or their representative of their right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility; failed to explicitly state that neither the resident nor their representatives were required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility; failed to ensure that the agreement was explained to the residents and their representatives in a form and manner that they understood; failed to ensure that the residents or their representatives acknowledged that they understood the agreement; failed to explicitly grant the residents or their representatives the right to rescind the agreement within 30 calendar days of signing it for three of three (R)23, R33, and R5) reviewed for binding arbitration agreements. The failure had the potential for residents not to be aware that they were giving up their legal rights to have their disputes resolved in a court of law.Findings include: Review of the facility's admission Agreement revealed: .16. The Home and Resident or Resident's Representative agree that any claim, controversy, or dispute relating directly or indirectly to this Agreement, except for the Home's action to collect for non-payment of fees, shall be resolved by a single arbitrator in an arbitration association. The Arbitrator will be appointed by the mutual Agreement of the Home and Resident. If the Home and Resident cannot agree as to the identity of the Arbitrator, the Arbitrator will be appointed by the American Arbitration Association. The arbitration will be held in the county of the location of the Home. The decision of the Arbitrator shall be conclusively binding in any court of competent jurisdiction. The Home and Resident shall each pay one-half of the fees and expenses of the Arbitrator and The American Arbitration Association. The Home and Resident will each be responsible for entire cost of their attorney and witnesses. During an interview with the Admissions Assistant on 07/23/25 at 12:59 PM, she stated she fills in the admission paperwork and then goes around to speak to each resident, to explain to them the fine points of the admission agreement as it applies to them. When asked what a binding arbitration was, the admission Assistant stated that she did not know, but it may have something to do with collecting payment of unpaid fees. The Admissions Assistant stated she could not explain the fine points to residents before they signed the arbitration agreement; when asked if she explained to residents that they did not have to sign an arbitration agreement as a basis for admission to the facility or continued treatment; that they had a right to a neutral arbitrator and the choice of a venue convenient to both parties; they had 30 days to rescind the agreement if they changed their minds; that they had to attest in the agreement that they understood the agreement and agreed with the contents, the admission Assistant stated, No, she did not know this information. During an interview on 07/23/25 at 1:23 PM, the Admissions Director (AD) stated that she and the Admissions Assistant are responsible for explaining the admission Agreement to residents and obtaining their signatures. The AD stated that Arbitration is when a resident or family agrees to mutual mediation of a point of concern. The AD stated she was not qualified to explain arbitration to residents, but that the facility lets residents know that the admission agreement contains an arbitration clause, and that it was the preference of the facility to arbitrate to resolve disputes. The AD stated if residents have a concern, the facility will review and respond accordingly. The AD stated she did not have the arbitration clause memorized nor did she read it verbatim to residents. When asked if she explains to the residents that they are giving up a legal right to go to court and sue if they have a dispute with the facility; that residents have to choice to opt out of the arbitration clause and annotate the paragraph addressing arbitration; that residents are told that signing the arbitration clause is not a condition to admission or continued admission in the facility; that residents are told that they have thirty days to rescind the arbitration agreement if they change their minds; that the arbitration agreement was binding and that an arbitrator's decision was final and legally binding; that residents have a right to a neutral arbitrator; that residents have the right to a mutually agreed venue, convenient to both parties; that residents are told that they have to acknowledge that the agreement has been explained to them and they understand and agree with the provisions, the AD stated, No. When asked if the arbitration agreement should not contain language that precludes the resident from speaking with the Ombudsman, and the state regulatory agency, the AD stated that she did not know. During an interview on 07/24/2025 1:15 PM, the Director of Nursing (DON) stated it was her expectation that residents should get the information they need to make an informed decision on arbitration and should be able to change their minds in line with federal regulations. Review of R23's admission Agreement dated 06/24/25 located under the Miscellaneous tab of the electronic medical record (EMR) revealed it was signed by R23. During an interview on 07/24/25 at 2:20 PM, R23 stated he did not recall all the papers he signed at admission, and that no one explained binding arbitration to him. Review of R23's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/25 revealed R23 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R33's the admission Agreement dated 06/24/25 revealed it was signed by R33. During an interview on 07/24/25 at 2:41 PM P33 stated she did not know what arbitration was. Review of R33's admission MDS with an ARD of 07/01/25 revealed R23 was admitted to the facility on [DATE] with a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Review of R5's admission Agreement dated 05/01/25 revealed it was signed by R5. During an interview on 07/24/25 at 2:56 PM, R5 stated his son took care of all that for him. P5 stated he could not recall signing any arbitration agreement. Review of R5's quarterly MDS with an ARD of 06/11/25 revealed R5 was admitted to the facility on [DATE] and readmitted on [DATE] with a BIMS score of 10 out of 15, which indicated the resident was moderately cognitively impaired. NJAC 8:39-5.1(a)

Based on record review, and interviews, the facility failed to provide for the selection of a neutral venue that is convenient to both parties in the binding arbitration agreement embedded in the facility's admission agreement signed by 131 of 139 residents currently residing in the facility. The failure had the potential for residents not to be aware of their legal right to have their disputes resolved in a court of law.Findings include:Review of the facility's admission Agreement revealed: .16. The Home and Resident or Resident's Representative agree that any claim, controversy, or dispute relating directly or indirectly to this Agreement, except for the Home's action to collect for non-payment of fees, shall be resolved by a single arbitrator in an arbitration association. The Arbitrator will be appointed by the mutual Agreement of the Home and Resident. If the Home and Resident cannot agree as to the identity of the Arbitrator, the Arbitrator will be appointed by the American Arbitration Association. The arbitration will be held in the county of the location of the Home. The decision of the Arbitrator shall be conclusively binding in any court of competent jurisdiction. The Home and Resident shall each pay one-half of the fees and expenses of the Arbitrator and The American Arbitration Association. The Home and Resident will each be responsible for entire cost of their attorney and witnesses.Review of the facility's document titled Seashore Gardens Living Center Detailed Census Report presented by the facility revealed 131 of the facility's 138 residents had signed the admission Agreement, including paragraph 16 of the agreement, which addressed binding arbitration.During an interview on 07/23/25 at 12:59 PM, the Admissions Assistant stated that she was unaware of the regulatory provision that residents could select a neutral venue that is convenient to both parties for arbitration.During an interview on 07/23/25 at 1:23 PM, the Admissions Coordinator (AC) stated that she and the Admissions Assistant are responsible for explaining the admission Agreement to residents and obtaining their signature. The AC stated that Arbitration is when a resident or family agrees to mutual mediation of a point of concern. The AC stated she was not qualified to explain arbitration to residents, but that the facility lets residents know that the admission agreement contains an arbitration clause, and that it was the preference of the facility to arbitrate to resolve disputes. The AC stated she was unaware of the regulatory provision that residents could select a neutral venue that is convenient to both parties for arbitration.During an interview on 07/24/2025 at 1:15 PM, the Director of Nursing (DON) stated that it was her expectation that residents should get the information they need to make an informed decision on arbitration and should be able to change their minds in line with federal regulations. NJAC 8:39-5.1(a)

Based on document review, interview and policy review, the facility failed to develop an effective infection surveillance program in order to conduct appropriate prevention or control activities and antibiotic stewardship for two (Resident (R)80 and R45) out of four residents reviewed for antibiotic stewardship. This failure had the potential to cause avoidable spread of infection or increase antibiotic resistance throughout the facility.Findings include: During an interview on 07/24/25 at 3:54 PM, the Infection Preventionist (IP) stated her monthly infection surveillance included tracking of the resident's location, diagnosis, need for isolation, whether the infection was facility or community-acquired, and the antibiotic order. Review of the June 2025 Infection Control surveillance log, provided on paper, revealed a total of 37 urinary tract infections listed, and all 37 residents had documented antibiotic treatment. Of those 37, only three had the organism listed. During the interview on 07/24/25 at 3:54PM, The IP stated if no organism was listed, it meant that there was no lab test or there was no organism detected. There were no dates of symptom onset or start and stop dates of antibiotic treatment. The IP stated antibiotics were used for several residents even though they did not have any lab results or they did not meet the criteria for a confirmed infection. The IP stated she completed separate assessments for determining if an infection met criteria, but did not keep track of this information in her surveillance to determine which of the infections listed were defined as true infections. (Refer to F881: Antibiotic Stewardship - the facility failed to ensure that antibiotics were used only in the presence of a diagnosed/confirmed infection for two residents (R80 and R45). During an interview on 07/24/25 at 5:01 PM, the IP stated having the organism listed and a determination of whether the infection met criteria would be important information to include in monthly surveillance to help identify any trends and actual infection rates. The IP stated she was aware many of the line listings on the surveillance log did not meet criteria for an infection. Review of the facility's policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes dated December 2016 revealed, All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include:.c. date symptoms appeared;.e. start date of antibiotic. NJAC 8:39-19.4

Based on record review, interview, and policy review, the facility failed to ensure that antibiotics were used only in the presence of a diagnosed/confirmed infection for two of four residents (Resident (R) 80 and R45) reviewed for antibiotic stewardship out of a total sample of 36 residents. These failures had the potential to lead to increased antibiotic resistance or adverse side effects related to unnecessary antibiotic usage. Findings include: 1. Review of R80's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE]. Review of R80's Medication Administration Record (MAR), dated June 2025 and located under the Orders tab of the EMR, revealed a physician's order, dated 06/02/265, for Fosfomycin tromethamine (an antibiotic), 3 grams one time only on 06/02/25 for urinary tract infection (UTI). Review of R80's EMR under the Progress Notes tab revealed there was no documentation of symptoms, including increased incontinence. Review of R80's EMR under the Results and Miscellaneous tabs revealed there was no evidence that a urine analysis or culture were completed to determine the presence of any bacteria and the most effective course of treatment. Review of R80's McGeer's Criteria assessment, provided on paper, revealed she met one of two criteria with new or marked increase in incontinence. The criterion for abnormal biology was not met, and the determination of the whether the infection met criteria was not met. 2. Review of Review of R45's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE]. Review of R45's MAR, dated June 2025 and located under the Orders tab of the EMR, revealed a physician's order, dated 06/02/25, for Keflex (an antibiotic), twice daily for ten days for UTI. Review of R45's EMR under the Progress Notes tab revealed there was no documentation of symptoms of UTI on or around 06/02/25. Review of R45's EMR under the Results and Miscellaneous tabs revealed there was no evidence that a urine analysis or culture were completed to determine the presence of any bacteria and the most effective course of treatment. Review of R45's McGeer's Criteria assessment, dated 06/03/25 and provided on paper, revealed it had not been completed to evaluate criteria for a UTI. During an interview on 07/24/25 at 3:54 PM, the Infection Preventionist (IP) stated there were several antibiotics in use in the facility to treat infections; however, those infections did not meet the criteria for true infection and/or were not confirmed via lab tests or cultures. The IP stated if a physician prescribed an antibiotic in the absence of a confirmed infection, she would reach out to the physician, but the physician typically ordered continued use of antibiotics. She stated she had never done education with the physicians regarding antibiotic stewardship and surveillance criteria. The IP stated this is a concern, as it could lead to unnecessary antibiotic use; however, she had never addressed the concern with administration or the medical director. Review of the policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, dated December 2016, revealed, The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Therapy may require further review and possible changes if:(1) the organism is not susceptible to antibiotic chosen;(2) the organism is susceptible to narrower spectrum antibiotic;(3) therapy was ordered for prolonged surgical prophylaxis; or(4) therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. NJAC 8:39-19.4

Based on interview, record review, and policy review, the facility failed to ensure timely reporting of an injury of unknown origin for one out of five residents reviewed for abuse (Resident (R) 97). This failure had the potential to contribute to further abuse or injury, which could result in mental anguish, physical harm, or fear. Findings include: Review of R97's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and anxiety. Review of R97's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/25 and located under the MDS tab of the EMR revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) and was assessed with severely impaired cognition. The resident had short and long-term memory problems and exhibited physical behaviors toward others almost daily and other behavioral symptoms and rejection of care occasionally. Review of R97's Care Plan initiated on 03/23/24 updated 06/05/24 and located under the Care Plan tab of the EMR revealed, I am at risk for misappropriation, neglect, abuse and/or exploitation r/t [related to] Dementia. The goal was, I will not experience any form of abuse, neglect, misappropriation and/or exploitation through review date. The approaches included, Assess me for s/s [signs/symptoms] of abuse and/or neglect (ex. bruises, wt [weight] loss, behavior, psychosocial status) and report to appropriate resources . Investigate all allegations of abuse & [and] neglect promptly . [and] provide support and ensure I am free from abuse.Review of R97's Nurse's Note written on 06/02/24 at 11:36 AM and located under the Progress Notes tab of the EMR revealed, Nurse was notified by CNA [Certified Nurse Aide] that resident presented with new bruises all over bilateral lower extremities, chest, abdomen, hip into coccyx area. Resident also has swelling on abdominal area. Review of R97's Reportable Event Record/Report dated 06/03/25, in the investigation packet, revealed bruising was noted to R97's sternal area, along the lateral aspects following the seams of the bra line, right posterior hip, and coccyx. R97 was unable to explain the bruising and staff was unaware of the cause of the bruising. The report documented R97's injury of unknown origin was found on 06/02/24 at 11:36 AM, and the initial report was called in to the State Survey Agency (SSA) on 06/02/24 at 5:31 PM, almost six hours after the injury was discovered.During an interview on 07/24/25 at 6:11 PM, the Director of Nursing (DON) stated she was unsure when she was alerted to R97's unexplained injuries, but the injury was discovered on 06/02/24 at 11:36 AM and should have been reported to her immediately. She stated with an injury of unknown origin, there was a two-hour reporting window, and it should have been reported to the SSA within two hours of discovery.Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, dated September 2022 revealed, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: . The state licensing/certification agency responsible for surveying/licensing the facility . 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury . NJAC 8:39-9.4(f)

Based on record review, interview, and policy review, the facility failed to send a written notification of transfer to the hospital and a bed hold notification with the daily rate to the resident and resident representative (RR) for two (Resident (R)97 and R130 ) of two residents reviewed for hospital transfer and bed hold notification. This failed practice had the potential to affect the resident and their resident representative (RR) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired or to make an informed decision on the bed hold. Findings include:Review of the facility's undated policy titled Admission, Transfer, and Discharge does not provide guidance related to providing the written notification of transfer to the resident and RR.Review of the facility's policy titled Bed-Holds and Returns indicated, All residents/representatives are provided written information regarding the facility and state bed -hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave), Resident regardless of payer source, are provided written notice about these policies. 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). The facility per diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents).Review of R130's Electronic Medical Record (EMR) revealed a discharge return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact.Review of R130's EMR located under the Census tab revealed that R130 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. There was no evidence in the EMR of the facility providing a written notice of transfer or a bed hold that displayed the daily rate to the resident or the RR. 2. Review of R97's admission Record, located under the Profile tab of the EMR revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and anxiety. Review of R97's annual MDS with an ARD of 06/12/25 and located under the MDS tab of the EMR revealed she was unable to complete the BIMS and was assessed with severely impaired cognition. She had short-and long-term memory problems.During a telephone interview on 07/22/25 at 2:30 PM, R97's Family Member (F2) stated R97 experienced a fall in September 2024 and had to go to the hospital for evaluation. F2 stated she was not alerted by the facility of the transfer to the hospital until after R97 was already at the Emergency Room. F2 stated she received verbal notice that R97 went to the hospital over the phone and did not receive any notice in writing. F2 stated the facility's bed hold policy had not been discussed with her at the time of the transfer.Review of R97's Nurse's Note dated 09/27/24 and located under the Progress Notes tab of the EMR revealed, Pt [resident] had fall.send to ER [emergency room] for treatment. [F2] called.and I sent her information along with her.Review of R97's Bed Hold Notice dated 09/27/24, revealed it was signed by the Receptionist and documented F2 was contacted via telephone and elected not to have a bed hold. The per diem rate for a bed hold was not included in the notice. There was no evidence that the written notice was provided to F2.Review of R97's Notice of Emergency Transfer dated 09/27/24 documented R97 was transferred to the hospital for a fall. The notice listed the contact information for the Ombudsman office. The notice did not include a statement of the resident's appeal rights, including the name, address, and phone number of the appeals office, or information on how to obtain an appeal form and assistance in completing and submitting the appeal. There was no evidence that the written notice was provided to F2.During an interview on 0724//25 at11:53 AM, the Director of Nurses (DON) stated that we follow the facility protocol and call the family. The DON stated that we do not send any written statement to the residents or the family.During an interview on 07/24/25 at 11:55 AM, the Social Services Director (SSD) stated that she was not sure about the written transfer notice being sent to the family, but she does send a list of residents transferred to the ombudsman. The SSD also stated that we don't fill out the daily rate unless the resident or resident representative decides to accept the bed hold.During an interview on 07/24/25 at 1:28 PM, the Receptionist stated that she looks at the census every day to see if someone that has been sent out and would require a bed hold. The Receptionist stated that if a bed hold is required, she will call the family to see if they want to hold the bed.During an interview on 07/24/25 at 6:06 PM with the DON, Receptionist, and SSD, the DON stated the nursing staff was responsible for sending applicable paperwork to the receiving hospital and calling the RR to alert them of the transfer. The Receptionist stated upon a transfer to the hospital, she would contact the resident's representative and verbally explain the bed hold policy to see if they wanted to elect the bed hold option. The Receptionist stated, Thereafter, I send the document via mail to the family. The SSD stated the per diem rate of the bed hold was not included in the written notice unless the representative elected to hold a bed. The SSD stated she completed the Notice of Emergency Transfer and mailed it to the RR The SSD confirmed the notice did not contain information on filing an appeal and the appeals office's contact information. NJAC 8:39- 4.1(a)NJAC 8:39-5.1(a)NJAC 8:39-5.3

Based on interview, record review, and policy review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of three residents (Resident (R)97, R45, and R154) out of a total sample of 36. These failures created potential for an incomplete or ineffective plan of care related to alarm use for R97 and behavioral symptoms for R45 and R154.Findings include: Review of the facility's policy titled, Certifying Accuracy of the Resident assessment dated [DATE] revealed, The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. 1. Review of R97's admission Record located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and anxiety. Review of R97's annual MDS with an Assessment Reference Date (ARD) of 06/12/25 and located under the MDS tab of the EMR, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and was assessed with severely impaired cognition. She was dependent on staff for assistance with transfers. She did not use any alarms. Review of R97's June 2025 Medication Administration Record, located under the Orders tab of the EMR, revealed the order, Chair alarm and check for proper placement and function was signed off as completed daily on all three shifts, including the seven-day lookback period for the annual MDS with an ARD of 06/12/25. Review of R97's Care Plan, dated 04/04/25 and located under the Care Plan tab of the EMR revealed, I am at risk for falls r/t [related to] Deconditioning, Impaired Balance and Mobility, [and] Poor Safety Awareness. The approaches included, Chair Alarm- check for proper function, proper cord length, proper mounting every shift. Review of R97's Orders tab of the EMR revealed a physician's order dated 08/23/24 for Chair alarm on and check for proper placement and function. During an interview on 07/24/25 at 2:50 PM, with MDS Coordinator (MDSC)1 and MDSC2, MDSC1 confirmed R97's MDS did not reflect alarm use. MDSC2 stated R97's tab alarm was in use at the time of completion of her MDS, and it should be coded on the assessment. MDSC2 stated this must have been an error and would be modified. 2. Review of R45's admission Record located under the Profile tab of the EMR revealed she was admitted to the facility on [DATE] with diagnoses including dementia, depression, and adjustment disorder. Review of R45's annual MDS with an ARD of 06/27/25 and located under the MDS tab of the EMR revealed she scored zero out of 15 on the BIMS indicating severely impaired cognition. She did not exhibit behavioral symptoms during the seven-day lookback period, but her behavior change was coded as worse. Review of R45's Care Plan dated 04/10/25 revealed, I can be non-compliant with medication administration, safety, daily care needs, and hygiene needs. Cognitive Impairment. The goal, I will have a reduction in my non-compliant behaviors with my current interventions by the review date. Review of R45's Nurse's Note dated 06/25/25 and located under the Progress Notes tab of the EMR revealed, Resident is agitated, combative during AM [morning] care. Unable to redirect. MD [physician] made aware and approve renewal of Lorazepam [anti-anxiety medication]. Review of R45's Nurse's Note dated 06/20/25 revealed, . technician in to perform Ultrasound of kidney and bladder and was unable due to resident agitation. Technician will return Saturday morning to attempt ultrasound when resident would have had pre-procedure medication. During an interview on 07/24/25 at 3:04 PM with MDSC1 and MDSC2, MDSC1 stated the notes indicated R45 exhibited behavioral symptoms during the seven-day lookback period, and they should have been reflected on her MDS. MDSC1 stated the Social Services Director (SSD) completed the behavior section of the MDS assessment. During an interview on 07/24/25 at 3:22 PM, the SSD stated she completed the behavioral assessment by speaking with the nursing staff and reviewing the notes. The SSD stated she would have to look further into the situation. During an interview on 07/24/25 at 6:00 PM, the SSD stated she had completed a modification of the MDS with ARD of 06/27/25 to accurately reflect R45's behavioral symptoms. 3. Review of R154's admission Record found on the Profile page of the EMR revealed R154 was admitted to the facility on [DATE] with diagnoses of bilateral primary osteoarthritis of the knee, and legal blindness. Review of R154's nurses notes found on the Progress Note tab of the EMR revealed on 04/26/24 at 12:03 AM, Resident became combative with CNA [Certified Nursing Assistant]. As resident was getting out of a chair to walk. CNA attempted to assist resident to her w/c [wheelchair] so she wouldn't fall. Resident then grabbed CNA by the hair and bit her hand breaking skin. Attempts to redirect behaviors minimally effective. Resident sitting at NS [nurse's station] in view of staff for safe monitoring. Review of R154's admission MDS with an ARD of 04/29/24 located under the MDS tab of the EMR indicated R154 had not exhibited any physical behaviors directed toward others. During an interview on 07/24/25 at 2:58 PM, MDSC2 reviewed R154's nurse's notes and admission MDS with ARD of 04/29/24and stated that R154 had exhibited physical behaviors toward others on 04/26/24 that were not reflected on the resident's MDS. The MDSC2 confirmed R154's admission assessment MDS was coded inaccurately. NJAC 8:39-33.2(d)

Based on observation, record review, interview and review of facility policy, the facility failed to maintain a medication error rate below five percent. During medication administration on one (2 South) of four wings, two errors/omissions occurred out of 25 opportunities for error for one (Resident (R)66) of six residents. The facility's medication error rate was 8%.Findings include: Review of the facility's policy titled Administering Medications dated April 2019 revealed, .4. Medications are administered in accordance with prescriber orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of R66's physician's orders located on the Orders tab of the Electronic Medical Record (EMR) revealed, Metoprolol Tartrate Oral Tablet 25 MG [milligram ] [Metoprolol Tartrate] - Give 1 tablet by mouth two times a day for HTN [hypertension] Hold for Systolic blood pressure <110 dated 06/25/25 and Potassium Chloride ER [Extended Release] Tablet 10 MEQ [milliequivalent]-Give 2 tablets by mouth one time a day for hypokalemia. Should be given with meals followed by a large glass of water dated 07/17/25. Observation and interview of medication administration on 07/23/25 at 9:41 PM revealed Licensed Practical Nurse (LPN)3 preparing to give medications to R66. LPN3 stated Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) and the Potassium Chloride ER Tablet Extended Release 10 MEQ were due at 8:15 AM and were out of compliance so she was not going to give them. When asked why she was not going to administer the medication, LPN3 stated, technically, you have an hour before and an hour after to give the medication. So, if it is 9:45AM right now, I am out of compliance with that. When asked if the R66 was not going to get the medication, LPN3 stated that she was going to ask her Unit Manager (UM2). LPN3 gave R66 the rest of her medications at 9:47AM but withheld the Metoprolol and Potassium. During an interview on 07/23/25 at 9:49 AM, the UM2 stated she was going to let the doctor know that she was out of compliance with those medications. When asked what the non-compliance was for the medications, UM2 stated it was past the time for the Metoprolol. The medication was supposed to be given with a meal, and that they would ensure that R66 got something to eat to take the medication. When asked about the Potassium, UM2 stated the Potassium was supposed to be followed with a glass of water or other appropriate liquid. When asked if these medications were late, would it be her expectation to just hold them and not give them, UM2 states she would always call the doctor, and the nurse should call the doctor. Interview on 07/23/25 at 9:54 AM, UM2 stated she had called the doctor, and the medications would be given once they obtained a peanut butter and jelly sandwich from the kitchen for R66. Review of R66's Medication Administration Record (MAR) dated July 2025 indicated that Metoprolol Tartrate Oral Tablet 25 MG and Potassium Chloride ER Tablet 10 MEQ were timed for 8:15AM, however, given on 07/23/25 at 10:40 AM, after she ate a peanut butter and jelly sandwich. During an interview on 07/23/25 at 10:45 AM, LPN3 stated her shift started at 8:00 AM. She was not aware that there were medications due at 8:15 AM and failed to prioritize those medications. LPN3 stated the previous shift should have given the early scheduled medications. During an interview on 07/24/2025 at 1:05 PM, the Director of Nursing (DON) stated she was aware of LPN3's predicament with the Metoprolol and Potassium. The DON stated all nurses had received enough education to know the facility's protocol and it was her expectation that LPN3 should have called the doctor when she realized the medications were being given late. LPN3 should have obtained an order from the doctor to give the medication and should have documented the events in the progress notes. The DON stated facility' shifts were 8:00AM to 4:00PM, 4:00PM to 12:00AM, and 12:00AM to 8:00AM. The DON stated the breakfast trays come at about 8:00 AM, and that is why the medications that need to be taken with meals are scheduled at 8:15 AM. The DON stated she was working on synchronizing medication times with mealtimes. NJAC 8:39-29.2(d)

Based on observation, interviews, record review and review of facility documentation, it was determined that the facility failed to properly execute its food and nutrition services by not following the established portion control procedure. This deficient practice was evidenced by the following: On 01/30/24 at 11:17 AM, the surveyor interviewed the Director of Dietary (DD) who stated that the facility utilized a four week cycle menu and that they were in week three. On 02/05/24 at 12:22 PM, in the presence of the DD, the surveyor observed the cook at the steam table plating food for the lunch meal. The cook was wearing a hair covering, surgical mask and gloves. The cook was observed to use the food scoop and tongs to plate the food, rested her hands on the counter, used the scoop and tongs again, then used her gloved hand to remove whole green beans from the steam table and placed them on a plate, rested her hands on the counter, touched the front of her surgical mask, then used the scoop to plate food again. On 02/02/24 at 12:24 PM, the surveyor interviewed the cook who stated her role was to get the plate, place the food that was called out on to the plate, and then pass it to the dietary aide. The cook was made aware of the surveyor's observation when she used her hands to serve the green beans. The cook acknowledged that she should not have used her hands to serve the food and stated that she was in a hurry and trying to get the food out of the kitchen. The cook stated that it was important to use the utensils to serve the food to prevent cross contamination. The surveyor inquired as to the portion size that was served on each plate and the cook stated, the scoop is four ounces. On 02/05/24 at 12:28 PM, the surveyor interviewed the DD who acknowledged that the cook plated the green beans with her hands. The DD stated that the cook should not have used her hands and that she should have used the tongs to serve the vegetables. The DD stated that it was important to use the scoop because it was a four-ounce (oz) measure for portions and that the portion sizes were established guidelines. The surveyor inquired that if the cook used her hands to serve the food how would she have known the portion size. The DD stated the cook did not know the portion size with her hands and that the scoop was accurate. The DD acknowledged that the use of hands to serve the food did not ensure an accurate four oz portion and that the cook would not have known the portion size using the tongs either. The DD stated that the cook should have used the scoop or spoodle (perforated measured spoon) to serve the green beans. On 02/05/24 at 01:07 PM, the surveyor interviewed the cook and inquired as to whether she knew what portion size to serve on meal trays. The cook stated that everyone got the same portion or if she was told it was a double portion that they would get double the protein. The cook stated that she knew what a portion size was because she had been doing this a long time. When the surveyor inquired about the portion size using her hands, the cook stated that it was the same as the tongs, my finger is just as long as the tong. The cook further stated that it was important to make sure the portion size was correct because she wanted to give the residents enough food to eat and that she did not want them to go hungry. On 02/06/24 at 11:30 AM, the surveyor interviewed the Corporate Registered Dietician (CRD) who stated she was contracted and that today was her first day in the facility. The CRD stated that portion sizes were determined, and most facilities would use a scoop and that it would have depended on whatever the menu extension was. The CRD was unable to speak to where the portion size information came from and who made the menu. The CRD stated that the cook should have used whatever scoop was indicated for that item. She stated that whatever company the facility used that they would use the menu extensions and serving sizes from their menu. The CRD stated, Usually whatever company comes in will have a Registered Dietician from that company that develops the menu. On 02/06/24 at 04:09 PM, the administration team was made aware of the kitchen concerns. At that time, the surveyor interviewed the Regional Nurse (RN) about meal portion sizes. The surveyor inquired as to what the expectation was for kitchen staff to accurately portion the food. The RN stated the cook should not have used her hands but should have used the appropriate scoops, spoodle, ladle, or premeasured devices to ensure the proper nutritional caloric intake of each resident. During the interview with the RN, the Regional Licensed Nursing Home Administrator stated the importance of accurate food portioning was adequate nutrition and intake for the resident. A review of the facility documentation, Week 4 menu, dated 11/29/23, revealed the menu on 02/05/24 included Seasoned Green Beans. A review of the facility documentation, Master Menu, September 2023, Week: 4, Day: MONDAY, revealed under MENU ITEM in the LUNCH column was Green Beans, and the portion size listed under the REGULAR column was 1/2 cup. A review of the facility documentation, Operations Policy and Procedure Manual Job Descriptions: Cook, revised 2/25/2008, revealed Duties and Responsibilities: Dietary Service: 3. Serve food in accordance with established portion control procedures. A review of the facility policy, Maintaining a Sanitary Tray Line, revised 3/2023, revealed Compliance guidelines: 3. During tray assembly, staff shall: b. Use utensils such as tongs, serving spoons, etc. to handle food as much as possible. NJAC 8:39-17.2(a); 17.4(a)(3)

Based on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination, and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 01/30/24 at 10:01 AM, the surveyor arrived in the kitchen and was informed by the Cook that the Director of Dietary (DD) was not on location. At 10:06 AM, in the presence of the Cook, the surveyor toured the kitchen and observed the following: 1. On a rolling metal rack in the dairy refrigerator, there were four trays containing oval tan patties, that the Cook identified as hash browns, that were uncovered with no label or dates. The Cook acknowledged the trays should have been covered, labeled and dated. There was one 3.5 pound (lb) opened package of [NAME] that was wrapped in clear plastic wrap with no open or use by date. The Cook stated that he did not know when it was opened and that it should have had a label marked when it was opened. The Cook stated it was important to make sure food was labeled and dated when it was opened so the staff knew when the food would have gone bad. The Cook stated they would be thrown away. There was one opened plastic bag marked grated parmesan cheese that was wrapped in clear plastic wrap with no open or use by dates. There was one opened plastic bag marked mozzarella cheese that was wrapped in clear plastic wrap with no open or use by dates. The Cook was unable to state when they could have been used by and stated he would discard them. At 10:16 AM, the Director of Dietary (DD) joined the tour, and the Cook left the area. 2. In the freezer, there was one box marked pancakes with the inner clear plastic bag open with the pancakes visible and open to air. The surveyor inquired as to whether the pancakes should be visible and open to air and the DD stated no, because something could have been wrong with them, and that she would throw them away. There was one tied clear plastic bag containing round tan dough with brown chips, with no label or dates. The DD stated the bag contained chocolate chip cookies and acknowledged that the bag had no label. The DD stated the bag should have had a label marked with the date that they were opened to make sure they were not old and out of date. There were two white undated cardboard packages marked cherry blintzes. The packages had tan stains and the edge of the packages were opened with the blintzes visible and open to air. The DD acknowledged the blintzes were not wrapped nor stored correctly and stated they should have been dated when they were taken out of the box. The DD removed them from the freezer. 3. In the can section in the dry storage room, there was one 6 lb dented can of crushed pineapple, one 106 ounce (oz) dented can of tropical fruit salad, and two 6 lb 10 oz dented cans of pumpkin. The DD removed the cans to the dented can section. 4. In the working supply overflow can section in the kitchen, there was one 6 lb 7 oz dented can of stewed tomatoes. The DD acknowledged the dented cans and removed them to the dented can section. The DD and stated it was important that the cans were not dented to prevent illness. 5. There was an uncovered mixer with the bowl visibly clean with white debris noted behind the bowl on the stand and brown debris on the handle. The DD acknowledged the debris, stated it should have been wiped and that it was important to keep the mixer clean to prevent cross contamination. 6. In the dairy prep area, there was one roll of clear plastic wrap that was uncovered and exposed and one roll of foil that was uncovered and exposed. The DD stated that the clear plastic wrap and the foil were used to cover pans and that they should not have been open and exposed because dust could have gotten on them. 7. In the spice area, there was one opened 16 oz jar of white pepper, one opened 18 oz jar of garlic powder, one opened 1 lb jar of celery seed, all with no open or use by dates and no expiration dates. The DD stated that the spices should have been dated when they were opened and threw the spices into the trash. 8. In the meat refrigerator, there was a large roasting pan partially covered with a sheet pan, with the meat visible and open to air and a label marked beef 1/30. The DD identified the meat as brisket and stated the meat should not have been visible. 9. In the freezer, there was a half pan covered with clear plastic wrap that was covered with ice with no labels or dates. The DD identified the contents as chicken backs bones and stated that it should have had a label with the date that the chicken was put in the freezer. The DD stated it was important that food was labeled and dated to ensure that it did not become potentially hazardous. The DD removed the pan from the freezer. Stuck to the underside of that half pan was a plastic bin that contained six packages of individually wrapped dark red meat, that the DD identified as beef [NAME], that had ice and frozen red liquid in the bags. There were no labels and no dates. Stuck to the underside of the plastic bin was a sheet pan that contained a tied bag of frozen tan meat with no label and no dates. The DD identified the meat as chicken legs. Resting under the sheet pan was a cardboard box labeled boneless shank meat, dated 2021. Inside the box was a knotted clear plastic bag that contained seven beef [NAME] with visible ice on the meat and in the bag, and a large piece of ice resting on the bag. The DD stated the meats were not stored correctly and that they should have been labeled with the received dates and dated when they were prepped and placed into the freezer. The DD further stated that it was important to store and label food correctly for safety, to decrease cross contamination and for the prevention of food borne illness. 10. In the dry storage area spice cabinet, there was one opened 8 oz jar of white pepper, one opened 12 oz jar of ground basil, one opened 1 lb jar of ground ginger and one opened 18 oz jar of garlic powder with no open or use by or expiration dates. The DD stated the spices should have been marked when they were opened and then disposed of them in the trash. 11. In the cook prep area, there was one roll of clear plastic wrap that was opened and uncovered. The DD stated the plastic wrap was used to cover food and that it should have been covered. On 02/05/24 at 12:22 PM, in the presence of the DD, the surveyor observed the cook at the steam table plating food for the lunch meal. The cook was wearing a hair covering, surgical mask and gloves. The cook was observed to use the food scoop and tongs to plate the food, rested her hands on the counter, used the scoop and tongs again, then used her gloved hand to remove whole green beans from the steam table and placed them on a plate, rested her hands on the counter, touched the front of her surgical mask, then used the scoop to plate food again. On 02/02/24 at 12:24 PM, the surveyor interviewed the cook who stated her role was to get the plate, place the food that was called out on to the plate, and then pass it to the dietary aide. The cook was made aware of the surveyor's observation when she used her hands to serve the green beans. The cook acknowledged that she should not have used her hands to serve the food and stated that she was in a hurry and trying to get the food out of the kitchen. The cook stated that it was important to use the utensils to serve the food to prevent cross contamination. On 02/05/24 at 12:28 PM, the surveyor interviewed the DD who acknowledged that the cook plated the green beans with her hands. The DD stated that the cook should not have used her hands and that she should have used the tongs to serve the vegetables. The DD further stated that it was important to use the utensils to serve the food to prevent cross contamination. A review of the facility policy, Maintaining a Sanitary Tray Line, revised 3/2023, revealed Policy: This facility prioritizes tray assembly to ensure foods are handles safely and held at proper temperatures to prevent the spread of bacteria that may cause food borne illness. Compliance guidelines: 3. During tray assembly, staff shall: b. Use utensils such as tongs, serving spoons, etc. to handle food .g. Change gloves after sneezing, coughing or touching face, hands or hair with gloved hand. A review of the facility documentation, Operations Policy and Procedure Manual Job Descriptions: Cook, revised 2/25/2008, revealed Duties and Responsibilities: Safety and Sanitation: 2. Ensure that safety regulations and precautions are followed at all times by all personnel. 3. Follow established Infection Control and Universal Precautions policies and procedures when performing daily tasks. NJAC 8:39-17.2(g)

Complaint NJ # 165358 Based on observation, interviews, and review of facility documentation, it was determined that the facility failed to follow appropriate infection control practices and perform hand hygiene as indicated: a) during a meal tray pass observation for 1 of 4 units, (2 North unit), b) during medication administration for 1 of 3 residents observed (Resident #143), and c) during wound care for 1 of 3 residents observed (Resident #65). The deficient practice was evidenced as follows: 1. On 01/30/24 at 12:34 PM, the covered food cart arrived on The [NAME] hallway on Unit 2 North. At 12:51 PM, surveyor #1 observed a Certified Nursing Aide (CNA #1) who approached the food cart, removed a tray from the cart, entered Resident # 302's room and placed it on their bed side table (BST). CNA #1 then removed the lid from the foam cup, removed the lid from the orange soda bottle that was previously resting on the Resident's BST, poured the soda into the foam cup and replaced the lids on the soda and the foam cup. CNA #1 then removed the wrapping from the straw and placed the straw into the foam cup lid, removed the plastic plate cover and exited the room. CNA #1 returned to the food cart and placed the plastic plate cover on top of the food cart, removed a meal tray from the cart and entered Resident #303's room and placed the meal tray on the BST. CNA #1 returned to the food cart, removed a tray, and placed it on top of the food cart. CNA#1 partially lifted the lid from the ice cream, removed the silverware from the plastic baggie with her hands and placed them on the tray, opened a can of cola and poured the contents into a foam cup, placed a lid on the cup, removed half the straw wrapper and placed the straw into the lid of the foam cup. CNA #1 then entered Resident #72's room and, while holding the meal tray in her left hand, used her right hand to remove trash from the BST and throw it into the trashcan. CNA #1 then placed the meal tray on the BST, moved the Resident's wheelchair closer to his/her bed, removed a blanket from the Resident, moved the Resident's legs over the side of the bed, assisted the Resident to sit up on the side of the bed, then provided hands on assistance to transfer the Resident to the wheelchair and repositioned the Resident once in the wheelchair. CNA #1 then moved the wheelchair closer to the bed, moved the BST in front of the Resident, removed the lid from the soup, removed the lid from the ice cream, moved the foam cup closer to the Resident, removed the plastic lid from the plate and exited the room. CNA #1 placed the plastic lid on top of the food cart then moved the beverage cart, that was next to the food cart, into the snack room, opened the refrigerator and placed the containers of juice into the refrigerator. No hand hygiene was observed during the observation. On 01/30/24 at 12:58 PM, surveyor #1 interviewed CNA #1 who stated that when the food carts arrived on the unit that it was the CNA and nurse's responsibility to check the trays for accuracy and to serve the trays to the residents. CNA #1 stated during meal tray pass that hand hygiene (HH), which she explained was washing with soap and water or using hand gel, should have been done before meal tray pass was started, when it was completed, and that sometimes she performed HH in between if she touched their stuff like silverware or cups and continued, I was rushed today because the trays were late. Surveyor #1 informed CNA #1 of the meal tray pass observation and that no HH was observed. CNA #1 acknowledged that she did not perform HH between passing each resident's tray and that she should have performed HH after delivering Resident #302's tray. CNA #1 stated that it was important to have performed HH correctly to prevent cross contamination and shared germs. On 01/30/24 at 01:15 PM, surveyor #1 interviewed the Licensed Practical Nurse (LPN #1) who stated that it was the CNA's responsibility to distribute meal trays on the unit and that HH should have been performed between each tray that was passed. Surveyor #1 informed LPN #1 of the CNA's meal tray pass observation. LPN #1 stated that CNA #1 did not perform HH correctly and that she should have cleaned her hands before and after touching each tray. LPN #1 further stated that it was important to perform HH correctly, so germs were not transferred from resident to resident. On 01/30/24 at 01:26 PM, surveyor #1 interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #1) who stated that staff were responsible for the distribution of meal trays on the unit and that she expected staff to perform HH before and after obtaining a meal tray and serving the next resident. Surveyor #1 informed the LPN/UM #1 of the CNA's meal tray pass observation. LPN/UM #1 acknowledged that CNA #1 did not perform HH correctly between each resident and stated that HH was important so germs were eliminated, and contamination was avoided. On 02/01/24 at 10:42 AM, surveyor #1 interviewed the Assistant Director of Nursing (ADON) who stated that it was the CNA's responsibility to distribute meal trays on the unit and that HH should have been performed after the resident's trays were set down, if the CNA had to help the resident open food items, any contact with the resident, and when anything was touched. Surveyor #1 informed the ADON of the CNA's meal tray pass observation from 01/30/24. The ADON stated that CNA #1 did not perform HH correctly and that it was important for proper HH to prevent food borne disease and passing of germs. On 02/01/24 at 11:26 AM, surveyor #1 interviewed the Infection Control Nurse (ICN) who stated that during meal tray pass, she expected HH to be performed when the trays were touched or when food was opened for a resident. Surveyor #1 informed the ICN of the CNA's meal tray pass observation from 01/30/24. ICN stated that CNA #1 did not perform HH correctly and that it was important for proper HH to prevent the spread of germs or infection. On 02/01/24 at 11:41 AM, surveyor #1 interviewed the Director of Nursing (DON) who stated that the CNAs passed the meal trays to the residents, and she expected HH to have been performed every time they touched anything or they go to get another tray on the cart. Surveyor #1 informed the DON of the CNA's meal tray pass observation from 01/30/24. The DON acknowledged that CNA #1 did no HH and that she expected staff to perform HH between each resident. The DON stated that it was important to perform HH correctly to prevent the passing of germs. On 02/06/24 at 03:39 PM, the surveyors met with the administration team who were made aware of CNA #1's meal tray pass observation from 01/30/24. A review of facility documentation revealed Meeting Sign-In Sheets for topics which included: Hand Hygiene .signed by CNA #1 and dated 11/29/23, and 12/12/23. A review of facility documentation, dated 12/02/23 and 01/10/24, revealed a Hand washing observation performed by CNA #1, and rated A=Performs skill independently and completely. Both forms were signed by an Observer. A review of facility documentation revealed an Employee Education Packet, Hand Hygiene, dated 11/29/23, for CNA #1 with Competency Demonstrated box checked YES and Observer Initials marked. 49712 2. On 02/01/2024 at 08:55 AM, during the Medication Administration task on 2 South unit, surveyor # 2 observed LPN # 2 administering medications to Resident # 19. Upon finishing the medication administration, surveyor # 2 observed LPN #2 exit the room and approach the medication cart. Surveyor # 2 then observed LPN #2 prepare medication for Resident #143. LPN #2 did not perform hand hygiene between finishing the medication administration with Resident # 19 and beginning the medication administration for Resident #143. During an interview with surveyor # 2 at that time, LPN #2 was asked when hand washing was to be performed and LPN #2 stated, between residents. When asked if she had washed her hands between Resident #19 and Resident # 143, LPN #2 responded, No, I forgot. On 02/01/24 at 11:37 AM, surveyor # 2 interviewed the Infection Preventionist (IP) who was asked when hand hygiene should have been done during medication administration. The IP stated, hand hygiene should be done prior to starting, and after giving medication. They should use hand sanitizer or washing hands with soap and water. It is recommended to wash with soap and water every three patients. 49175 3. On 02/02/24 at 11:00 AM, on 2 South Unit, surveyor #3 observed LPN#3 perform a wound care treatment for Resident #65, assisted by CNA#2. LPN/UM#2 was also present for the observation. LPN/UM #2 stated she was there to observe the wound care task, to complete competencies for LPN#3, and as moral support. Surveyor #3 observed CNA #2 enter the resident's room and don gloves. She then assisted LPN #3 in repositioning Resident #65's incontinence diaper which was opened in the front, while the back of incontinence diaper was pulled down. CNA#2 then rolled the resident to their left side allowing LPN#3 to perform the wound care. At that time, CNA#2 held the resident in the side position by placing her gloved hands-on the resident's buttock area and lower back. LPN#3 then proceeded to complete the wound care on resident #65. With the same gloves, CNA#2 and LPN#3 redressed the resident, reapplied the incontinence diaper, and repositioned the resident. With the same gloves, CNA#2 then held the resident's hands, repositioned the resident's blankets, and adjusted the bed pillows. CNA#2 then removed her gloves and proceeded to the bathroom to wash her hands with soap and water for 40 seconds. On 02/02/24 at 11:25 AM, surveyor#3 interviewed CNA#2 and made her aware of the wound care observations. CNA #2 stated that she was not aware of any breach in the infection prevention protocol and was not aware she did not change her gloves. CNA#2 stated she should have changed her gloves and that improper hand hygiene could have spread infection. On 02/02/24 at 11:35 AM, surveyor#3 interviewed LPN/UM#2 and discussed the wound care observation. LPN/UM#2 stated that CNA#2 should have changed her gloves after she assisted with the dressing change, before she proceeded to reposition the resident, and when she touched the resident's hands. A review of the facility policy, Hand Hygiene, accessed June 2023, revealed, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or use of an antiseptic hand rub .Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The handout Hand Hygiene Table revealed Condition: Between resident contacts, After handling contaminated objects, Before preparing or handling medications, Before and after handling clean or soiled dressings, linens etc., After handling items potentially contaminated with blood, body fluids, secretions, or excretions, When, during resident care, moving from a contaminated body site to a clean body site . A review of the undated facility policy, Nursing Pertinent Policies, revealed, Assisting the Resident with In-Room Meals, Preparation: 11. Employees must wash their hands before serving food to residents .if there is contact with soiled dishes, clothing or the resident's personal effects, employee must wash his/her hands before serving food to the next resident. NJAC 8:39-19.4 (m)(n)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to develop a person-centered comprehensive care plan to include residents' a.) preference for activities and b.) risk for pain. This deficient practice was identified for 1 of 1 resident (Resident #253) reviewed for activities and for 2 of 2 residents (Resident #145 and #301) reviewed for pain management and was evidenced by the following: 1. On 01/30/24 at 10:39 AM, the surveyor observed Resident #253 sitting in a wheelchair in his/her room. The resident stated that he/she would like to go to activities, but that there is no one to take him/her. According to the Admission Record, Resident #253 had diagnoses which included, but were not limited to, unspecified hearing loss, muscle weakness, and altered mental status. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated, 01/10/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident's cognition was moderately impaired. Further review of the MDS included it was very important to the resident to do things with groups of people, and, participate in religious services or practices. Review of the Recreation Assessment, dated 01/11/24, included, religion is important to [Resident #253] and [he/she] expressed interest in receiving Communion and religious visits. Review of the care plan, initiated 01/04/24, did not include the resident's preferences for activities or interventions to ensure the resident's activity preferences were met. During an interview with the surveyor on 02/01/24 at 11:52 AM, the Activities Director (AD) stated that the activities staff complete an initial assessment when residents are admitted to determine their activity preferences. During an interview with the surveyor on 02/01/24 at 12:10 PM, the Assistant Activities Director (AAD) stated that every resident was assessed for activity preferences upon admission to the facility. The AAD further stated she completed the Resident #253's Recreation Assessment, and that the resident was religious and Communion was available for the resident to attend. During a follow-up interview with the surveyor on 02/06/24 at 9:32 AM, the AD stated that the assigned activities staff member will document a resident's Recreation Assessment in the Electronic Medical Record (EMR) and then initiate a care plan related to the resident's preferences. The AD further stated that the activities staff who completed Resident #253's Recreation Assessment should have included the resident's activity preferences in the resident's care plan. During an interview with the surveyor on 02/06/24 at 11:30 AM, the Director of Nursing (DON) stated that resident care plans are initiated upon admission and should include resident preferences. The DON further explained that care plans include the resident's needs in order to develop a plan of care with appropriate interventions. When asked about Resident #253, the DON stated the care plan should have included the resident's activity preferences. 2. On 01/30/24 at 10:26 AM, the surveyor observed Resident #145 lying in bed. The resident complained of abdominal pain and stated he/she reported it to the facility staff. On 02/02/24 at 10:53 AM, the surveyor observed Resident #145 sitting in a wheelchair in his/her room. The resident stated that he/she had been receiving medication from the nurse that had helped with the abdominal pain. The resident also stated that he/she had an ultrasound of the abdomen and was waiting for the results. According to the Admission Record, Resident #145 was admitted with diagnoses which included, but were not limited to, calculus of kidney (kidney stone), unspecified abdominal pain, hydronephrosis (kidney swelling), and cirrhosis of liver (liver damage). Review of the admission MDS, dated [DATE], included the resident had a BIMS score of 13, which indicated the resident's cognition was intact. Review of the Order Summary Report, as of 02/05/24, included an order for an ultrasound of the abdomen, dated 01/30/24. Further review of the Order Summary Report included an order for Mylanta Maximum Strength Oral Suspension give 30 milliliters by mouth every 6 hours as needed for stomach upset and heartburn, ordered 01/29/24, and Carafate 1 gram give one tablet by mouth four times a day for stomach pain, ordered 01/30/24. Review of the Physician Note, dated 11/26/23, included, under assessment/plan, belly pain. Review of the Physicians Progress Note, dated 01/31/24, included Resident #145 complains of belly pain. Review of the Physicians Progress Note, dated 02/03/24, included Resident #145 complains of belly pain, and, Ascites [fluid collecting in the abdomen] with renal cyst on US [ultrasound], will add Aldactone [a diuretic] 25 mg [milligram] daily. Review of the care plan, initiated 12/19/23, did not include the resident's risk for pain or pain management interventions. During an interview with the surveyor on 02/05/24 at 11:00 AM, the Licensed Practical Nurse (LPN) stated that care plans are initiated upon admission and includes resident treatments. The LPN further stated that care plans inform the staff about the care required for the resident. When asked about Resident #145, the LPN stated the resident complained of abdominal pain, and the physician ordered Carafate and an abdominal ultrasound. The LPN then stated that since the resident was admitted with a diagnosis of abdominal pain and received treatment for the pain, the resident's pain management should have been included on the care plan. During an interview with the surveyor on 02/05/24 at 11:50 AM, the LPN/Unit Manager (LPN/UM) stated each department is responsible for updating the resident care plans and that care plans should include anything the resident requires interventions for. The LPN/UM further stated that care plans benefit the resident because staff can refer to them for the appropriate interventions. When asked about Resident #145, the LPN/UM stated the resident complained of abdominal pain and the physician ordered an abdominal ultrasound and medication to help with the pain. At that time, the LPN/UM checked the resident's care plan and acknowledged that it did not include the resident's abdominal pain. The LPN/UM further stated she was unsure if the abdominal pain should be included on the care plan, but that it can be added on and probably will be. During an interview with the surveyor on 02/05/24 at 9:10 AM, the MDS Coordinator (MDSC) stated UMs are responsible for initiating and updating the resident care plans which includes any ongoing problems or risks for problems the resident has. The MDSC explained that care plans should be initiated within 24-72 hours and be updated as soon as there are nay new changes to the resident's treatment. The MDSC further stated that the purpose of care plans were to be able to give proper care to the resident, prevent deterioration, and to refer to any special services. When asked about Resident #145, the MDSC stated the resident's diagnosis of abdominal pain and the facility's management of that pain should have been included on the care plan. During an interview with the surveyor on 02/06/24 at 11:30 AM, the Director of Nursing (DON) stated that resident care plans are initiated upon admission and should include the resident's diagnoses. The DON further explained that care plans include the resident's needs in order to develop a plan of care with appropriate interventions. When asked about Resident #145, the DON stated the resident's pain management should have been included on the care plan. 43307 3. On 01/30/24 at 11:56 AM, Resident #301 was observed in bed, restless and groaning. There was a private duty caregiver at the resident's bedside who stated that she was a live-in caregiver (LIC). The LIC stated that the resident fell at home and broke their leg and had gotten pain medication when needed. On 02/02/24 at 11:52 AM, Resident #301 was observed in a wheelchair accompanied by their son. The surveyor inquired with the son as to whether the resident was having pain and the son stated, not now and stated that he/she would have made it verbally known if they had pain. According to the Admission Record, Resident #301 had diagnoses which included, but were not limited to, Alzheimer's disease, unspecified fracture of shaft of left femur, fracture of superior rim of left pubis, and osteoarthritis of knee. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated, 01/29/24, included the resident had a Brief Interview for Mental Status score of 99 which indicated that the resident was unable to complete the interview. Review of the Care Plan (CP), initiated 01/22/24, did not include a resident's Focus for Pain. Review of the Order Summary Report, dated Active orders as of 02/06/24, revealed and order for Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for mild pain. Review of the Medication Administration Record, dated 01/01/2024-01/31/2024, revealed Resident #301 received pain medication on 01/23/24 at 0712 and again on 01/24/24 at 0713. During an interview with the surveyor on 02/02/24 at 12:05 PM, the Certified Nursing Assistant (CNA) who was caring for Resident #301, stated that she would ask the resident if he/she had pain and they would respond by stating, ouch. The CNA stated that if the resident had pain that she would tell the nurse and she would also make sure the resident did not seem to be in distress. During an interview with the surveyor on 02/05/24 at 11:03 AM, LPN #2 stated that a CP included interventions used for the residents as a part of their care. LPN #2 further stated that if a resident had pain that she would have expected to see pain management interventions on the CP. During an interview with the surveyor on 02/05/24 at 11:25 AM, the Licensed Practical Nurse Unit Manager (LPN/UM #2) stated that she would have expected to see a Focus of pain on a CP for a resident that had fractures with the interventions to choose from. She stated that there was a pain template that could have been modified for a resident. During an interview with the surveyor on 02/06/24 at 10:49 AM, the Director of Rehabilitation (DOR) stated that a CP was a snapshot of a resident and their needs and that every discipline was able to add to the CP their perspective from their discipline. The DOR stated that unless a resident complained of pain that she would not have expected to see a Focus of pain on the CP. The surveyor and the DOR reviewed Resident #301's CP together in the EMR and the DOR acknowledged that she did not see a focus of pain on the CP. During an interview with the surveyor on 02/06/24 at 11:47 AM, the surveyor and LPN #2 reviewed Resident #301's CP together in the EMR and LPN #2 acknowledged that she did not see a Focus of pain on the CP and that she would have expected to have seen it. LPN #2 stated that it was important to include pain on the CP because the interventions and goals were specific for each resident. During an interview with the surveyor on 02/06/24 at 11:56 AM, the surveyor and LPN/UM #2 reviewed Resident #301's CP together in the EMR and LPN/UM #2 acknowledged that she did not see a Focus of pain on the CP. She stated that if a resident was in pain, that pain should have been on the CP and that it was important that the pain was addressed. LPN/UM #2 then stated, I will put it in now. During an interview with the surveyor on 02/06/24 at 12:11 PM, the Assistant Director of Nursing (ADON) stated that if a resident had a femur and pelvic fractures that she would have expected to see pain on the CP. The surveyor and the ADON reviewed Resident #301's CP together in the EMR and the ADON was made aware that the Focus Pain was added by LPN/UM #2 after surveyor inquiry. During an interview with the surveyor on 02/06/24 at 12:19 PM, the DON stated that if a resident had a femur and pelvic fractures that she would have expected to see pain on the CP. The surveyor and the DON reviewed Resident #301's CP together in the EMR and the DON was made aware that the Focus Pain was added by LPN/UM #2 after surveyor inquiry. During an interview with the surveyor on 02/06/24 at 12:27 PM, the MDSC acknowledged that if a resident had a diagnosis of femur and pelvic fractures that she would have expected to see pain on the CP. On 02/06/24 at 03:39 PM, the surveyors met with the administration team and the surveyor discussed concerns about Resident #301's pain not being addressed on a CP and that it was added after surveyor inquiry. On 02/07/24 at 11:19 AM, the surveyors met with the administration team and the Regional Nurse (RN) stated that a full house pain CP audit was completed and that every resident that had a pain assessment with a pain CP, and in-services were completed. Review of the facility's Comprehensive Care Plans policy, undated, included, 1. The care planning process will include an assessment of the resident's strengths and needs .2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . Other factors identified by the interdisciplinary team, or in accordance with resident's preferences, will also be addressed in the plan of care, and, The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being .f. Resident specific interventions that reflect the resident's needs . Review of the facility's Pain Assessment and Management policy, revised October 2022, included, Defining Goals and Appropriate Interventions. 1. The pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. NJAC8:39-11.2 (e)(f)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide a resident with meaningful activities that reflected the resident's preferences for 1 of 1 resident (Resident #253) reviewed for activities. This deficient practice was evidenced by the following: On 01/30/24 at 10:39 AM, the surveyor observed Resident #253 sitting in a wheelchair in his/her room. The resident stated that he/she would like to go to activities, but that there is no one to take him/her. On 02/01/24 at 9:45 AM, the surveyor sat in the lounge outside of Resident #253's room. There was an Activities Calendar on the table in the lounge that included a 10:00 AM sing-along activity. The calendar did not indicate where the activity was located. At 10:15 AM, the surveyor did not observe any sing-along activities on the unit, and staff did not enter the resident's room to offer to take her to an activity. Further review of the Activities Calendar included a 10:45 AM Communion activity. At 10:49 AM, the surveyor was still seated in the lounge and did not observe any Communion activity on the unit or staff offering to take the resident to the activity. At 10:51 AM, the surveyor observed a visitor enter the resident's room. When the surveyor entered the resident's room, the visitor identified him/herself as the resident's family member. When asked if the resident was offered to attend the sing-along or the Communion, the resident's family member asked the resident who stated, no. The resident's family member further stated that those would have been activities the resident would have attended. According to the Admission Record, Resident #253 had diagnoses which included, but were not limited to, unspecified hearing loss, muscle weakness, and altered mental status. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated, 01/10/24, included the resident had a Brief Interview for Mental Status score of 10 which indicated the resident's cognition was moderately impaired. Further review of the MDS included it was very important to the resident to do things with groups of people, and, participate in religious services or practices. Review of the Recreation Assessment, dated 01/11/24, included, religion is important to [Resident #253] and [he/she] expressed interest in receiving Communion and religious visits. Review of the care plan, initiated 01/04/24, included the resident had a communication problem r/t [related to] hearing deficit, with an intervention that staff will anticipate and meet needs. The care plan did not include the resident's preferences for activities or interventions to ensure the resident's activity preferences are met. During an interview with the surveyor on 02/01/24 at 10:55 AM, the Certified Nursing Assistant (CNA) stated that there were no activities offered on the first floor subacute unit and that the calendar posted indicated the activities offered on the second floor units. The CNA further stated that if a resident needed assistance getting to and from an activity, the activities staff would assist the resident. The CNA added that it was important for residents to attend activities to prevent boredom and provide socialization. When asked about Resident #253, the CNA stated the resident does not attend activities. During an interview with the surveyor on 02/01/24 at 11:00 AM, the Licensed Practical Nurse (LPN) stated there were no specific activities on the subacute unit and if residents needed help going to and from an activity, the resident should have notified the staff. The LPN further stated that activities were important so that residents felt more at home. When asked about Resident #253, the LPN stated that he/she attends physical therapy, and the nursing staff place him/her in the lounge to watch television. During an interview with the surveyor on 02/01/24 at 11:08 AM, the LPN/Unit Manager (LPN/UM) stated that the activities calendar posted on the subacute unit informs the residents of activities available on the second floor and that if residents needed assistance getting to and from the activity, the nursing or activity staff would assist the resident. The LPN further stated that activities were important because they provided stimulation, distraction, and socialization. When asked about Resident #253, the LPN stated the resident required moderate assistance with activities of daily living and that staff could have assisted the resident with going to activities. During an interview with the surveyor on 02/01/24 at 11:52 AM, the Activities Director (AD) stated that the activities staff completed an initial assessment when residents were admitted to determine their activity preferences. During an interview with the surveyor on 02/01/24 at 12:10 PM, the Assistant Activities Director (AAD) stated that every resident was assessed for activity preferences upon admission to the facility. The AAD further stated she completed the resident's Recreation Assessment, and that Resident #253 was religious and Communion was available for the resident to attend. The AAD also stated she was unsure if staff assisted the resident with attending activities, but that staff should have offered to take the resident to activities as long as there were no schedule conflicts with physical therapy. During an interview with the surveyor on 02/06/24 at 11:30 AM, the Director of Nursing (DON) stated upon admission, the activities staff assess the resident to determine what activities the resident enjoys. The DON further stated that residents on the subacute unit have to attend activities on separate units. The DON added that nursing or activities staff will assist residents to and from the activities if needed and that activities are important for the residents' psychosocial wellbeing. When informed about Resident #253 missing activities that he/she would have liked to participate in, the DON stated that the CNAs on the unit are familiar with the resident's routine and should have taken him/her to the activities. Review of the facility's undated Activities policy, included, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Further review of the policy included, All staff will assist residents to and from activities when necessary. NJAC 8:39-7.3(a)

Complaint #NJ168566 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) ensure a pressure reducing device was used correctly and b.) failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development specifically by not providing protective boots to heels as ordered. This deficient practice was identified for two (2) of four (4) residents (Resident #3 and #104) reviewed for pressure ulcer management. This deficient practice was evidenced by the following: 1. On 1/30/24 at 11:57 AM, during the initial tour, Resident #104 was not in their room. A staff member identified Resident #104 in the dayroom, sitting in a high back wheelchair, with a chair alarm on the back of the wheelchair. The surveyor reviewed the medical record for Resident #104. According to the Admission Record (AR), Resident #104 had diagnoses which included: unspecified dementia with behavioral disturbance, hypertension (high blood pressure), and senile degeneration of brain (progressive decline in a person's ability to think and remember). A review the annual Minimum Data Set (MDS), an assessment tool, dated 11/25/23, reflected the Brief Interview for Mental Status (BIMS) score was left blank as it indicated in section C0100 it was not conducted due to the resident rarely/never understood. A review in Section H - Bladder and Bowel indicated the resident was frequently incontinent. A review in Section M - Skin condition revealed the resident was at risk for developing pressure ulcers/injuries. A further review indicated the resident did not have one or more unhealed pressure ulcers/injuries. A review of the individualized comprehensive care plan (ICCP) included a focus area, dated 9/11/23, for I am at risk for skin breakdown r/t [related to] dementia. Interventions included to assess for changes in skin condition each shift, change bedding as needed, complete skin risk assessment as per facility policy, keep skin clean and dry, low air loss mattress, monitor skin care daily, provide incontinence care prn [as needed], and provide protective/preventative skin care. A review of the skin assessments from 09/25/23 to 02/06/24, indicated that the resident's skin was intact. On 02/01/24 at 10:24 AM, the surveyor observed Resident #104 in the dayroom sitting in a high back wheelchair. At that time, the surveyor observed the resident seated on a pressure reducing device, which was a black cushion covered with a white towel, that was directly underneath the resident. On 02/01/24 at 01:04 PM, the surveyor observed Resident #104 in the dayroom sitting in a high back wheelchair. At that time, the surveyor observed the resident was still seated on top of the white towel covered black cushion that was directly underneath the resident. On 02/02/24 at 10:41 AM, the surveyor observed Resident #104 in the dayroom sitting in a high back wheelchair. At that time, the surveyor observed the resident seated on a white towel covered black cushion that was directly underneath the resident. On 02/05/24 at 10:28 AM, the surveyor observed Resident #104 in the dayroom sitting in a high back wheelchair. At that time, the surveyor observed the resident seated on a white blanket covered black cushion that was directly underneath the resident. On 02/05/24 at 10:29 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that she rounded on her residents every 2 hours and more frequently if needed. CNA #1 stated that most of the residents sat in the dayroom/dining room so staff would monitor the residents on the comfort care (dementia) unit. When asked if she placed anything underneath the residents while they were sitting in the chairs? CNA #1 stated that she did not personally put anything underneath her residents unless the resident was in the bed then she would put a blue chuck (pad) underneath the resident. CNA #1 then stated that if you put something underneath the resident it could damage their skin. She further stated that she felt that some CNAs placed towels underneath residents because it was a way of being lazy, so they did not have to toilet the resident frequently. CNA #1 then stated that the towel could have been used to prevent the resident from sliding and slipping out of their chair. She concluded that instead of putting a towel or blanket underneath a resident they could have gotten another cushion to prevent residents from sliding. On 02/05/24 at 10:35 AM, the surveyor interviewed CNA #2 who stated that she was caring for Resident #104 today (2/5/24). CNA #2 stated that she rounded on her residents when she first came in, after breakfast and then frequently throughout the day. She stated that the staff was very helpful and assisted her if she needed anything, because she was from an agency. When asked if she would put anything underneath the resident for those that needed to be toileted more frequently, CNA #2 stated that sometimes she would put a bath blanket underneath the resident but not a towel because the bath blanket was softer. She further stated that some cushions were plastic and the bath blanket was a barrier for comfort. CNA #2 emphasized that it was not to absorb anything but more of a cushion and comfort for the resident. She explained that a towel should not be underneath the resident because if a resident was sitting on it for a long period of time it could cause skin irritation and the goal was to prevent skin breakdown. CNA #2 stated that most of the resident's skin were fragile, and that staff needed to be mindful and ensure the resident was comfortable. CNA #2 stated that Resident #104 was on hospice and that the hospice aide came and provide morning care, dressed the resident, assisted with breakfast, and placed the resident in the wheelchair this morning. On 02/05/24 at 10:55 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that staff rounded on the resident every hour. She further stated that if a resident needed to be toileted more frequently then they ensured that the resident was toileted more often. When asked if they would put anything underneath the resident, LPN #1 stated that they did not put anything underneath the resident because if they allowed urine to soak if could cause skin break down. She explained if the resident had a cushion seat, then they still should not place anything on top of the cushion directly underneath the resident because it could have caused skin breakdown. LPN #1 stated that Resident #104 was incontinent and currently did not have any wounds or skin breakdown. At that time, the surveyor and LPN #1 walked over to Resident #104 sitting in their high back wheelchair. LPN #1 confirmed Resident #104 was sitting directly on a white blanket that was placed on top of the black cushion. She acknowledged the resident should not have been sitting on the blanket. LPN #1 stated that the hospice aide got the resident up in the morning but that if someone had seen the blanket that they should have removed it. LPN #1 concluded they should remove the blanket to prevent skin breakdown. On 02/05/24 at 11:04 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) for the comfort care unit who stated that the residents in wheelchairs were provided seat cushions which helped prevent skin breakdown. The LPN/UM stated that the therapy department provided a blue gel pad that was placed underneath the seat cushion to prevent the resident from sliding. When asked if they placed anything on top of the cushion the LPN/UM stated that the resident should not have anything like a towel or blanket directly underneath them. She explained that the towels could have slid and it would not be conducive for the residents skin integrity. At that time, the surveyor and the LPN/UM walked over to Resident #104. The LPN/UM confirmed the resident was sitting directly on a white blanket that was placed on top of the black cushion. She then stated that the resident should not have had the blanket directly underneath them as it was not normal procedure. On 02/05/24 at 11:11 AM, the surveyor observed staff remove the blanket from underneath Resident #104. On 02/05/24 at 11:42 AM, the surveyor interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team. The DON stated that the unit managers, the nurses, and the CNAs should round on their residents as soon as they started their shift. She further stated that the CNAs should have rounded on their residents at least every 2 hours and more often as needed. When asked if the staff needed to put anything underneath the resident that needed to be toileted frequently the DON stated it was very rare if you see the staff placing the chucks underneath the resident, which was used on the beds to prevent anything penetrating the sheets. The DON then stated that sometimes the staff used a towel or blanket to prevent residents from sliding. The DON then acknowledged they should not be placing a towel or blanket directly underneath the resident. At that time, the LNHA confirmed that staff should not have a towel of blanket on top of the cushion and should not be underneath as a barrier for residents that were incontinent. The LNHA then stated that a towel or blanket should only be placed underneath a resident if the resident or resident's representative requested it, and it was care planned for it. The LNHA acknowledged that the towel and blanket should not have been directly underneath the resident because it could have compromised the resident's skin integrity. On 02/05/24 at 12:05 PM, the LNHA stated in the presence of the survey team that she went to the comfort care unit and the LPN/UM informed her that it was the hospice aide that had placed the blanket underneath the resident because she thought to make the resident more comfortable. On 02/07/24 at 09:49 AM, the surveyor interviewed the Director of Rehab (DOR) who stated that every resident with a wheelchair had the blue gel pad placed directly underneath the cushion to prevent the resident from sliding out of the chair. The DOR stated that the purpose of the cushion was for additional support, to prevent any skin breakdown, wounds and for comfort. She stated that there should not have been a towel or blanket on top of the cushion because the resident could have slid, and it was not supportive. The DOR emphasized another layer should not have been between the resident and the cushion. She then stated that some residents do request it, but they should be care planned as a preference. On 02/07/24 at 11:27 AM, Regional Nurse #1 stated in the presence of the Licensed Nurse Home Administrator (LNHA), the Director of Nursing (DON), Regional Nurse #2, the Regional LNHA and the survey team that items such as a towel and blanket should not be placed directly underneath the resident because it increased the risk for falls and skin integrity issues. She further stated that you are not getting the benefit of the cushion if you are putting something on top of the cushion. 43936 b.) On 02/01/2024 at 10:01 AM, the surveyor observed Resident # 3 in his/her room. At that time, Resident # 3 did not have protective heel boots on. During this time, he/she said they do not get protective heel boots put on him/her. On 02/05/2024 at 10:48 AM, the surveyor observed Resident # 3 in his/her room. At that time, Resident # 3 did not have protective heel boots on. On 02/05/2024 at 11:16 AM during an interview with the surveyor, Licensed Practical Nurse #2 confirmed an order for protective heel boots appeared in the orders in the Electronic Medical Record (EMR). On the same date at 11:20 AM, during an interview with the surveyor, CNA # 3 assigned to Resident # 3 said that protective heel boots were not in Resident # 3's room. On the same date at 11:37 AM, during an interview with the surveyor while in Resident # 3's room, the Registered Nurse/Unit Manager (RN/UM # 1) observed that the resident did not have protective heel boots on. At that time, RN/UM # 1 stated that the order could have been transcribed improperly. She concluded by saying she will make sure it appeared on the nurse's end. On 02/06/2024 at 4:00 PM during an interview with the surveyor, the Director of Nursing (DON) replied, Yes when asked by the surveyor if a resident had an order for protective heel boots to be worn while in bed every shift, should they have been placed on the resident's heels while they were in bed. The DON concluded by replying, Effects the skin integrity when asked by the surveyor what potential results could have occurred if the protective heel boots were not worn according to the order. A review of the EMR for Resident # 3 revealed a physician's order for protective boots to heels for every shift that was revised on 11/11/2023 and discontinued on 02/05/2024 at 11:24 AM. A review of the paper-chart for Resident # 3 revealed a telephone order sheet dated 11/11/2023 that revealed, Protective boots to heels. An initial and hand-written statement revealed, Noted 11/11/23 adjacent to the order. A review of the facility's policy Pressure Injury Prevention and Management revised 7/25/22, included, 4. Interventions for Prevention and to promote healing c.i. Redistribute pressure (such as repositioning, protecting and or offloading heels, etc.), iii. Provide appropriate, pressure re-distributing, support surfaces, iv. Provide non-irritating surfaces. N.J.A.C. S 8:39-27.1 (a)

Complaint #NJ168222 and NJ168566 Based on observation, interview, and record review it was determined that the facility failed to ensure an environment was free from accident hazards by failing to place assistive devices, specifically bilateral floor mats, to prevent avoidable accidents for 1 of 7 residents (Resident # 97) investigated for Accidents. The deficient practice was evidenced by the following: On 01/30/2024 at 10:55 AM, during the initial tour of the facility, the surveyor observed Resident # 97 in their room in bed. The surveyor observed two blue floor mats folded and leaning against the wall on either side of the room. At that time, Resident # 97 replied, They haven't used them. when the surveyor asked if the facility had used the floor mats while he/she was in bed. On 02/05/2024 at 09:46 AM, the surveyor observed Resident # 97 in their room in bed. The surveyor observed the two blue floor mats folded and leaning against the wall on either side of the room. At that time, Resident # 97 replied, No when the surveyor asked if the facility had used the floor mats while he/she was in bed. A review of Resident # 97's Minimum Data Set (an assessment tool) dated 07/17/2023, revealed under section J that he/she had a fall in the last month prior to admission. A review of Resident # 97's Electronic Medical Record (EMR) revealed under Orders, a physician's order for bilateral floor mats beside bed while in bed every shift. The order was started on 08/30/2023. A review of Resident # 97's EMR revealed under Care Plan a focus for risk of falls related to impaired balance and mobility. The focus revealed an initiated date of 09/08/2023. The care plan revealed an intervention for bilateral floor mats at bedside. The intervention revealed an initiated date of 09/25/2023. On 02/05/2024 at 09:54 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM #1) replied, Yes. [He/She] should have them [floor mats] by the bed. At the time of the interview the surveyor showed RN/UM #1 the bilateral floor mats placed against the walls in Resident # 97's room. On 02/06/2024 at 4:00 PM, during an interview with the surveyor, the Director of Nursing said the bilateral floor mats should not have been folded against the wall. During the same interview, the Regional Nurse #1 replied, Injury could occur when the surveyor asked what potential results could have occurred if the floor mats were not placed according to the order. A review of the facility policy titled, Comprehensive Care Plans with a copyright date of 2023, revealed under subsection, Policy Explanation and Compliance Guidelines number 3. letter a. that, The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. S 8:39-27.1 (a)

Complaint Intake NJ 3 Based on interviews, record review, and facility policy review, it was determined that the facility failed to investigate to determine the causative factors of falls to help prevent and/or reduce risk for falls and implement new fall interventions, if needed; and failed to ensure fall interventions were implemented to help prevent falls. This affected 1 of 3 residents (Resident #1) reviewed for falls. Resident #1 had multiple falls, with one fall that resulted in a [CONDITION(S)]. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included history of falls, closed traumatic compression fracture of [MEDICATION(S)] vertebra, end stage heart failure, fracture of the T-11 vertebrae, hypertension, lack of coordination, unilateral primary [CONDITION(S)], left hip arthroplasty, and [CONDITION(S)]. A review of Resident #1's medical records revealed the resident was placed on hospice on [DATE] due to heart failure, hypertensive heart disease with heart failure, [CONDITION(S)], and collapse. A review of Resident #1's hospice nurse's notes from February 2020 through [DATE] revealed that Resident #1 was an extreme fall risk due to syncopal episodes and was no longer able to ambulate with or without assistance. Resident #1 expired on [DATE] in the facility. Resident #1 had a care plan that indicated the resident was at risk for falls related to impaired mobility, impaired cognition, incontinence, history of falls, and use of cardiovascular medications. The resident had the following care plan interventions as of [DATE]: -receive assistance with transfers to reduce the risk of falls -receive assistance with locomotion as needed -receive assistance with walking -provide clutter free environment -place call bell within reach, with prompt response to all requests -attend activities that do not put resident at risk for falls -ensure resident wears appropriate, well-fitting footwear to minimize the risk of slipping -mobility devices/equipment side rails, wheelchair -full side rails x 2 -rehab evaluation and follow up as ordered Additional interventions added to the care plan included the following: - ([DATE]), Chair/bed alarm on and functioning every shift - ([DATE]), Bilateral floor mats applied at bedside. Low bed. - ([DATE]), Shell program (Residents have a picture of a seashell displayed outside their room to let staff know the resident is a risk for falls and needs to be checked on frequently.) A review of the facility's incident reports revealed the following falls for Resident #1: - [DATE] - [DATE] - [DATE] - [DATE] - [DATE] A review of a nurse's note, dated [DATE], indicated an additional fall on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated on [DATE] revealed Resident #1's cognition was severely impaired. The resident required extensive assistance for bed mobility, transfer, dressing, and toilet use. The resident required supervision and set-up during eating and physical help for part of bathing activity. The MDS indicated the resident was not steady moving from seated to standing position, moving on and off the toilet, and surface to surface transfer. The resident had no upper or lower extremity impairment and used a wheelchair. A review of the incident report for the fall on [DATE] indicated Resident #1 was found lying on the resident's back, alert and verbally responsive, on the floor next to a wheelchair. Resident #1 verbalized that he/she was trying to walk. Resident #1 had confusion at times. The report indicated the possible cause of the incident/accident as confusion and noncompliance. The action taken to prevent reoccurrence was to monitor Resident #1's whereabouts and a chair/bed alarm. A review of a hospice note, dated [DATE], indicated the resident was able to transfer from bed to chair with one person assisting. A nurse aide reported increased weakness. A geriatric chair was implemented. (The geriatric chair was not added to the facility's care plan. A geriatric chair is a large, padded chair with a wheeled base, that can be fully reclined.) A review of the incident report for the fall on [DATE] indicated Resident #1 was found on the floor next to the bed by Certified Nursing Assistant (CNA) #10. It appeared Resident #1 had climbed out of bed over the side rails. The resident had bilateral side rails up. A skin tear was noted to the left arm near the elbow. The report indicated the bed alarm was not in place at the time of the fall. The possible cause of incident/accident was noted as, Trying to climb OOB [out of bed. The action taken to prevent reoccurrence indicated, Re-educating CNA [of] the importance of putting bed alarm on bed. Additional notes under actions taken indicated, Bed put in low position - floor mats added - bed alarm add [sic]. A review of a nurse's note, dated [DATE], indicated an additional fall on [DATE] at 9:40 PM. The resident got out of bed and claimed he/she slid. The resident was found sitting on the floor mat. A review of the incident report for the fall on [DATE] indicated Resident #1 was found by a CNA who alerted the nurse that Resident #1 was on the floor, lying on the right side, in front of geriatric chair. The RN supervisor was called to assess the resident. Upon assessment, a small 1 centimeter (cm) puncture wound was noted to the right side of the head. A skin tear (2 cm x 1 cm) was noted near the right elbow, with a skin tear appropriately 6 cm x 2 cm noted to the right posterior forearm. The possible cause of incident/accident was, Attempting to get up to walk. The actions taken to prevent reoccurrence indicated, Brought resident out to nurse's station to be monitored closely. An additional note in the incident report indicated the shell program was added on [DATE]. A review of the fall-risk evaluation dated on [DATE] revealed that Resident #1 had a score of 20 (high risk for falls). A review of the incident report for the fall on [DATE] indicated Resident #1 was found sitting on the floor mat beside the resident's bed. The incident report indicated that Resident #1 fell from the geriatric chair. No injuries noted. The action taken to prevent occurrence indicated that staff were to monitor Resident #1. The possible cause of incident/accident indicated Resident seems to [have] slide [sic] or climb out of the [NAME] [sic] chair. The action taken to prevent reoccurrence was Staff to monitor resident. The incident report indicated the bed alarm was on, but the resident fell from the chair. The chair alarm was not checked on the report as being in place at the time of the fall. The floor mat was in place. No new fall interventions were implemented for Resident #1. A review of the incident report for the fall on [DATE] at 7:30 PM indicated Resident #1 was found lying on the resident's left side beside the bed on the floor mat, and the bed was in the lowest position. The report indicated the resident fell from the chair. A skin tear was noted to the upper back side of head. The possible cause of incident/accident was, Resident showed signs of confusion saying [he/she] wants to go home. The action taken to prevent reoccurrence was, Put on a frequent watch or placing resident in a [NAME] [sic] chair and seat by the nursing station. The section of the report to indicate if alarms were in place was blank. There was also no written narrative to indicate if the alarms were in place. The intervention to put the resident on a frequent watch or place the resident in a geriatric chair and seat at the nursing station was not added to the care plan. A review of a Nursing assistant fall monitoring form for the incident on [DATE], revealed CNA #1 indicated that she saw Resident #1 after dinner sitting in the geriatric chair at approximately 7:00 PM. CNA #1 indicated that no alarm was in place and the alarm was not sounding at the time of incident. CNA #1 was counseled. A review of a nurse's notes written by LPN #4 (no longer employed at the facility) on [DATE] revealed Resident #1 was found lying on the resident's left side on the floor by the bed. A skin tear was noted at the upper posterior part of the head. The resident was able to move all extremities. A review of the nurse's notes written by Registered Nurse (RN) #5 on [DATE] revealed Resident #1 was seen and examined. The resident was noted to be lying on the resident's left side on the floor mat. A small amount of blood was noted at a skin tear to the upper back of the head. The resident denied pain, and there was no loss of consciousness. The resident was noted to be forgetful with confusion. The affected area was cleaned, and treatment was initiated. The resident was transferred back to the geriatric chair with 3 persons assisting. Resident #1 remained on fall precautions. A review of the hospice nurse's notes written by Registered Nurse (RN) #3 on [DATE] revealed the nurse received a call from the facility last evening reporting that Resident #1 was found on the floor at bedside, with a minor laceration to the head. The hospice note indicated the resident was lying in bed supine, guarding the right lower extremity, grimacing, and unable to perform passive range of motion to right lower extremity without extreme pain. The right lower extremity had external rotation. Recommendations were made to x-ray the right lower extremity/hip to rule out fracture. A review of Resident #1's radiology report dated on [DATE] revealed there was a right sub capital fracture with impaction and mild displacement of the right hip. The joint showed no dislocation. The conclusion was an acute right [CONDITION(S)]. A telephone interview on [DATE] at 11:54 AM with the RN #3 (Hospice Nurse) indicated that Resident #1 had end-stage heart failure and was a fall risk. RN #3 indicated that RN #5 called and said Resident #1 fell and cut the resident's head, and there was a small amount of blood. RN #3 indicated that the fall was on the weekend, and she came in on the following Monday and saw Resident #1. RN #3 indicated that Resident #1's right leg was externally rotated, and the resident was guarded and grimacing with pain. RN #3 indicated she ordered an x-ray of the right hip. RN #3 indicated that the fall could have been avoided because Resident #1 was at risk for falls and the resident's room was at the end of the hall. RN #3 further indicated that Resident #1's family member did not want the resident sent out of the hospital after the [CONDITION(S)] on [DATE]. RN #3 indicated that Resident #1's family wanted pain management and comfort measures for the resident. RN #3 indicated that hospice initiated the geriatric chair when Resident #1 was put on hospice. During an interview on [DATE] at 4:09 PM, Certified Nursing Assistant (CNA) #1 stated that she found Resident #1 on the floor and notified the nurse. CNA #1 indicated Resident #1 would at times unplug the chair alarm. CNA #1 indicated she remembered feeding Resident #1 dinner and she thought Resident #1 fell from the geriatric chair. CNA #1 further indicated that Resident #1 would get up unassisted. After family visits, Resident #1 would become agitated and want to go home. CNA #1 indicated that she was counseled for not making sure the chair alarm was in place during the fall on [DATE]. During an interview on [DATE] at 4:31 PM with RN #5, she stated she assessed Resident #1, and the resident did not complain of pain and was able to move lower and upper extremities after the fall. During an interview on [DATE] at 4:35 PM with LPN #6, he indicated Resident #1 was forgetful and confused and was a fall risk. LPN #6 further indicated the resident had bed and chair alarms. LPN #6 indicated Resident #1 was seated in a geriatric chair near the nurses' station at times. LPN #6 stated the resident was in a low bed and would still try to get up but was easily redirected. During an interview on [DATE] at 11:24 AM with LPN #7, she indicated she did not recall talking to Resident #1's family member, and to her knowledge it was agreed by Resident #1's family, Hospice Nurse #3, and the MD that Resident #1 would not go to the hospital and would instead be on pain management. LPN #7 indicated that Resident #1 had a history of falls at home. During an interview on [DATE] at 2:50 PM with LPN #2, she indicated she was made aware that Resident #1 had a fall, and Hospice Nurse #3 ordered the x-ray. LPN #2 indicated Hospice Nurse #3 reported that when she moved Resident #1's right leg on the next day, Resident #1 moaned. During an interview on [DATE] at 11:44 AM with Resident #1's MD, he indicated he was very familiar with Resident #1 prior to coming to the nursing home. The MD indicated Resident #1 fell several times at home, did not eat well, and the resident's memory was fading. The MD further indicated Resident #1's health had declined due to hypertension, advanced dementia, Alzheimer's, and protein malnutrition, and the resident was put on hospice. The MD said with the [CONDITION(S)] in [DATE], the resident's health further declined. The MD stated the hospice nurse recommended no surgery and just pain management and comfort measures due to the resident having all the other medical conditions. The MD agreed with Hospice Nurse #3 and Resident #1's family member for pain management. The MD indicated Resident #1's family member said no surgery. The MD stated that with Resident #1's poor intake and other diagnoses, Resident #1 would probably not make it through the surgery. MD indicated Resident #1 continued to decline after the [CONDITION(S)] and was not eating. The MD indicated probably the [CONDITION(S)] could have been a contributing factor of Resident #1's death, along with advanced dementia, Alzheimer's disease, and dysphagia. During an interview on [DATE] at 3:44 PM, the Administrator indicated that Resident #1's fall on [DATE] was during COVID-19, and residents were kept in their rooms. The Administrator indicated that staff were constantly checking on residents. The Administrator further indicated that the facility currently met on falls daily. She indicated it was hard to determine causal factors for residents who cannot verbalize what they were trying to do prior to the fall. During an interview on [DATE] at 4:00 PM, the Director of Nursing (DON) revealed that her employment started at the facility on [DATE], after the resident's falls. A review of the facility's Fall Management Policy, dated [DATE], read in part, Procedure: b) Implement a plan of care which promotes maximum safety from falls, yet maintaining the resident's autonomy, dignity, and ability to function at his/her highest practicable physical, mental, and psychological level. 2. When a resident experiences a fall: a) An Accident and Incidence Report shall be completed by the charge nurse. b) The Resident Safety Committee shall evaluate each resident following a fall for progression of interventions. c) Fall interventions may include: low beds, half side rails, eye glasses, lap buddies, rest periods, reclining geriatric chair, supportive footwear and/or slipper socks, monitoring for [CONDITION(S)], positioning devices, pain management, food/hydration, mobility aids, toileting programs, reassurance, activity programs, optimal lighting, ambulation program, maintenance of communication with family/friends, accessible call lights, use of bedside commode, varied sitting locations, physical examination by attending physician or consulting physicians as needed, screen for use of wander guard alarm, and medications for mood/behavior problems. 3. Those residents assessed at high risk will be in the Shell Program. 4. The Interdisciplinary Care Team shall monitor for any indicators of increased falls, examining possible causative factors and then implementing a plan of care to eliminate these factors. 5. The Interdisciplinary Care Team and Falls Team will also note a reduction in the frequency of falls. Incidents and Accidents - Investigating and Recording a) The Resident Safety Committee shall evaluate incident reports and review falls for additional recommendations. b) Representation on the Resident Safety Committee shall include, but is not limited to, nursing, rehabilitation, administration, recreation, and social services departments. c) The committee shall establish a meeting schedule based upon need and meet at least once a week. d) The Medical Director will review all Incidents and Accidents Reports, including those with no injury. New Jersey Administrative Code § 8:39- 5.1(a)

C#: NJ 9 Based on interviews, medical records (MR's) review, and review of other pertinent facility documents on 4/9/2019 and 4/22/2019, it was determined that the facility failed to adequately supervise a resident with a known history of falls on 3/7/2019, which resulted in a fracture to the left hip for 1 of 5 residents (Resident #3) reviewed for falls. This deficient practice required Resident #3 to be transferred to the hospital for a surgical repair of the left hip. This deficient practice was evidenced by the following: 1. According to the Record of Admission reviewed on 4/22/2019, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 2/7/2019, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 11/15, which indicated Resident #3 had moderate cognitive impairment. The MDS also indicated that Resident #3 required extensive one person assist for transfers, and extensive assist with Activities of Daily Living (ADLs). Review of a facility's document titled, Fall Risk Evaluation, an assessment tool for falls dated 2/12/19, revealed Resident #3 had a score of 16. According to the Fall Evaluation document a resident with a total score of 10 or above represents high risk for falls. According to the Occupational Therapy (OT) Evaluation & (and) Plan of Treatment, dated 1/28/2019, under section Assessment Summary, revealed the following: Risk Factors. Due to documented physical impairments and associated functional deficits, the patient is at risk for falls, further decline in function and immobility. Review of Resident #3's Plan of Care, initiated 10/30/2017, the Resident was a Risk for falls due to difficulty walking and muscle weakness related to left [MEDICAL CONDITION], poor safety awareness, history of recent falls, and use of cardiovascular medications. The Plan of Care, initiated 2/19/19 included the following interventions: Resident to be supervised at all times during toileting. Review of Resident #3's Resident Incident or Accident Report (RIAR) dated 1/22/2019 at 7:00 a.m., completed by the Registered Nurse (RN), revealed that the resident was sitting on the toilet in the resident's room and fell off of the toilet, and hit his/her head. The RIAR also showed that there was no injury noted. Review of the facility's Department /Supervisor Follow Up Quality Assurance Evaluation, reviewed by the Supervisor/District Manager on 2/7/2019, revealed the Possible cause of the incident/accident was that the Resident was sitting on the toilet and fell off, and hit his/her head. The document also showed Action taken to prevent reoccurrence: safety awareness, stay with resident when on toilet. Review of Resident #3's RIAR dated 3/7/2019 at 10:00 a.m., completed by the Licensed Practical Nurse (LPN #1), revealed that the Resident was put on the toilet in the resident's room by the Certified Nursing Assistant (CNA #1). The RIAR also revealed that CNA #1 heard a thump and went into the bathroom and found the Resident on the floor lying on the left side. Review of the Department / Supervisor Follow Up Quality Assurance Investigation, evaluated by Nursing Administration on 3/14/2019, revealed the Possible cause of the incident/accident was: The Resident attempted to get up from toilet. Under Action taken to prevent reoccurrence: Educate aide to stay with resident at all times. Under Investigation revealed CNA #1 placed Resident #3 on the toilet and stepped out from the BR (bathroom) to obtain the resident's clothes from the closet and heard a thump sound. Review of a facility's document unnamed written by CNA #1 dated 3/7/2019, included the following: the CNA took Resident #3 to the bathroom in the resident's room, and transferred the resident to the toilet. The document also indicated that the CNA left the resident on the toiled and went to the resident's closet to get the Resident's hat and coat. CNA #1 further wrote that the CNA heard a thump within a second, and the Resident had fallen off of the toilet. Review of Resident #3's Integrated Progress Notes (IPN), dated 3/7/2019 at 10:00 a.m., revealed the resident complained of left leg pain at 3:08 p.m., the Medical Doctor (MD) was notified and an x-ray of the left leg was ordered at 3:12 p.m. Review of Resident #3's Telephone Orders (TO's) dated 3/7/2019 at 1:00 p.m., revealed the following physician's orders [REDACTED]. The order included an x-ray of the left femur and left tibia/fibula due to a DX. (diagnosis) of pain. Review of the Radiology Report (RR) dated 3/7/2019 at 9:03 p.m., under section Examination revealed the following: Results: No dislocation or destructive bony process. No soft tissue abnormality. Acute, left hip intertrochanteric fracture. Distal femur is intact. Review of Resident #3's TO's dated 3/7/2019 at 9:30 p.m., revealed the following PO's: Send the resident to the ER (emergency room ) for eval (evaluation), due to a [DIAGNOSES REDACTED]. Review of Resident #3's hospital records dated 3/7/2019 at 10:32 p.m., Under Provider Documentation Final Report revealed the following: Under Medical Decision Making: Differential [DIAGNOSES REDACTED]. Review of the Resident's hospital RR dated 3/7/2019 at 11:20 p.m., under final report revealed the following: Impression: Left intertrochanteric fracture with superior displacement Under Impression and Plan, showed Diagnosis: [REDACTED]. Review of Resident #3's Intraoperative Report, dated 3/8/2019 at 3:14 p.m., showed the Resident pain was a 5 out of 10 on a 0-10 pain intensity scale (with 0 being no pain and 10 being the worst pain). According to the hospital records Resident #3 was ordered [MEDICATION NAME] 50 mg (milligram), orally every 4 hours, as needed. Review of Resident #3's hospital Operative Report dated 3/8/2019 at 3:45 p.m., showed the Resident had a surgical repair of the left [MEDICAL CONDITION]. During an interview with the Assistant Director of Nursing (ADON) on 4/22/2019 at 3:12 p.m., the ADON stated that on 3/7/2019, CNA #1 took Resident #3 to the bathroom and sat the resident on the toilet. In addition, the ADON stated that the CNA left the Resident on the toilet and went into the closet to obtain the Resident's hat and coat resulting in the Resident's fall. The ADON also explained that the CNA should not have left the Resident in the bathroom, this was care planned because the Resident had a previous fall in the Resident's bathroom. The facility staff failed to follow Resident #3's care plan interventions for supervision during toileting to prevent falls, when CNA #1 placed the resident on the toilet and left the resident unsupervised. This resulted in Resident #3 sustaining a fall which caused the resident to have a [MEDICAL CONDITION] hip. Review of the Facility's Policy titled, Fall Management/ Fall Assessment with a review date of 2/14, included but were not limited to the following: Under Policy Statement: Each resident is entitled to the freedom to pursue the highest possible level of independent physical functioning Under Procedure: 1. Falls have a profound impact upon the physiological and physical health of our residents and a multidisciplinary approach is used in order to: b) Implement a plan of care which promotes maximum safety from falls, yet maintaining the resident's autonomy, dignity and ability to function at his/her highest practicable physical, mental and psychological level. N.J.A.C: 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to: a.) investigate eight separate incidents of resident to resident sexual abuse by a cognitively impaired male resident (Resident #1) toward two cognitively impaired female residents (Residents #21 and #25) and b.) protect four alert and oriented residents (Residents #27, #28, #29 and #30) from resident to resident physical and mental abuse on multiple and separate occasions by another alert and oriented resident (Resident #14) who resided on the same unit. There were incidents perpetrated by Resident #1 from 4/21/13 through 6/13/13, with no interventions implemented to protect the victims or to modify the behaviors of Resident #1. In addition, there were no interventions implemented to protect the victims or to modify the behaviors of Resident #14 to address the documented incidents of physical and mental abuse from January 2013 to July10, 2013. This deficient practice constituted an Immediate Jeopardy situation for 8 of 9 residents reviewed for abuse (Residents #1, #21 and #25 and for Residents #14, #27, #28, #29 and #30). The Immediate Jeopardy was identified on 7/10/13. An acceptable plan of correction was submitted on 7/10/13 and the team verified that the jeopardy situation was corrected on that date based upon actions taken by the facility. The following evidenced the deficient practice: 1.) During the initial tour of the Comfort Care unit that was conducted by the surveyor on 7/08/13 at 10:00 am, the Registered Nurse stated that Resident #1 was alert and confused. The RN also stated that Resident #1 "liked the ladies" and was known to make sexual advances toward female residents and staff. At this time, Resident #1 was observed seated in a wheelchair in attendance at group activity. The resident was observed again at 10:30 am self-propelling in his wheelchair, and moving freely through out the unit. According to the medical record, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Resident Assessment Instrument (RAI) dated 4/8/13, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating that the resident was identified as being moderately impaired for cognition. This RAI also indicated that Resident #1 required supervision from staff for transferring from the bed to a wheelchair, and was able to ambulate with the use of a cane or walker. A review of the medical record revealed that on 1/06/13, 1/09/13, 1/30/13 and 1/31/13, Resident #1 had made sexually inappropriate comments, gestures, and/or physical advances toward a female staff member. A review of an "Integrated Progress Notes" dated 4/21/13 (untimed) revealed that staff had found Resident #1 inside of his room with a Resident #25, a cognitively impaired, female resident. Resident #1 had cornered Resident #25 inside the room and was trying to "kiss" the resident. Resident #1 did not want to let Resident #25 out of the room and this incident was reported to Resident #1's physician. A review of an "Integrated Progress Notes" dated 5/06/13 at 7:30 am revealed that Resident #1 was inside a dining room on the unit. The note indicated that Resident #1 left the table that he was seated at and moved to another table were an unidentified female resident was seated. At this time, a staff member observed Resident #1 "flirting" with the female resident. The note also revealed that the resident became annoyed with Resident #1's behavior, and the staff removed Resident #1 from the table. A review of an "Integrated Progress Notes" dated 5/30/13 (untimed) revealed that Resident #1 was observed by staff making inappropriate sexual comments to another unidentified female resident. Staff redirected Resident #1 for his behavior, and a few minutes later, Resident #1 was observed again making sexual comments to female residents. The note indicated that this incident was also reported to the resident's physician. A review of "Integrated Progress Notes" dated 6/5/13 at 1:15 pm revealed that during an activity program, Resident #1 was seated next to a resident and "pulled out his penis trying to get female resident to touch it." Further review of "Integrated Progress Notes" dated 6/8/13 at 1:00 pm, revealed that staff found Resident #1 undressed inside a bathroom with an unidentified female resident. The note revealed that staff observed Resident #1 asking a female resident to remove her clothes. The female resident was removed from the bathroom by staff and this incident was reported to a nurse. Further review of this same note revealed that Resident #1 continued to say inappropriate sexual comments to female residents residing on the unit. According to this same note, the staff felt "uncomfortable" and had even attempted to ask the Resident #1 to leave activity programs for acting inappropriately. Additionally, this note revealed that when Resident #1 behavior was corrected by staff, the resident still found everything "funny." A review of a "Integrated Progress Notes" dated 6/8/13 at 4:00 pm revealed that staff found Resident #1 with Resident #21, a female resident, inside his room. Both Resident #1 and Resident #21 were undressed from the waist down. According to this note, Resident #21 was lying on the bed, and Resident #1 was seated on the bed with "full hand contact" on Resident #21's "genitalia." This same note revealed that both residents were separated by staff and that the doctor and the facility's Director of Social Services were notified. According to this note Resident #1 was place on hourly checks for observation. When interviewed by the surveyor on 7/10/13 at 10:15 am, the Administrator (LNHA) and the Assistant Director of Nursing (ADON) stated that they were aware of the "incidents" involving Resident #1. The LNHA stated that it was known to staff that Resident #1 made "flirtatious remarks" to female residents and staff. The LNHA said that staff was to remove Resident #1 from the area where residents that he liked were gathered or keep the resident occupied with activities. During this same interview, the LNHA stated that the female resident involved in the 6/8/13 sexual assault incident was Resident #21. The LNHA stated that Resident #21 was not sent to the hospital for an evaluation because the nurse on duty at the time of the incident performed a physical examination and determined that "nothing" happened. When interviewed further, the LNHA stated that the nurse did not have any experience or training in examining victims of sexual assault. The LNHA also stated that the nurse documented the physical assessment in Resident #21's record. According to the record for Resident #21's, the resident was admitted to the facility with [DIAGNOSES REDACTED]. A review of the RAI dated 4/24/13 revealed that Resident #21 had long and short term memory problems. This same RAI revealed that Resident #21 could ambulate with the use of cane. A review of Resident #21 record lacked any documentation of a physical examination being done following the sexual assault that occurred on 6/8/13 and there was no documentation of the incident on the record. During a follow-up interview on 7/10/13 at 10:40 am, the LNHA stated that the Director of Social Services was responsible for doing the investigations. The LNHA said that no incident report or investigation had been done for any of the incidents involving Resident #1. The LNHA also stated that none of these incidents were reported to the Department of Health. During a follow-up interview conducted on 7/10/13 at 11:05 am, the Director of Social Services stated that she was in the building at the time the incident occurred on 6/8/13. The Director of Social Services stated that there was no investigation was done nor was (DOH) notified. In addition, the Director of Social Services stated that Resident #1's physician was also in the building on 6/8/13 and was had been seen by the physician. When interviewed on 7/10/13 at 11:15 am, the Director of Social Services stated that after the 6/5/13 incident, Resident #1 was placed on hourly checks. During this same interview, the LNHA stated that Resident #1 was not on hourly checks and that the resident was being monitored by staff. The LNHA stated that staff was trying to keep Resident #1 within eye site. The LNHA also stated that Resident 1's behavior constituted abuse. Then during a subsequent review of the medical record, an "Integrated Progress Notes" dated 6/11/13 at 5:05 am revealed that Resident #1 came out of his room, and wheeled down the hallway. According to the note, a certified nursing assistant (CNA) heard a resident yell "Stop That." This CNA discovered that Resident #1 was exposing himself to a another unidentified female resident who was seated in a wheelchair, in hallway of the nursing unit. A review of an "Integrated Progress Notes" dated 6/13/13 at 12:10 pm revealed that Resident #1 was observed by several staff members exposing himself to female residents. According to the note, Resident #1 was redirected by staff, and was moved away from the other residents. This same note revealed that Resident #1 could only be redirected by staff for short periods of time. The note revealed that Resident #1 would move back to an area where the female residents were and would make sexual comments to them. According to the Abuse Reporting policy dated 2/13, The facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. Any alleged violation involving mistreatment, neglect, or abuse including injuries of an unknown source and misappropriation of resident proper must be reported to the Administrator...According to this policy, sexual abuse is defines as, but not limited to, sexual harassment, sexual coercion, or sexual assault...Upon receiving reports of physical or sexual abuse, the charge nurse shall immediately examine the resident and report to his/her supervisor. Findings of the examination must be record in the resident's medical record. (Note: If sexual abuse is suspected, DO NOT bathe the resident or wash the resident's clothing or linen. Call the police immediately.) 2. During a tour of the nursing unit on 7/8/13 at approximately 10:45 a.m. the Charge Nurse (CN) stated Resident #14 had behavioral issues and argued with and made negative statements to and about other residents. The CN said there were certain other residents whom Resident #14 did not like. The CN said Resident #14 was a "handful" and "in [AGE] years of being a nurse" this resident was "the worst I've ever seen." On 7/10/13 at 9:20 a.m., the surveyor observed Resident #14 in the bedroom in a wheelchair. The resident's legs were on the bed and the resident was watching television. The surveyor spoke to the resident for some time. The resident was alert and oriented and very pleasant. Resident #14 said there were some other residents at the facility whom he/she did not like because they were "nosy" about personal issues. The resident said he/she simply avoided those other residents. The resident denied any verbal or physical altercations with other residents. On 7/10/13 at approximately 9:45 a.m., the surveyor began reviewing the medical record of Resident #14. The record indicated Resident #14 was admitted to the facility on [DATE] from the hospital. According to the admission Integrated Progress Notes (IPN), Resident #14 did not exhibit any behavioral issues and was pleasant, social and cooperative. According to a "Daily Skilled Nurse's Note" dated 1/28/13, Resident #14 complained in physical therapy that another resident had touched him/her inappropriately during breakfast. There was no information in the note about who the other resident was and no subsequent notes mentioned the incident. On 7/10/13 at 3:12 p.m. the surveyor reviewed the incident investigations for Resident #14 which were provided by the Assistant Director of Nursing (ADON). There was no incident investigation for this complaint. According to the medical record, there was a note dated 1/27/13 in the "Psychoactive Drug Use Summary" indicating that the targeted behavior of Resident #14 was anxiety. The note indicated the resident was demanding, uncooperative with staff and anxious at times but interacted with peers and staff. Resident #14 was evaluated by the psychologist on 1/31/13. The reason for referral was listed as "suspicious, critical, and demeaning of another resident and uncooperative with physical therapy." There was no documentation of these behavioral issues found in the IPN or Daily Skilled Nurses Notes. The psychologist indicated the resident was receiving as-needed [MEDICATION NAME] for anxiety and [DIAGNOSES REDACTED].#14 had experienced a single episode of mild [MEDICAL CONDITION], had early onset dysthymic disorder (a [MEDICAL CONDITION]), and had moderate [MEDICAL CONDITION]. The psychologist recommended starting the anti-depressant drug [MEDICATION NAME]. According to a Daily Skilled Nurse's Note, dated 2/11/13 during the day shift, Resident #14 threatened to have family members "come after" a resident who resided on another unit. The note, written by the CN, stated Resident #14 did not like this resident. The other resident was not identified in the note. An IPN on 2/12/13, indicated Resident #14 was cooperative with care and had periods of being argumentative with staff but was interactive with other residents. An IPN written by the Social Worker (SW) on 2/14/13 indicated Resident #14 had been argumentative but did not indicate with whom or how often. The SW indicated Resident #14 was alert and oriented. According to a Progress Report (PR) dated 2/14/13, Resident #14 was evaluated by the psychologist who indicated the resident had been experiencing "paranoid behavior - fearful a man is watching" him/her. Documentation of these behaviors was not found in the IPN or the Daily Skilled Nurse's Notes. The resident denied any fears to the psychologist. According to a Progress Report (PR) dated 2/26/13, Resident #14 was evaluated by the psychologist who indicated the resident had been "angry, insulting and cursing at peers and staff." Documentation of these behaviors was not found in the IPN or the Daily Skilled Nurse's Notes. Additional IPN were reviewed by the surveyor and the following was revealed: On 2/28/13 at 11 a.m., Resident #14 became agitated because of a missing personal item. The resident was given a dose of [MEDICATION NAME] and spoken to by the SW. The missing item was located in the resident's room in a short period of time. On 3/1/13 at 7 p.m. the resident was heard yelling at another resident and making threatening statements. As the other resident was taken to the room, Resident #14 followed and was observed shaking his/her fists. On 3/8/13 at 2 p.m. the resident was overheard making "threatening comments" to another resident. The comments were not described in the note. According to the note, the SW was made aware. On 3/10/13 at 10:30 a.m. the CN was told by another resident that Resident #14 had begun an argument with him/her while in an activity. The CN indicated Resident #14 had been spoken to several times by the SW regarding behavioral issues. On 3/10/13 at 3:30 p.m. an activities staff member documented that Resident #14 had been disruptive during morning and afternoon activities. There was no information about what had occurred or how often. On 3/10/13 at 6:30 p.m. a late entry was written for 3/9/13 by a nurse. This note indicated Resident #14 had been heard yelling at another resident. On 3/10/13 at an unreadable time, a nurse documented that Resident #14 stomped his/her right foot and was yelling at another resident. When attempting to counsel the resident about the behavior, Resident #14 became loud and argumentative with the nurse. On 3/11/13 at 11 a.m. Resident #14 was overheard by a nurse speaking to another resident in an "aggressive and threatening" manner about that resident's roommate, who was not in the area. There was no description about what was said or done. The note stated the nursing office was made aware of the incident. According to a Progress Report (PR) dated 3/12/13, Resident #14 was evaluated by the psychologist who indicated the resident had been "yelling, threatening, arguing" with other residents. The PR indicated the resident denied behavioral issues and accused the psychologist of "picking on" him/her. The resident asked for proof of behaviors and the psychologist read several medical record entries to Resident #14. The resident then removed him/herself from the evaluation and began telling staff and other residents "The psychologist, he's after me. He needs a job so he's not picking on me." The psychologist attempted to intervene but was dismissed by the resident. The psychologist indicated the following "Recommend: Consider transfer to a facility with a behavior unit." IPN (cont): On 3/12/13 at 8 p.m. Resident #14 was heard screaming at another resident and was not able to be redirected. On 3/13/13, SW documented that Resident #14 had been yelling and threatening others and was being counseled. The note indicated the resident's son was being notified and the SW would discuss placement of the resident in another facility. According to a Progress Report (PR) dated 3/14/13, Resident #14 was evaluated by the psychologist who indicated the resident's son had been interviewed separately by the psychologist. The psychologist indicated Resident #14 was mildly delusional, felt persecuted and had poor reasoning abilities. The psychologist recommended starting the anti-anxiety drug, [MEDICATION NAME]. An IPN written by the SW on 3/19/13 indicated she had a meeting with the son of Resident #14 on 3/14/13. The SW indicated that the resident's behaviors, possible discharge and names with phone numbers of other nursing facilities were discussed and given to the son. The SW documented that the son preferred Resident #14 to stay at the facility. On 3/28/13 at 8 a.m. indicated Resident #14 was screaming at another resident who was in a wheelchair. The note indicated Resident #14 "always makes negative statements toward" this resident. The note documented that the CN overheard Resident #14 say that if the other resident had been ambulating he/she would have kicked the other resident. The note indicated the Assistant Director of Nursing was made aware of the incident. On 4/2/13 at 12 noon indicated Resident #14 "continues with aggressive, bully-like behaviors toward peers today." The note indicated Resident #14 began screaming at another resident and that these two residents had been in a verbal altercation at 9 a.m. that same day. The note indicated that "this nurse had to physically break-up the two of them" and walked the other resident away from the area. Resident #14 was overheard saying in regard to the other resident "I'm going to murder that woman if she comes near me or says anything else to me. I'm not afraid of that bit**. She doesn't know what I can do to her." Social Services and the nursing office were notified according to the IPN. On 4/2/13 at 1 p.m. was written to clarify another IPN written on 3/11/13 at 11 a.m. The 3/11/13 note indicated the resident was "threatening" but did not reveal how. This clarification note indicated Resident #14 put two fingers up to his/her head and make a "gun-like gesture" while saying to a resident "I want to do this to your roommate. Pow-Pow." The roommate was not in the area. On 4/3/13 at 5:30 p.m. indicated Resident #14 was heard yelling at another resident in the dining room. When staff attempted to redirect the resident, Resident #14 continued to speak, called the other resident a "Bit**" and threatened to throw a glass of water at the other resident. According to a Progress Report (PR) dated 4/9/13, Resident #14 was evaluated by the psychologist who indicated the resident had been "rude, aggressive, threatening and insulting to peers." The psychologist documented "The patient is challenging and is unable to take responsibility for the behavior. There is a sense of grandiosity and entitlement" for this resident. The psychologist then diagnosed the resident with Borderline Personality Disorder with histrionic and narcissistic characteristics. The psychologist indicated Resident #14 was "appropriate for a facility with a behavior unit that provides structure to manager the behaviors more successfully." An IPN on 4/11/13 at 9 a.m. indicated Resident #14 was yelling at another resident while being pushed in the wheelchair to attend an activity. The resident yelled "Why do you keep staring at me?" and the other resident said he/she was not looking at Resident #14. The note indicated Resident #14 was counseled by the ADON. On 4/11/13 the SW indicated the son of Resident #14 was informed of the behaviors of the resident. The note indicated the son said he did not believe the SW and was yelling at the SW. On 4/12/13 at 11 a.m. Resident #14 was evaluated by the Statewide Clinical Outreach Program for the Elderly (S-COPE). The recommendations were as follows: a. Attempt to limit opportunities for resident to come into contact with the "target residents" of Resident #14. b. Reward for positive behaviors. c. Educated staff on use of behavioral logs and left handouts for behavioral escalation and Borderline Personality Disorder. d. Offered in-service on working with personality disorders. e. Quickly and calmly removed from situation and do not try to reason with resident. These recommendations were relayed to the SW and CN per documentation on the form. An IPN on 4/24/13 at 5 p.m. indicated Resident #14 was heard arguing with another resident in the hallway. Resident #14 claimed the other resident bumped his/her wheelchair. While attempting to redirect the situation, Resident #14 became loud and argumentative and said "Staff don't help. I'll take it in my hand." On 4/27/13 at 2:30 p.m. indicated Resident #14 was "still noted to be argumentative towards other residents, picks fight/confrontation, swears at them." The note indicated redirection was successful but lasted only a short while. On 5/2/13 at 4:25 p.m. indicated Resident #14 was loudly cursing at the psychologist while at the nurse's station. While being separated Resident #14 was screaming "Fu**ing Bit**." The resident was brought to the bedroom and could not be redirected and told the staff to "get out of my face." According to a Progress Report (PR) dated 5/2/13, Resident #14 was evaluated by the psychologist for anxiety, agitation and aggressive behavior. The psychologist indicated the resident became argumentative and mentioned his/her son. The psychologist asked the resident whether the son's involvement would be wanted at this time and the resident said yes. The psychologist called the son and Resident #14 became histrionic (excessively emotional and attention seeking) and upset the nursing unit. The psychologist stated that Resident #14 was not appropriate for the facility due to behavioral issues. The psychologist indicated he would no longer follow this resident. An IPN on 5/3/13 indicated Resident #14 was making "smart comments" about other residents, was starting arguments and was very disruptive. The note also indicated Resident #14 was expressing hatred for other residents on the unit. On 5/6/13 an IPN indicated Resident #14 continued to make negative comments about a resident every time he/she saw that other resident. An IPN on 5/10/13 at 9 a.m. indicated Resident #14 was being "verbally abusive" to another resident when that resident attempted to visit the roommate of Resident #14. Resident #14 told the other resident to leave the room, called the other resident a "Bit**" and slammed the door in the face of the other resident. An IPN on 5/10/13 at 3:30 p.m. indicated Resident #14 was "making snide remarks" about other residents while at the nurse's station. On 5/11/13 the SW wrote an entry that indicated it was a late entry for 5/3/13. The SW indicated the behaviors of Resident #14 had "become a problem" and that the resident was threatening and cursing at other residents. The SW stated "at this time" the resident "may be considered for a behavioral unit." An IPN on 5/11/13 at 8:30 a.m. indicated that Resident #14 was laughing while going to dining room and said "I love it, each time they see me, they shake. I like that." The staff asked the resident not to return to the dining room but the resident ignored the request. An IPN on 5/13/13 indicated it was a late entry for 5/3/13 and revealed Resident #14 continued to make "inappropriate abusive remarks toward other residents" and had been counseled by staff. According to a Progress Report (PR) dated 5/16/13, Resident #14 was evaluated by the psychologist who indicated that when approached, the resident became verbally abusive. The psychologist re-stated "considering the patient's behavior history, patient is not appropriate for this facility and requires a more restrictive environment. Discharge to a facility with a behavior unit." The psychologist indicated he would not approach this resident again because both the resident and his/her son threatened to sue the psychologist. An IPN on 5/19/13 indicated Resident #14 was aggressive and made "snide" comments to another resident. An IPN on 5/25/13 indicated that at 9:30 a.m. Resident #14 began an argument with another resident and said "Fu** you, get away before I kick your a**, I'm gonna punch you in the face." According to the note, the argument started because Resident #14 was jealous of attention that the other resident was providing to a third resident. The note indicated the nurse "had to physically separate" the arguing residents and while taking the third resident down the hall, the other nurse had to stand in front of Resident #14 to prevent Resident #14 from returning to the nurse's station to "get at" the other resident. An IPN on 5/31/13 at 10 a.m. indicated Resident #14 was overheard arguing with another resident and said "I hate that woman, she makes me sick just looking at her, who does she think she is?" The note indicated the SW spoke to the resident. An IPN on 6/6/13 at 4:30 p.m. indicated Resident #14 was screaming at another resident while at the nurse's station. Resident #14 was observed going toward the other resident, trying to get to the other resident while arguing about a third resident. Staff intervened but Resident #14 was still loud and cursing. After being spoken to about the behavior, the note described the resident as "nasty." The note indicated the SW was aware. An IPN on 6/10/13 at 8 a.m. indicated Resident #14 was laughing at another resident. That resident called Resident #14 an "idiot." Resident #14 became "enraged" and began propelling the wheelchair toward the other resident and said "What did you call me? You and your big glasses. Why don't you shut the fu** up?" The note indicated that the staff intervened. On 6/11/13 the SW indicated Resident #14 was counseled several times about behavioral issues. An IPN on 6/17/13 at 4:25 p.m. indicated Resident #14 called another resident a "bit**" during an activity at approximately 2 p.m. The note indicated that the resident was asked to stop but continued the behavior. In an IPN on 6/17/13 the SW indicated Resident #14 was counseled about behavior and making negative comments about others. The resident denied being the cause of issues. The SW indicated the facility would look into a room change to another unit of the facility when the resident said he/she could not "relate" to the other residents. On 6/19/13 the SW indicated Resident #14 was counseled for another incident with a resident. This incident was not documented in the medical record so its nature and severity were not known. The SW indicated Resident #14 said he/she hated another resident during the counseling session. The SW documented that Resident #14 said he/she wanted to be transferred to another facility. The SW indicated Resident #14 was shown a room on another unit of the facility but the resident said he/she did not want to move there. The SW indicated the family of the resident would be contacted. In an IPN on 6/20/13 the SW indicated that the son of Resident #14 refused to speak to her and requested that someone else call him. On 6/20/13 by another SW indicated that the facility requested a meeting on 6/27/13 with the son regarding the behaviors of Resident #14. The SW indicated that the son was informed that the Office of the Ombudsman might need to be contacted. On 6/28/13 the SW indicated that at 9:30 a.m. Resident #14 began to yell at another resident "Do you have something to say to me" and requested that if something was to be said, it was said face to face. When the nurse attempted to redirect the situation, Resident #14 loudly said "I am not going any damn where, why am I the one to be separated?" The note indicated the resident's son was called and a message was left. The note indicated the son failed to keep the previous day's appointment with the SW. The subsequent SW note on 6/28/13 indicated the Ombudsman's office was contacted regarding the behaviors of Resident #14. A notation at 11:30 am indicated the resident's son called the facility but hung up on the SW. The next SW note, at 11:45 a.m. indicated that Resident #14 asked to speak with the SW after speaking with the son. Resident #14 was "very argumentative" with the SW as the resident did not believe he/she caused any issues. On 6/28/13 a note indicated Resident #14 was screaming at another resident and said "I hate all of these people here. Everyone here is against me. I'm sick and tired of being here and being picked on." The note indicated the SW spoke with the resident. On 7/2/13 at 9 a.m. an IPN indicated Resident #14 started shouting at another resident "You are a nosy Mother Fu**er, I hate you, I can't stand looking at you. You ugly bit**." The other resident did not respond. Resident #14 was removed from the area. On 7/3/13 an IPN indicated Resident #14 attempted to run his/her wheelchair into another resident who was ambulating with a walker. The other resident screamed for help in removing Resident #14. Resident #14 was noted with "resistance" to being removed and said "I am not going any damn where." The resident was "very argumentative" with the CN and the Assistant Administrator and said "I want to get the Hell out of this place. I don't like it here. Everyone picks on me." On 7/3/13 an IPN written by the SW indicated Resident #14 was counseled regarding behaviors. The resident denied the behaviors to the SW and said he/she wanted to go somewhere else and asked for assistance. In an IPN on 7/5/13 the SW indicated Resident #14 said he/she did not want to move. The SW counseled the resident about the behavioral issues. The SW indicated that 2 other facilities were contacted but the resident said he/she did not want any referral made. The surveyor reviewed the "Psychoactive Drug Use Summary" forms for January 2013 through June 2013 and the following was identified: a. The resident's targeted behavior was anxiety for January through April. In May "verbally loud/abusive" was added as a targeted behavior. In the area of the form for documenting the monthly episodes observed of each targeted behavior, all were blank. b. The 2/13 note (no specific date documented) included general remarks which indicated Resident #14 could be argumentative and aggressive with peers. c. The 3/23/13 note included general remarks which indicated Resident #14 could be loud, argumentative and threatening with other residents and could not be redirected. d. The 4/14/13 note included general remarks which indicated Resident #14 could be argumentative with other residents at times. e. The 5/25/13 note included remarks that Resident #14 had periods of anxiousness and pacing back and forth in the hallway and bedroom. The pacing behavior was not found documented in the medical record. The note also made a general reference to be

Based on observation, interview and record review, it was determined that the facility failed to implement their abuse policy and procedure for: a.) a cognitively impaired male resident (Resident #1) who had a history of [REDACTED].#25) who along with Resident #1 resided on the same secured dementia unit and b.) an alert and oriented resident (Resident #14) who was physically and mentally abusive to four alert and oriented residents (Residents #27, #28, #29 and #30) who all resided on the same nursing unit. The facility staff were aware of the sexually abusive behavior of Resident #1 and the physically and mentally abusive behavior of Resident #14 and failed to implement their policy and procedure for abuse prevention. Resident #1 continued to subject Residents #21 and #25 to inappropriate sexual gestures, sexual harassment, and in one case, the sexual assault of Resident #21. Resident #14 continued to subject Residents #27, #28, #29 and #30 to mental abuse, and in one case, physical abuse to Resident #27. Although there were documented incidents perpetrated by Resident #1 from 4/21/13 through 6/13/13, there were no interventions implemented from the facility's abuse prevention policy to protect the victims of Resident #1 and Resident #14. The incidents documented in the medical record of Resident #1 included but were not limited to: notations of this cognitively impaired male resident being permitted by the staff to wander, unsupervised, through a secured nursing unit for residents with dementia. As a result, two cognitively impaired female residents (Residents #21 and #25) suffered inappropriate sexual gestures, sexual harassment and sexual assault. The incidents documented in the medical record of Resident #14 included but were not limited to: notations of an alert and oriented resident being permitted by staff to wander, unsupervised, through one of the two second floor nursing units. As a result, four alert and oriented residents were subjected to being punched (Resident #27) and threatened with bodily harm (Residents #27, #28, #29 and #30). This deficient practice constituted an Immediate Jeopardy situation for Residents #1, #21and #25 and for Residents #14, #27, #28, #29 and #30 who were 8 of 9 residents reviewed for abuse. The Immediate Jeopardy was identified on 7/10/13. An acceptable plan of correction was submitted on 7/10/13 identifying that the jeopardy situation was corrected on that date based upon actions taken by the facility. These actions included: a.) 1:1/ 24 hour supervision of Resident #1 and counciling of Resident #14 on behavior; b.) revision and implementation of the care plan of Resident #1 and Resident #14; c.) possible discharge of Resident #1 and Resident #14 to a more appropriate setting; d.) the hourly documentation by staff of the location and activity of Residents #1 and #14; d.) education of staff to identify, supervise and manage the behaviors of residents with resident to resident abusive behaviors. The following evidenced the deficient practice : 1.) During the initial tour of the Comfort Care unit that was conducted by the surveyor on 7/08/13 at 10:00 am, the Registered Nurse stated that Resident #1 was alert and confused. The RN also stated that Resident #1 "liked the ladies" and was known to make sexual advances toward female residents and staff. At this time Resident #1 was observed seated in a wheelchair in attendance at group activity. The resident was observed again at 10:30 am self-propelling in his wheelchair and moving freely through out the unit. According to the medical record, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Resident Assessment Instrument (RAI) dated 4/8/13, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating that the resident was identified as being moderately impaired for cognition. This RAI also indicated that Resident #1 required supervision from staff for transferring from the bed to a wheelchair, and was able to ambulate with the use of a cane or walker. During the initial tour of the Comfort Care, the facility's secured dementia unit, and conducted on 7/08/13 at 10:00 am, the Registered Nurse stated that Resident #1 was alert and confused. The RN stated that Resident #1 "liked the ladies" and was known to make sexual advances toward female residents and staff. At this time, Resident #1 was observed seated in a wheelchair in attendance at group activity. The resident was observed again at 10:30 am self-propelling in his wheelchair, and moving freely through out the unit. A review of the medical record revealed that on 1/06/13, 1/09/13, 1/30/13, and 1/31/13, Resident #1 had made sexually inappropriate comments, gestures and/or physical advances towards a female staff member. A review of an "Integrated Progress Notes" dated 4/21/13 (untimed) revealed that staff had found Resident #1 inside of his room with Resident #25, a cognitively impaired, female resident. According to this note, Resident #1 had cornered Resident #25 inside the room and was trying to "kiss" the resident. The note revealed that Resident #1 did not want to let Resident #25 out of the room. The documentation revealed that this incident was reported to Resident #1's physician. A review of an "Integrated Progress Notes" dated 5/06/13 at 7:30 am revealed that Resident #1 was inside a dining room on the unit. The note indicated that Resident #1 left the table that he was seated at and moved to another table were an unidentified female resident was seated. At this time, a staff member observed Resident #1 "flirting" with the female resident. The note also revealed that the resident became annoyed with Resident #1's behavior. The staff removed Resident #1 from the table. A review of an "Integrated Progress Notes" dated 5/30/13 (untimed) revealed that Resident #1 was observed by staff making inappropriate sexual comments to another unidentified female resident. According to this note staff redirected Resident #1 for his behavior. A few minutes later, Resident #1 was observed again making sexual comments to female residents. This note indicated that this incident was also reported to the resident's physician. A review of another "Integrated Progress Notes" dated 6/5/13 at 1:15 pm revealed that during an activity program, Resident #1 was seated next to an unidentified female resident and pulled his "penis" out from his pant. According to this note, staff observed Resident #1 as he tried to get the female seated next him to "touch" his genitals. A review of an "Integrated Progress Notes" dated 6/8/13 at 1:00 pm, revealed that staff found Resident #1 undressed inside a bathroom with an unidentified female resident. The note revealed that staff observed Resident #1 asking a female resident to remove her clothes. The female resident was removed from the bathroom by staff and this incident was reported to a nurse. Further review of this same note revealed that Resident #1 continued to say inappropriate sexual comments to female residents residing on the unit. According to this same note, the staff felt "uncomfortable" and had even attempted to ask the Resident #1 to leave activity programs for acting inappropriately. Additionally, this note revealed that when Resident #1 behavior was corrected by staff, "the resident still found everything funny." A review of a "Integrated Progress Notes" dated 6/8/13 at 4:00 pm revealed that staff found Resident #1 with Resident #21, a female resident, inside his room. Both Resident #1 and Resident #21 were undressed from the waist down. According to this note, Resident #21 was lying on the bed, and Resident #1 was seated on the bed with "full hand contact" on Resident #21's "genitalia." This same note revealed that both residents were separated by staff and that the doctor and the facility's Director of Social Services were notified. According to this note Resident #1 was place on hourly checks for observation. When interviewed by the surveyor on 7/10/13 at 10:15 am, the Administrator (LNHA) and the Assistant Director of Nursing (ADON) stated that they were aware of the "incidents" involving Resident #1. The LNHA stated that it was known to staff that Resident #1 made "flirtatious remarks" to female residents and staff. The LNHA said that staff was to remove Resident #1 from the area where residents that he liked were gathered or keep the resident occupied with activities. During this same interview, the LNHA stated that the female resident involved in the 6/8/13 sexual assault incident was Resident #21. The LNHA stated that Resident #21 was not sent to the hospital for an evaluation because the nurse on duty at the time of the incident performed a physical examination and determined that "nothing" happened. When interviewed further, the LNHA stated that the nurse did not have any experience or training in examining victims of sexual assault. The LNHA also stated that the nurse documented the physical assessment in Resident #21's record. According to the record for Resident #21's, the resident was admitted to the facility with [DIAGNOSES REDACTED]. A review of the RAI dated 4/24/13 revealed that Resident #21 had long and short term memory problems. This same RAI revealed that Resident #21 could ambulate with the use of cane. A review of Resident #21 record lacked any documentation of a physical examination being done following the sexual assault that occurred on 6/8/13 and there was no documentation of the incident on the record. During a follow-up interview on 7/10/13 at 10:40 am, the LNHA stated that the Director of Social Services was responsible for doing the investigations. The LNHA said that no incident report or investigation had been done for any of the incidents involving Resident #1. The LNHA also stated that none of these incidents were reported to the Department of Health. During a follow up interview conducted on 7/10/13 at 11:05 am, the Director of Social Services stated that she was in the building at the time the incident occurred on 6/8/13. The Director of Social Services stated that there was no investigation done nor was (DOH) notified. In addition, the Director of Social Services stated that Resident #1's physician was also in the building on 6/8/13 and had been seen by the physician. When interviewed on 7/10/13 at 11:15 am, the Director of Social Services stated that after the 6/5/13 incident, Resident #1 was placed on hourly checks. During this same interview, the LNHA stated that Resident #1 was not on hourly checks and that the resident was being monitored by staff. The LNHA stated that staff was trying to keep Resident #1 within eye site. The LNHA also stated that Resident 1's behavior constituted abuse. During a subsequent review of the medical record, an "Integrated Progress Notes" dated 6/11/13 at 5:05 am, revealed that Resident #1 came out of his room, and wheeled down the hallway. According to the note, a certified nursing assistant (CNA) heard a resident yell "Stop That." This CNA discovered that Resident #1 was exposing himself to a another unidentified female resident who was seated in a wheelchair in the hallway of the nursing unit. A review of an "Integrated Progress Notes" dated 6/13/13 at 12:10 pm revealed that Resident #1 was observed by several staff members exposing himself to female residents. According to the note Resident #1 was redirected by staff and was moved away from the other residents. This same note revealed that Resident #1 could only be redirected by staff for short periods of time. The note revealed that Resident #1 would move back to an area where the female residents were and would make sexual comments to them. According to the Abuse Reporting policy dated 2/13, The facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. Any alleged violation involving mistreatment, neglect, or abuse including injuries of an unknown source and misappropriation of resident proper must be reported to the Administrator...According to this policy, sexual abuse is defines as, but not limited to, sexual harassment, sexual coercion, or sexual assault...Upon receiving reports of physical or sexual abuse, the charge nurse shall immediately examine the resident and report to his/her supervisor. Findings of the examination must be record in the resident's medical record. (Note: If sexual abuse is suspected, DO NOT bathe the resident or wash the resident's clothing or linen. Call the police immediately.) There was no documented evidence this policy was consistently followed. 2. During a tour of the nursing unit on 7/8/13 at approximately 10:45 a.m. the Charge Nurse (CN) said Resident #14 had behavioral issues. The CN said the resident argued with and made negative statements to and about other residents. The CN said there were certain other residents whom Resident #14 did not like. The CN said Resident #14 was a "handful" and "in [AGE] years of being a nurse" this resident was "the worst I've ever seen." On 7/10/13 at approximately 9:45 a.m. the surveyor began reviewing the medical record of Resident #14. The record indicated Resident #14 was admitted to the facility on [DATE]. The medical record of Resident #14 documented multiple instances of verbally abusive incidents to other residents. In addition, multiple instances of incidents which were referred to, but not documented, were found in the medical record. Further, there were instances of physical contact between Resident #14 and other residents which were not documented. In all of the above, no investigations were provided to the surveyor and there was no evidence these instances were reported to the state agency. The issues were as follows: a. According to a "Daily Skilled Nurse's Note" dated 1/28/13, Resident #14 complained in physical therapy that another resident had touched him/her inappropriately during breakfast. There was no information in the note about who the other resident was and no subsequent notes mentioned the incident. On 7/10/13 at 3:12 p.m. the surveyor reviewed the incident investigations for Resident #14 which had been provided by the Assistant Director of Nursing (ADON). There was no incident investigation for this complaint. b. On 1/31/13 Resident #14 was evaluated by the psychologist. The reason for referral was listed as "suspicious, critical and demeaning of another resident and uncooperative with physical therapy." Documentation of these behavioral issues was not found in the Integrated Progress Note (IPN) or Daily Skilled Nurses Notes. c. According to a Progress Report (PR) dated 2/26/13, Resident #14 was evaluated by the psychologist who indicated the resident had been "angry, insulting and cursing at peers and staff." Documentation of these behaviors was not found in the IPN or the Daily Skilled Nurse's Notes. d. An IPN on 3/1/13 at 7 p.m. the resident was heard yelling at another resident and making threatening statements. As the other resident was taken to the room, Resident #14 followed and was observed shaking his/her fists. e. An IPN on 3/8/13 at 2 p.m. indicated the resident was overheard making "threatening comments" to another resident. The comments were not described in the note. f. An IPN on 3/10/13 at 6:30 p.m. indicated it was a late entry written for 3/9/13. This note indicated Resident #14 had been heard yelling at another resident. g. An IPN on 3/10/13 documented that Resident #14 stomped his/her right foot and was yelling at another resident. h. An IPN on 3/11/13 at 11 a.m. indicated Resident #14 was overheard by a nurse speaking to another resident in an "aggressive and threatening" manner about that resident's roommate, who was not in the area. There was no description about what was said or done. i. According to a Progress Report (PR) dated 3/12/13, Resident #14 was evaluated by the psychologist who indicated the resident had been "yelling, threatening, arguing" with other residents. j. An IPN on 3/12/13 at 8 p.m. indicated Resident #14 was heard screaming at another resident. k. According to an IPN from the SW on 3/13/13, Resident #14 had been yelling and threatening others and was being counseled. l. An IPN on 3/28/13 at 8 a.m. indicated Resident #14 was screaming at another resident who was in a wheelchair. The note indicated Resident #14 "always makes negative statements toward" this resident. The note documented that the CN overheard Resident #14 say that if the other resident had been ambulating he/she would have kicked the other resident. m. An IPN on 4/2/13 at 12 noon indicated Resident #14 "continues with aggressive, bully-like behaviors toward peers today." The note indicated Resident #14 began screaming at another resident and that these 2 resident had been in a verbal altercation at 9 a.m. today also. The note indicated that "this nurse had to physically break-up the two of them" and walked the other resident away from the area. Resident #14 was overheard saying in regard to the other resident "I'm going to murder that woman if she comes near me or says anything else to me. I'm not afraid of that bit**. She doesn't know what I can do to her." n. An IPN on 4/2/13 at 1 p.m. was written to clarify another IPN written on 3/11/13 at 11 a.m. The 3/11/13 note indicated the resident was "threatening" but did not reveal how. This clarification note indicated Resident #14 put 2 fingers up to his/her head and make a "gun-like gesture" while saying to a resident "I want to do this to your roommate. Pow-Pow." The roommate was not in the area. o. An IPN on 4/3/13 at 5:30 p.m. indicated Resident #14 was heard yelling at another resident in the dining room. When staff attempted to redirect the resident, Resident #14 continued to speak, called the other resident a "Bit**" and threatened to throw a glass of water at the other resident. p. According to a Progress Report (PR) dated 4/9/13, Resident #14 was evaluated by the psychologist who indicated the resident had been "rude, aggressive, threatening and insulting to peers." q. An IPN on 4/11/13 at 9 a.m. indicated Resident #14 was yelling at another resident while being pushed in the wheelchair to attend an activity. The resident yelled "Why do you keep staring at me?" and the other resident said he/she was not looking at Resident #14. r. An IPN on 4/24/13 at 5 p.m. indicated Resident #14 was heard arguing with another resident in the hallway. Resident #14 claimed the other resident bumped his/her wheelchair. While attempting to redirect the situation, Resident #14 became loud and argumentative and said "Staff don't help. I'll take it in my hand." s. An IPN on 4/27/13 at 2:30 p.m. indicated Resident #14 was "still noted to be argumentative towards other residents, picks fight/confrontation, swears at them." t. An IPN on 5/2/13 at 4:25 p.m. indicated Resident #14 was loudly cursing at the psychologist while at the nurse's station. While being separated Resident #14 was screaming "Fu**ing Bit**." u. An IPN on 5/3/13 indicated Resident #14 was making "smart comments" about other residents, was starting arguments and was very disruptive. The note also indicated Resident #14 was expressing hatred for other residents on the unit. v. An IPN on 5/6/13 indicated Resident #14 continued to make negative comments about a resident every time he/she saw that other resident. w. An IPN on 5/10/13 at 9 a.m. indicated Resident #14 was being "verbally abusive" to another resident when that resident attempted to visit the roommate of Resident #14. Resident #14 told the other resident to leave the room, called the other resident a "Bit**" and slammed the door in the face of the other resident. x. An IPN on 5/10/13 at 3:30 p.m. indicated Resident #14 was "making snide remarks" about other residents while at the nurse's station. y. On 5/11/13 the SW wrote an entry that indicated it was a late entry for 5/3/13. The SW indicated the behaviors of Resident #14 had "become a problem" and that the resident was threatening and cursing at other residents. z. An IPN on 5/11/13 at 8:30 a.m. indicated that Resident #14 was laughing while going to dining room and said "I love it, each time they see me, they shake. I like that." The staff asked the resident not to return to the dining room but the resident ignored the request. aa. An IPN on 5/13/13 indicated it was a late entry for 5/3/13 and revealed Resident #14 continued to make "inappropriate abusive remarks toward other residents." bb. An IPN on 5/19/13 indicated Resident #14 was aggressive and made "snide" comments to another resident. cc. An IPN on 5/25/13 indicated that at 9:30 a.m. Resident #14 began an argument with another resident and said "Fu** you, get away before I kick your a**, I'm gonna punch you in the face." According to the note, the argument started because Resident #14 was jealous of attention that the other resident was providing to a third resident. The note indicated the nurse "had to physically separate" the arguing residents and while taking the third resident down the hall, the other nurse had to stand in front of Resident #14 to prevent Resident #14 from returning to the nurse's station to "get at" the other resident. dd. An IPN on 5/31/13 at 10 a.m. indicated Resident #14 was overheard arguing with another resident and said "I hate that woman, she makes me sick just looking at her, who does she think she is?" ee. An IPN on 6/6/13 at 4:30 p.m. indicated Resident #14 was screaming at another resident while at the nurse's station. Resident #14 was observed going toward the other resident, trying to get to the other resident while arguing about a third resident. Staff intervened but Resident #14 was still loud and cursing. ff. An IPN on 6/10/13 at 8 a.m. indicated Resident #14 was laughing at another resident. That resident called Resident #14 an "idiot". Resident #14 became "enraged" and began propelling the wheelchair toward the other resident and said "What did you call me? You and your big glasses. Why don't you shut the fu** up?" The note indicated that the staff intervened. gg. An IPN on 6/17/13 at 4:25 p.m. indicated Resident #14 called another resident a "bit**" during an activity at approximately 2 p.m. The note indicated that the resident was asked to stop, however, the resident continued the behavior. hh. An IPN on 6/19/13 by the SW indicated Resident #14 was counseled for another incident with a resident. This incident was not documented in the medical record so its nature and severity were not known. ii. An IPN on 6/28/13 by the SW indicated that at 9:30 a.m. Resident #14 began to yell at another resident "Do you have something to say to me" and requested that if something was to be said, it was said face to face. When the nurse attempted to redirect the situation, Resident #14 loudly said "I am not going any damn where, why am I the one to be separated?" jj. The next IPN on 6/28/13 indicated Resident #14 was screaming at another resident and said "I hate all of these people here. Everyone here is against me. I'm sick and tired of being here and being picked on." kk. An IPN on 7/2/13 at 9 a.m. indicated Resident #14 started shouting at another resident "You are a nosy Mother Fu**er, I hate you, I can't stand looking at you. You ugly bit**." ll. An IPN on 7/3/13 indicated Resident #14 attempted to run his/her wheelchair into another resident who was ambulating with a walker. The other resident screamed for help to remove Resident #14. Resident #14 was noted with "resistance" to being removed and said "I am not going any damn where." On 7/10/13 between 2:08 p.m. and 2:35 p.m. the surveyor interviewed Resident #27, #28, #29 and #30. These were alert and oriented residents residing on the same unit as Resident #14. Of these, three had been identified by the SW as most often involved in conflict with Resident #14. All four stated they had been threatened by Resident #14 and were distressed about the ongoing conflict. Of these, one said he/she had been physically touched by Resident #14 and three had been approached in a physically aggressive manner. On 7/10/13 at 2:55 p.m. the surveyor interviewed the Administrator and SW. The SW said there had been no reports of physical contact between Resident #14 and other residents. The SW said there had been documentation about the incident with Resident #30 and that it was on a complaint form. On 7/10/13 At 3:08 p.m. when asked about physical contact between Resident #14 and Resident #27, the SW now confirmed that Resident #27 had reported such contact to her. On 7/10/13 at 3:12 p.m. the surveyor asked the SW and Administrator whether the issues between Resident #14 and the other residents was considered resident to resident abuse. They said that it was. The facility policy titled "Abuse Reporting" was reviewed with the SW and Administrator at this time and the following was revealed: "Our facility is committed to protecting our residents from abuse by anyone including, but not limited to: other residents. When an incident of resident abuse is reported, the Administrator will appoint a staff member to investigate the incident." When asked if any investigations had been conducted for the resident to resident incidents involving Resident #14, the Administrator and SW said there had not. At 4:08 p.m. on 7/10/13 the SW said she was aware of the incident on 1/28/13 between Resident #14 and another resident. The SW knew that the other party involved was Resident #1 because Resident #14 told her who it was. However, the SW said no investigation was conducted. At 4:09 p.m. the SW said Resident #30 filed a formal complaint with the Social Services office regarding an incident with Resident #14. The surveyor was provided the "Investigation & Resolution Quality Assurance Form Confidential Information" form which was dated 6/10/12 (but actually occurred on 6/10/13) and timed at 10:15 a.m. Resident #30 complained that Resident #14 said to him/her "Shut the fu** up" and then propelled the wheelchair over while raising an arm as if to hit Resident #30. Resident #30 said "Don't threaten me" to Resident #14 and two staff members intervened and "held down" Resident #14. (Refer to F224, F250) According to the facility's Abuse Investigation policy dated 2/13, All reports of resident abuse, neglect, misappropriation of resident property, and injuries of an unknown source shall be properly and thoroughly investigated. According to this policy when an incident of suspected incident of resident abuse, neglect, misappropriation of resident property, or injury of unknown source is reported, the Administrator will appoint a staff member to investigate the incident. The Administrator will provide the person in charge of the investigation a copy of the Resident Abuse Report Form and any supporting documents relative to the incident. The investigation shall consist of, as appropriate: A review of the completed Resident Abuse Report Form; an interview with the person(s) reporting the incident;Interviews with any witnesses to the incident; an interview with the resident; a review of all circumstances surrounding the incident. Witness statements shall be writing. Witnesses will be required to sign and date such statements. Finally, the administrator or designee will immediately notify the office of the ombudsman and the State Department of health that abuse investigation is being conducted. The notification shall be documented and followed within 72 hours with written confirmation using the Reportable Event Record/Report. The administrator or his/her designee will keep the resident and his/her representative informed about the investigation. The resident and resident's family shall be offered to report the incident to the local police department and will receive assistance on such, an appropriate; otherwise the Administrator shall report to the local police. The results of the investigation will be recorded on the Resident Abuse Investigation Report Form. A copy of the Resident Abuse Investigation Report Form will be provided to the Administrator within five(5) working days of the reported incident. The results of the investigation shall be reported to the office of the Ombudsman and the State Department of Health and Senior Services upon completion of the investigation. In addition, the facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. Any alleged violation involving mistreatment, neglect, or abuse including injuries of an unknown source and misappropriation of resident proper must be reported to the Administrator...According to this policy, sexual abuse is defines as, but not limited to, sexual harassment, sexual coercion, or sexual assault...Upon receiving reports of physical or sexual abuse, the charge nurse shall immediately examine the resident and report to his/her supervisor. Findings of the examination must be record in the resident's medical record. (Note: If sexual abuse is suspected, DO NOT bathe the resident or wash the resident's clothing or linen. Call the police immediately.) There is no evidence this policy was consistently followed. The immediate jeopardy was identified on 7/10/13 at 4:22 p.m. Facility Administration was notified and a plan of correction was submitted to the survey team and accepted on 7/10/13 at 6:40 p.m. The interventions were verified by the team beginning 7/10/13 and continued throughout the survey. The jeopardy was corrected at that time, based on the actions of the facility which included the following: a.) Beginning on 7/10/13, staff were assigned to provide 1:1 supervision to Resident #1 until a consult with a psychologist can occur. Hourly documentation of Resident #1's location and activity will be done. Staff were to intervene immediately and redirect Resident #1. b.) Beginning on 7/10/13, staff counselled Resident #14 regarding the resident's behavior, including speaking to other residents in a non-negative tone. Staff were assigned to intervene and separate Resident #14 and other residents as to not cause other residents distress. Resident #14's physician will be evaluating this resident for medication to assist in behavioral management. The staff would be documenting on Resident #14's location and activities. c.) Beginning on 7/10/13, all alert and oriented residents will be interviewed to identify any additional incidents. Counseling and reassurance would be provided to these alert and oriented residents. d.) The charge nurse and the SW assigned to nursing units where Residents #1 and #14 reside will observed and report these resident's behaviors every shift for 30 days then monthly. e.) Inservice education will be provided to all employees on all shifts beginning on 7/10/13 on the facility's abuse prevention policy. In addition, inservice education will be provided to all employees on effective documentation and communication when incidents of any type, including abuse, occur. The staff would be interviewed by the LNHA or designee on the abuse policy and procedure. This would occur once per shift per day for 30 days and thereafter monthly. f.) Quality Assurance Committee to review the audits and reports from nursing administration, social services and administration on a monthly basis for any alterations and recommendations. g.) The Social Worker was assisting with obtaining alternate placement for Resident #1 and Resident #14 to a more appropriate environment. NJAC 8:39-4.1(a) (5) 8:39- 27.1 (b)

Based on interview and record review, it was determined that the facility failed to develop and implement interventions for the sexually abusive behaviors of Resident #1, 1 of 9 residents reviewed for abuse, towards other cognitively impaired residents which had the potential for serious harm to the other residents at the facility. The immediate jeopardy was identified on 7/10/13 and through interviews with the facility's Administrator (LNHA) and Social Worker (SW), as well as record review, the surveyor confirmed the lack of a plan of care during the period of time between 4/21/13 and 6/11/13, which during that time Resident #1 was exhibiting inappropriate sexual behaviors. The immediate jeopardy that was removed on 7/10/13 when an acceptable plan of correction was submitted. These actions from the acceptable plan of correction included: a.) Resident #1's plan of care was up-dated to include 1:1/24 hour supervision and; b.) Resident#1's plan of care was reviewed to ensure that the plan reflected interventions that were individualized to this resident's needs. The following evidenced the deficient practice: According to the medical record, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Assessment Instrument (RAI) dated 4/8/13, revealed that Resident #1 had a Brief Interview for Mental Status score of 8 which indicated that the resident was moderately impaired for cognition. This RAI also indicated that Resident #1 required supervision by staff for transferring from the bed to a wheelchair. The resident was able to ambulate with the use of a cane or walker. A review of the medical record revealed that from 4/21/13 through 6/11/13, Resident #1 had eight documented incidents of sexually inappropriate behavior towards female residents who resided on the secured dementia unit of the facility. An "Integrated Progress Note" dated 6/11/13 revealed that a care plan to address Resident #1's inappropriate sexual behavior had been initiated. A review of the care plans for Resident #1 revealed a plan of care for "Inappropriate sexual behavior toward female residents and staff" that was dated 6/10/13. There was no plan of care prior to 6/10/13 to address Resident #1's inappropriate sexual behaviors towards female residents and staff from 4/21/13 through 6/10/13. When interviewed by the surveyor on 7/10/13 at 10:05 am, the LNHA and the Director of Social Services stated that the reason a care plan was not initiated for the inappropriate sexual behavior prior to 6/10/13 was because it did not "trigger" for the "Minimum Data Set." During this same interview, the LNHA stated that a care plan for Resident #1's inappropriate sexual behaviors should have been done prior to 6/10/13. (Refer to F-224 & F- 226) The immediate jeopardy was identified on 7/10/13 at 4:22 p.m. Facility Administration was notified and a plan of correction was submitted to the survey team and accepted on 7/10/13 at 6:40 p.m. The interventions were verified at the time. The jeopardy was corrected at that time, based on the actions of the facility which included the following: a.) The plan of care that was developed after the sexual abuse perpetrated by Resident #1 was reviewed and updated. b.) All residents who exhibit inappropriate behaviors will be reviewed for plans of acre. Upon exhibited inappropriate behavior, a plan of care will be initiated by the facility's interdisciplinary team. Any needed care plan will be reported to the LNHA or designee immediately. c.) The facility's policy and procedure for reporting inappropriate behaviors will be reviewed and updated for timely reporting. d.) Quality Assurance Committee to receive report from administrator and/or designee on plan of care on residents with identified behavior issues and outcomes on a monthly basis. NJAC 8:39-27.1(a & b)

Based on observation, interview and record review, it was determined that the facility failed to implement care plan interventions for the sexually abusive behaviors of Resident #1 towards other cognitively impaired resident. This failure to implement interventions jeopardized the safety of cognitively impaired female residents by preventing Resident #1's sexually abusive behavior. This deficient practice constituted an Immediate Jeopardy situation for Resident #1, who was 1 of 9 residents reviewed for abuse. The immediate jeopardy was identified on 7/10/13. An acceptable plan of correction was submitted to the team on 7/10/13 identifying that the jeopardy situation was corrected on that date based upon the actions taken by the facility. The actions included: a.) Resident #1 would have 1:1/24 hour supervision until evaluated by a psychiatrist; b.) Staff would document hourly on Resident #1's location and activity and; c.) Social service will initiate a search for alternate placement of Resident #1 to a facility/unit that would meet this resident's needs. The following evidenced the deficient practice: According to the medical record, Resident #1 was admitted to the facility on [DATE] with diagnose that included [MEDICAL CONDITION], Dementia, and [MEDICAL CONDITION]. According to the Resident Assessment Instrument (RAI) dated 4/8/13, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated that the resident was moderately impaired for cognition. This RAI also indicated that Resident #1 required supervision from staff for transferring from the bed to a wheelchair, and was able to ambulate with the use of a cane/walker. A review of the record revealed that from 4/21/13 through 6/11/13, Resident #1, had nine documented incidents of sexually inappropriate behavior towards female residents residing at the facility. A review of a "Integrated Progress Note" dated 6/11/13 revealed that care plan for inappropriate sexual behavior was not initiated until 6/10/13. A review of the care plans for Resident #1 revealed a plan of care for "Inappropriate sexual behavior toward female residents and staff" that was dated 6/10/13. The interventions listed on care plan included: a.) The monitoring of Resident #1's "whereabouts" and that staff should redirect the resident with "activities, conversation, snacks if behaving inappropriately." b.) "Psych consults" follow up visits by the psychologist. c.) "Supportive counseling" whenever necessary. d.) "Medications as ordered" e.) "Seat residents with male peers for meals and activities" f.) "Keep daughter updated on any incidents of inappropriate behavior" g.) "Discuss possible options for alternate facilities...with daughter" and to "assist daughter in applying if necessary." During the initial tour of the Comfort Care unit conducted by the surveyor on 7/08/13 at 10:00 am, the Registered Nurse stated that Resident #1 was alert and confused. The RN also stated that Resident #1 "liked the ladies" and was known to make sexual advances toward female residents and staff. At this time, Resident #1 was observed seated in a wheelchair attending a group activity. The resident was observed again at 10:30 am self-propelling freely through out the unit, in his wheelchair. On 7/10/13 at 11:30 am, the surveyor observed that Resident #1 was observed seated at a table with a female resident, in the dining room of the dementia unit. On the same day at 11:33 a.m., the surveyor observed that a second female resident (Resident #26) was standing next to Resident #1 as he sat at the table with the first female resident. There was a Licensed Practical Nurse (LPN) standing in the dining room at the time of this observation. On 7/10/13 at 12:30 p.m., the surveyor observed Resident #1 and Resident #26, a female resident, seated in the activity room section of the dining room. These residents were alone in the room. There were two Certified Nursing Assistants (CNAs) in the pantry of the dining room where they did not have visual contact with Resident #1 and Resident #26. On 7/10/13 from 12:45 p.m. to 1:07 p.m., the surveyor observed that Residents #1 and #26 were seated alone in the activity section of the dining room. There were no staff in this room, the dining room or the hallways around these common rooms. When interviewed by the surveyor on 7/10/13 at 3:45 pm, CNA#1 stated that staff tries to keep an eye on Resident #1 and that when Resident #1 "disappears" staff will go and look for the resident. When interviewed by the surveyor on on 7/10/13 at 3:55 pm, the Licensed Practical Nurse (LPN) stated that Resident #1 was a "handful." The LPN stated that the resident was not on hourly checks but the staff tries to keep Resident #1 in the main area, however "he gets away from us." The LPN stated that Resident #1 was able to use the bathroom independently so the staff does not accompany the resident the bathroom. During another interview on 7/10/13 at 4:00 p.m., CNA#2 stated that staff was responsible for making sure Resident #1 was seated with the men during meals and activities. The CNA stated that the resident moves about the unit freely and was only being monitored when he was in the main area. The CNA was unable to offer alternate identified interventions. (Refer to F224 & F226) The immediate jeopardy was identified on 7/10/13 at 4:22 p.m. Facility Administration was notified and a plan of correction was submitted to the survey team and accepted on 7/10/13 at 6:40 p.m. The actions were verified by the team. The jeopardy was corrected at that time, based on the actions of the facility which included the following: a.) Resident #1's plan of care will be reviewed for appropriateness to the resident's behavior and will be revised to reflect the 1:1/24 hour supervision that would be provided by the facility staff. b.) Beginning on 7/10/13, all appropriate staff will be inserviced on the implementation of Resident #1's care plan. c.) Beginning on 7/10/13, the nursing staff will be interviewed by a supervisor, on a weekly basis, regarding Resident #1's care plan. d.) Outcome of interviews on behavioral care plan interventions reported to Quality Assurrance Committee for anyaysis on a monthly basis. NJAC 8:39-27.1(b)