Every finding on record at Broadway House for Continuing Care

Complaint # 2961489Based on interviews, medical record reviews, and review of pertinent facility documents on 3/26/26, it was determined that the facility failed to report to the New Jersey Department of Health an injury of unknown origin that was identified on 3/18/26, following the resident's transfer to the emergency room (ER), where they were diagnosed with left femur (leg) fracture. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1).The evidence was as follows: According to the Resident Face Sheet, Resident #1 was admitted to the facility with diagnose that included but were not limited to Dementia, with behavioral disturbances, psychotic disorder with hallucinations, seizures, and chronic candidiasis of vulva and vagina. According to the quarterly Minimum Data Set (MDS), an assessment tool, dated 1/15/26, Resident #1 had a Brief Interview Mental Status score of 9 out of 15, indicated that the resident was moderately cognitively impaired. A review of Progress Notes dated 3/19/26 at 8:41 AM revealed that the facility was contacted by a Hospital Registered Nurse (RN), who revealed that Resident #1 was admitted to the hospital with diagnosis of anemia, and Acute Kidney Injury (AKI). The RN further revealed that the resident had left leg swelling and redness that was tender to touch, and that CT scan was done which showed that Resident #1 had left femur fracture. Review of an undated document titled Conclusion Summary of Investigation which revealed under imaging, an acute displaced fracture of left femoral (left leg). The report further revealed a large adjacent hemorrhage with areas. suspicious for active bleeding. On 3/26/26 at 1:27 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated after the hospital notified them about the fracture, the facility conducted an investigation and determined that there was no harm done in the facility. The LNHA stated that she would report abuse and neglect to the Department of Health and that she was not sure where Resident #1's fracture happened. She also stated the incident may have occurred during the resident's transfer to or in the hospital. When the Surveyor questioned the LNHA regarding facility protocol on injury of unknown origin, the LNHA stated that facility facility did not know how the injury occurred. On 3/26/26 at 2:45 PM, the surveyor interviewed the President and Chief Operating Officer (CEO) about facility's protocol regarding injury of unknown origin, she responded that it is supposed to be reported to the Department of Health (DOH). When asked if the resident's fracture would be considered an injury of unknown origin, she stated, yes. A review of the facility policy titled Abuse (long version) with a revised date of 1/1/2025 written in pen, under the State and Local Agencies to be notified, it states that New Jersey Department of Health and Senior Services must be called immediately at 1-609-588-77-25 to report that the facility is investigation an allegation of abuse, neglect etc . written confirmation must follow the call within 72 hours to describe the result of the investigation. NJAC 8:39-9.4(f)

Based on observation, interview, and record review, the facility's failed to have an adequate water management program. The facility's water management program was incomplete and was not consistent with current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, which specifically called for design and maintenance procedures for the potential exposure of Legionnaire's disease (a serious pneumonia infection) within a healthcare facility. This failure created the potential for the 65 facility residents, who were either over the age of 65 and/or were autoimmune compromised, to be infected by Legionella. Findings include: Review of website for ASHRAE titled Successfully Managing the Risk of Legionellosis dated 04/07/21 indicated . Legionellae the biological classification name for a [NAME] of bacteria.is the plural, referring to more than one Legionella bacterium.Legionellosis: any illness (disease) caused by the exposure to Legionella. Legionnaires' disease (LD) and Pontiac fever (PF) are the two known types of legionellosis.Potentially fatal, multisystem respiratory illness, accompanied by pneumonia.Symptoms.high fever, chills, muscle pain, headache, dry cough, diarrhea, vomiting, confusion, and delirium common.Immune suppressed.transplant patients, cancer, cardiac, diabetes, steroid/drug therapy.Sick/in poor health. Elderly/infirm.Heavy smokers, lung/COPD diseases.Describe the building water systems using flow diagrams & a written description: Include details such as where the building connects to the (municipal) water supply, how water is distributed and used (processed), where hot tubs, water heaters, cooling towers, etc. are located. Review of a document provided by the facility titled Water Management Plan and Procedure for Broadway House for Continuing Care (BHCC) undated indicated .The purpose of this Water Management Plan (WMP) is to ensure the safe and reliable delivery of water to all areas of the nursing home, with a focus on maintaining the health and safety of residents and staff, preventing waterborne illnesses, and managing water resources efficiently. The facility failed to ensure their water management program contained a diagram or a description of the building's water system. During an interview on 02/19/25 at 9:16 AM, the Maintenance Director stated he tested water temperatures on a daily basis as part of the facility's water management program. The Maintenance Director stated there was no diagram of the facility's water system which would identify potential areas for water pathogen development. The Maintenance Director stated there were no schematics of the building's water system. The Maintenance Director stated he would need to reach out to the owners of the building to see if they had any additional information. During an interview on 02/19/25 at 3:24 PM, the Administrator stated he had been recently hired as an interim Administrator and said his expectations were to monitor the facility's water management program, which included reviewing the facility's water system. NJAC 8:39-19.1(a)(b) NJAC 8:39-19.4

Based on interview, record review, and facility policy review, r the facility failed to ensure residents were free of abuse for one of one resident reviewed for abuse (Resident (R) 3) out of 21 sampled residents. R3 was physically abused by R119. This failure placed the resident at risk for physical injury and psychosocial harm. Findings include: Review of a facility policy titled Abuse, dated 01/01/25 indicated .Physical Abuse.Any inappropriate physical contact with a resident, such as hitting, slapping, striking with an open or closed hand, pinching, biting, kicking, rough handling, pulling of hair, twisting of limbs, or punching. Review of a document provided by the facility titled Resident Face Sheet indicated R3 was admitted to the facility on [DATE]. Review of a document provided by the facility titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident was moderately cognitively impaired. Review of a document provided by the facility titled Resident Face Sheet indicated R119 was admitted to the facility on [DATE]. Review of a document provided by the facility titled nursing Progress Notes dated 08/09/24 indicated R3 was overheard by Licensed Practical Nurse (LPN) 1 when R3 and R119 were arguing. The progress notes revealed by the time LPN1 approached the two residents, R119 hit R3 twice in the face. LPN1 separated R119 from R3. LPN1 assessed R3 and he sustained no injuries. Both the physician and the responsible party were notified of the resident-to-resident incident. An order was obtained to transfer R119 to a crisis unit, and initially R119 voiced that he did not want to go but then spoke with a family member and R119 complied. A review was conducted of R119's clinical records and there were no prior aggressive/physical behaviors identified with other residents. Review of a document provided by the facility titled Summary of Investigation dated 08/09/24 indicated a resident-to-resident incident which involved R3 and R119. The facility's investigation revealed R119 had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. The investigation indicated R3 was sitting in his wheelchair and in front of the nursing station when R119 approached R3 and stepped on his right foot and punched him twice in the face. As part of the facility's investigation the Director of Nursing (DON) watched camera footage of the incident between R3 and R119 and verified the resident-to-resident incident. The investigation revealed R3 was placed one-on-one and R119 was sent to the emergency room for crisis intervention and was eventually transferred back to the facility on [DATE]. During an interview on 02/18/25 at 2:03 PM, LPN1 confirmed she witnessed R119 hit R3. LPN1 confirmed R119 was sent to another facility. LPN1 verified she heard R3 tell R119 to hit him, and when she began to go towards the two residents, she witnessed R119 hit R3 twice in the face. LPN1 stated she considered the resident-to-resident abuse and reported the incident immediately to her supervisor. LPN1 confirmed she was interviewed by the DON as part of the facility's investigation. A subsequent interview was conducted on 02/19/25 at 8:50 AM, LPN1 verified R119 was immediately sent out to the emergency room to be evaluated by a crisis team and considered resident-to-resident abuse. LPN1 stated R119 was eventually transferred to another facility. During an interview on 02/19/25 at 11:44 AM, R3 confirmed R119 stepped on his foot but did not remember if he was hit in the face. R3 stated he believed the actions made by R119 were abuse. R3 stated he was not fearful of R119. During an interview on 02/19/25 at 1:12 PM, the DON stated her expectation was to protect R3 and the staff provided him with one-on-one supervision. The DON stated both R3 and R119 had counseling related to the incident. The DON stated there were no prior incidents which involved R119 and other residents. The DON stated R119 was placed on the first floor and R3 was on the second floor. During a subsequent interview on 02/19/25 at 3:24 PM, the DON and the Administrator were present. The DON stated R119's attack on R3 was unprovoked. The DON stated the goal was to keep R3 protected, and we wanted to make sure no one suffered any triggers as a result of the resident-to-resident, and this was why both residents received counselling after the incident. NJAC 8:39-4.1(a)5 NJAC 8:39-9.4(f)

Based on interview, record review, and policy review, the facility failed to ensure two of two residents discharged to the hospital (Resident (R) 51 and R57) out of a total sample of 21 residents were provided with a bed hold notice within 24 hours of emergent transfer to the hospital. This failure increased the potential that residents would not know to request a bed hold and may be unable to return to the facility. Findings include: Review of the facility's policy titled Bed-Holds and Returns dated 01/01/25 revealed the following Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy (3) Prior to a transfer, written information will be given to the residents and resident representatives that explains in detail: (a) the rights and limitations of the resident regarding bed-holds; (b) the reserve bed payment policy as indicated by the state plan (Medicaid Residents) (c) the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid Residents); and (d) the details of the transfer (per the Notice of Transfer). 1. Review of R57's undated admission Record, located in the resident's electronic medial record (EMR) under the Resident Summary tab revealed R57 was admitted to the facility on [DATE]. Review of R57's Progress Note located in the EMR under the Resident Summary tab dated 07/28/24 revealed the following resident in bed with fever. Resident lethargic with elevated heartrate on 2L oxygen via nasal canula. Vitals: BP 122/89, HR 138, Temp 101.8, Resp 22, Sat 95%, Resident skin flush and hot to touch, no complaint of shortness of breath or pain. Nurse notified supervisor and the medical director (MD). The MD notified staff to send resident out to hospital to r/o [rule out] sepsis. Tylenol 650mg given prior to transport to hospital. Family notified. Review of R57's Progress Note dated 08/05/24 located under the Resident Summary tab of the EMR revealed Resident readmitted to the facility at 3:00 pm . 2. Review of R51's admission Record located in the resident's EMR under the Resident Summary tab revealed R51 was admitted on [DATE]. Review of R51's Progress Note dated 01/04/25 and located in the resident's EMR under the Resident Summary tab revealed Resident tolerated all due meds, observed with a discoloration bump on the right side of the head. MD made aware, ordered to send resident to the ER for CT SCAN of the head. A review of the EMR did not reveal any evidence to indicate R51 received a bed hold notice. During an interview on 02/19/25 at 10:42 AM, the Director of Nursing (DON) stated the facility did not provide the residents and/or their representatives with a bed hold policy when they were sent to the hospital. During an interview on 02/19/25 at 1:58 PM, the Business Office Assistant (BOA) stated they do not provide the residents or their representatives with a bed hold policy when they are sent to the hospital. NJAC 8:39-4.1(a)31 NJAC 8:39-5.1 NJAC 8:39-5.3(b)

Complaint #NJ00164204 Based on interviews and a review of the medical records (MRs) and other facility documentation on 5/18/23, it was determined that the facility staff failed to implement interventions to prevent an elopement and follow the facility's policy for 1 of 3 sampled residents (Resident #1) reviewed for elopement. This deficient practice is evidenced by the following: Review of the facility policy titled Facility Passes & Pass Violation revised 5/16/22, included but was not limited to: Passes are given after 14 days admission .All escorts must be an adult .4 different types of passes are given out at the discretion of the medical director, primary physician, or nurse practitioner. Residents are granted 1 independent pass a day .Each pass is color coded. If escorted, resident is granted 2 passes a day to be with loved ones. Store pass (red form) means the resident must return to the facility within 1 hour. Day pass (yellow form) means that a resident must return back to the facility by 9PM. Medical pass means that a resident must return back to the facility on ce that appointment is finished and cannot wander away, this is an escorted pass .Staff cannot escort any resident for day pr store passes. 1. According to the Face Sheet, Resident #1 was admitted to the facility on [DATE]. The physician progress notes (PNs) dated 5/9/23 revealed diagnoses which included but were not limited to: Lung Cancer and Emphysema. The admission nursing assessment dated [DATE] revealed that Resident #1 was alert and oriented to person, place, time, and situation. The resident was able to ambulate and complete activities of daily living (ADLs) without assistance. Review of Resident #1's baseline care plan (CP), dated 5/10/23, revealed that Resident #1 was scheduled for radiation therapy (RT) three times a week at a cancer treatment center (CTC). There were no goals or interventions indicated in the CP. Review of Resident #1's Physician Order (PO) did not reveal a PO for radiation therapy. The Resident Master Listing (RML) document dated 5/12/23 included a list of residents and their pass status. Resident #1's pass status indicated a medical hold or medical pass for the first 14 days of admission which required the resident to be escorted by a staff member for a medical appointment and must return to the facility after an appointment. The Director of Nursing (DON) explained during an interview on 5/18/23 at 11:34 AM, that the master list is updated every Friday or when the facility admitted a new resident. The updated list is given to the security staff. Security and nursing staff are required to verify the pass status each time a resident would request to leave the facility. The Resident Appointments calendar (RAC) from 5/8/23-5/12/23 included a list of residents and the appointment details including destination, time of appointment, and assigned escort. However, Resident #1's RT appointments on 5/10/23 and 5/12/23 were not included in the calendar. The Director of Nursing (DON) explained during an interview on 5/18/23 at 11:34 AM that the weekly calendar is handed to the security staff every Monday. She added security personnel (SP) and nursing staff must not allow any resident to leave the facility for an appointment unless it was scheduled in the calendar. Review of an elopement incident Reportable Event Record/Report (RER) sent to the New Jersey Department of Health (NJDOH) on 5/13/23 included that Resident #1 left the faciity on [DATE] at 2:12 PM for an RT appointment. Review of the undated summary of investigation revealed that an elopement incident occurred on 5/12/23 at 2:12 PM when the unit manager (UM) acted independently and allowed Resident #1 to leave the facility without an escort for a RT appointment. The initial interventions the facility put in place after the elopement included: contacting the CTC and the resident, filing a police report, and implementing the facility's protocol for elopement. A statement from the Registered Nurse/UM (RN/UM) revealed that on 5/10/23, the RN/UM allowed Resident #1 to leave the facility for a RT appointment without an escort. A statement from SP #1, who was responsible for supervising residents who sit in front of the facility, revealed on 5/12/23, SP #1 allowed Resident #1 to leave the facility unaccompanied because she presumed the resident did not need an escort since the RN/UM approved the resident to leave without an escort for the same appointment earlier that week. Review of the nursing PNs dated 5/12/23 at 12:08 PM indicated that Resident #1 informed RN #1 he/she was scheduled for a RT at CTC three times a week at 12:30 PM, and transportation had been pre-arranged and on the way. There was no indication in the PN that RN #1 verified the resident's pass status or checked the RAC. Further review of the nursing PNs dated 5/12/23 at 10:43 PM revealed that RN #1 notified the RN/nursing supervisor (RN/NS) when Resident #1 did not return from RT appointment. RN #1 reached out to the resident, but the cellphone was not in service. At 8:45 PM, the SP on duty confirmed the resident did not call. It was indicated in the nursing PNs the RN/NS completed a facility search and confirmed with the transportation provider the resident canceled the service at 1:38 PM pick up from the facility to CTC. Additionally, the RN/NS notified the physician and the DON and left a voice message on his/her cellphone at 9:45 PM. The RN/NS made an inquiry to nearby hospitals and notified the police. The police responded at 5:50 AM on 5/13/23. During an interview with the surveyor on 5/18/23 at 11:34 AM, the DON explained she could not get in touch with the CTC staff until 5/15/23 because of the weekend closure. She stated the resident could not be reached after leaving the facility. She then went to CTC on 5/17/23 and spoke with the resident about returning to the facility. However, the resident declined and signed out against medical advice (AMA). The AMA form dated 5/17/23, signed by Resident #1, the DON, and a witness, included that the medical risk/benefits were explained and understood by the resident. During an interview with the surveyor on 5/18/23 at 1:15 PM, SP #1 confirmed on 5/12/23, she did not check the RAC if Resident #1 was scheduled for an appointment or the RML for the pass status. She allowed Resident #1 to leave the facility unaccompanied for a RT appointment on 5/12/23 because the RN/UM approved the same appointment on 5/10/23. The SP acknowledged she should have asked the nursing staff and not assumed the resident did not require an escort. During an interview with the surveyor on 5/18/23 at 9:00 AM and 11:08 AM, the RN/UM stated that newly admitted residents must be escorted by facility staff to medical appointments. However, the RN/UM approved Resident #1 to leave the facility for a medical appointment without an escort on 5/10/23 because the resident's cognition was intact. The RN/UM acknowledged she failed to follow the facility's policy and should have let an aide escort the resident to the appointment. Additionally, the RN/UM was unable to explain why the appointment calendar was not updated to include Resident #1's RT appointments on 5/10/23 and 5/12/23. During an interview with the surveyor on 5/18/23 at 2:34 PM, RN #1 who was the assigned nurse for Resident #1 on 5/12/23 stated she was unsure of the escort requirements for medical appointments but confirmed she allowed Resident #1 to leave for a medical appointment unaccompanied on 5/12/23. She added she allowed it because the resident had the capacity to make decisions. However, RN #1 agreed she failed to follow the facility's policy and stated she should have verified the escort requirements with the administration staff. During an interview with the surveyor on 5/18/23 at 11:34 AM, the DON stated that the RN/UM, RN #1, and SP #1 should have followed the facility's policy and not allowed Resident #1 to leave for a medical appointment without an escort. The resident required an escort regardless of having an intact cognition. She further stated they should have verified the resident's pass status. During an interview with the surveyor on 5/18/23 at 3:03 PM, the Administrator stated that all staff are expected to follow the facility's pass or escort requirements procedure. Review of the facility policy titled Code Gray-Missing Resident-Resident Elopement-Management of Missing Resident dated 12/16/21 included but was not limited to: It is the responsibility of all personnel to report any resident attempting to leave the premises unauthorized, or is suspected of being missing, to the security department and the nursing department immediately. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to: a.) follow interventions in the resident's care plan for smoking, b.) thoroughly complete two out of last three facility required safe smoking evaluations for a resident and c.) accurately code the resident's annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care as a smoker. This deficient practice was identified for one of one resident's, (Resident #19) reviewed for smoking and was evidenced by the following: On 12/15/22 at 10:24 AM, the surveyor observed Resident #19 seated in a wheelchair in front of the nurse's station. The resident stated that he/she lived at the facility before the Pandemic and that he/she liked to go outside and smoke cigarettes. The resident further told the surveyor that the facility had designated smoking times in which the resident was required to follow. The resident explained that he/she had to follow the rules if he/she wanted to keep smoking at the facility and was only allowed to go outside if staff was present in the area during the designated smoking times. The resident further told the surveyor that he/she was not allowed to hold onto his/her cigarettes or lighter and that the staff handed out these items when he/she wanted to smoke. On 12/19/22 at 11:38 AM, the surveyor walked outside the main entrance of the facility and observed Resident #19 outside actively smoking a cigarette in the front patio area. The surveyor observed that the resident could hold the cigarette on his/her own. At the time of the observation, it was cold outside. The resident was wearing gloves without fingers, a heavy winter coat, and baggy, thick, long pants. The surveyor further observed a staff member present in the area. The surveyor observed the resident safely extinguish his/her cigarette and self-propel himself/herself by way of wheelchair back into the building. The surveyor did not observe that the resident was wearing a smoking apron at the time of the observation. On 12/20/22 at 11:48 AM, the surveyor observed the resident sitting in his/her wheelchair in front of the nurse's station. The resident stated that he/she had not gone outside to smoke yet today because it was too cold out. The surveyor reviewed the medical record for Resident #19. A review of the resident's annual MDS dated [DATE], reflected that the resident had a Brief Interview for Mental Status Score (BIMS) score of 12 out of 15 which indicated the resident's cognition was moderately impaired. A review of Section I - Active Diagnoses reflected that the resident had diagnoses which included but were not limited to hypertension (high blood pressure), diabetes mellitus, depression, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A further review of the resident's annual MDS, Section J1300 - Current Tobacco Use indicated that the resident was not a smoker. A review of the residents Safe Smoking Evaluation (SSE) dated 04/23/22, completed by the activities department indicated that the resident smoked, did not wear oxygen, the resident's cognitive short term, long term, and decision-making skills were intact and consistent. The SSE further reflected that the resident had the functional capacity, balance, range of motion, and fine motor skills to hold a cigarette. The observation/education section of the form was filled out in its entirety indicating that the resident was safe to smoke independently. The summary of the SSE indicated, smokes safety in the designated smoking areas and also understands the smoking policy. The SSE did not indicate that the resident had to wear an apron while smoking. A review of the resident's SSE dated 07/24/22, completed by the activities department indicated that the resident smoked, did not wear oxygen, the resident's cognitive short term, long term, and decision-making skills were intact and consistent. The SSE further reflected that the resident had the functional capacity, balance, range of motion, and fine motor skills to hold a cigarette. The observation/education section on the SSE was not completed and was left blank indicating the resident was not observed smoking a cigarette or educated by staff the day of the assessment. The summary of the SSE indicated, Resident does not have cigarettes at the moment. Upon purchasing or receiving observations will be completed. The SSE did not indicate that the resident had to wear an apron while smoking. A review of the resident's SSE dated 10/22/22, indicated that the resident was a smoker. The medical section, cognitive patterns, functional capacity, and observation/education section of the SSE was not filled out and left blank. The summary of the SSE reflected that the resident does smoke but did not have cigarettes at the time of the SSE and upon purchasing or receiving cigarettes an evaluation would be completed for the resident. The SSE did not indicate that the resident had to wear an apron while smoking. A review of the resident's Care Plan updated 8/22/22, reflected a focus area that the resident was a smoker. The resident's Care Plan indicated that the resident had committed multiple infractions, such as buying and selling cigarettes to other residents and violated the facility's smoking policy. As a result of the resident not adhering to the smoking policy, the resident was restricted from smoking for 30 days. The resident's Care Plan further indicated that Resident #19 complied with the facility's agreement of not smoking and was given back smoking privileges at the facility upon completion of his/her restriction. The Care Plan further reflected a focus area dated 2/19/21 that the resident continues to utilize/wear smoke apron for safety. The interventions in the resident's Care Plan included to provide resident with smoke apron to be left near security desk, re-educated resident on smoking policy, and resident will receive his/her cigarettes during the following break times from the Activities staff: 10 AM, 12:30 PM, 2:00 PM, and 4:00 PM. On 12/19/22 at 11:30 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident was alert, oriented, and very capable of making his/her needs known. The CNA told the surveyor that the resident smoked and had behaviors at times. The CNA gave the example that when the resident wanted something, he/she wanted it immediately, and if the resident did not get what he he/she wanted, the resident would get loud and curse. The CNA further stated that the resident didn't have behavioral outburst often and stated, hasn't had an episode in a minute. On 12/20/22 at 9:59 AM, the surveyor interviewed the receptionist. The receptionist desk was large, directly in front of the main doors to the facility, and to the right of the receptionist desk when walking into the building, the surveyor observed a box with smoking aprons in it. The receptionist stated that the activities department were the staff responsible for giving the resident's their cigarettes. The receptionist explained that there were three residents that lived at the facility who smoked that were required to wear an apron. The receptionist mentioned Resident #19 by name and stated that the residents knew that they had to put on the smoking apron. The receptionist pointed at the box with the aprons in them when she explained the process to the surveyor. The receptionist further stated that she and the security guard were the staff responsible for making sure the residents wore their aprons while smoking. The surveyor inquired if the resident was non-compliant with wearing his/her smoking apron. The receptionist told the surveyor that we wouldn't let the resident go outside without wearing the apron then stated, They try and get around wearing it. The receptionist then gave the example that the resident would say that he/she just wanted to go outside to get fresh air. On 12/20/22 at 11:31 AM, the surveyor interviewed the MDS/Coordinator who stated that section J1300 was filled out incorrectly on the resident's annual MDS dated [DATE], and the resident was a smoker. On 12/20/22 at 12:01 PM, the surveyor interviewed the security guard who was sitting at the front door watching the outside of the building. The security guard told the surveyor that it was her job to watch the resident's when they smoked. The security guard was able to tell the surveyor that Resident #19 was required to wear a smoking apron upon inquiry. The security guard stated that if she was to observe that the resident was not wearing the apron, she would go get it and bring it to the resident. The surveyor told the security guard the observation and time of the observation from the day prior in which the resident was observed smoking without wearing his/her apron. The security guard stated that she was out to lunch at the time of the surveyor's observation and normally Resident #19 would wear his/her apron when outside smoking On 12/20/22 at 12:54 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the resident was alert and oriented to person, place, and time and the resident smoked cigarettes. The LPN further stated that activities came today to ask the resident if he/she wanted to smoke, and the resident declined. The LPN further stated that she worked agency and she was unsure of the facility's protocol for smoking assessments. On 12/20/22 at 1:01 PM, the surveyor interviewed the Activities Director (AD) who stated that the activities department was responsible for completing the Safe Smoking Evaluations for the residents upon admission, quarterly, annually, and as needed if there was a change in the resident's cognitive or physical function. The AD stated that the facility evaluated the residents for safety, mental and physical capability of holding the cigarettes, lighting the cigarette, and extinguishing it. The AD stated safety was the most important component of the safe smoking evaluation. The AD was familiar with Resident #19 and stated that the facility implemented the smoking apron after a burn mark was identified on the resident's clothes. The AD stated that the resident never burned his/her skin and had been wearing the apron for a few years now. The AD told the surveyor that the activities department staff gave the residents his/her cigarettes and apron. The AD stated, when we give the resident [his/her] cigarette they make sure [he/she] was wearing the smoking apron, also communicate to the security staff that the resident needs a smoking apron. The AD explained that the resident could be non-compliant at times related to smoking, therefore we have him/her on smoking restrictions for safety and monitoring. The AD further stated that if activity department staff noticed the resident did not have cigarettes the day of the scheduled smoking assessment, we were supposed to go back and generate a new smoking assessment to evaluate the resident's smoking capabilities. On 12/21/22 at 12:55 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the resident should have been wearing his/her smoking apron prior to going outside and smoking. The RN/UM further stated that the resident's Care Plan would be updated to reflect the non-compliance with not wearing the smoking apron and the activity department was responsible for performing the Safe Smoking Evaluation which should have been completed. A review of the facility's, Resident Smoking Policy dated 03/05/07 indicated that all residents had to follow the smoking rules the facility implemented. The policy further indicated, Residents will be assessed for their ability to smoke safely upon admission/readmission, quarterly, and when experiencing a significant change in status. Areas to be assessed include: a. Cognition and decision making skills b. Ability to independently propel to and from designated smoking area c. Ability to safely light a cigarette d. Ability to safely hold a cigarette e. Ability to keep ashes from falling on a person f. Ability to extinguish a cigarette safely. The facility's, Resident Smoking Policy indicated that residents that are placed on a smoking restriction must be reassessed by the activities department to determine their ability to smoke safely. NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to timely transmit a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with federal guidelines. This deficient practice was identified for one of 18 residents, (Resident #22) reviewed for the timely transmission of MDS's and was evidenced by the following: On 12/20/22 at 11:36 AM, the surveyor interviewed the MDS/Coordinator (MDS/C) who stated that she completed Resident #22's quarterly MDS dated [DATE], but she forgot to submit it to the Center for Medicare & Medicaid Services (CMS). The MDS/C stated that the facility had 14 days to submit an assessment after it was completed The surveyor reviewed the medical record for Resident #22. A review of the resident's Face Sheet (An Admission Summary) reflected that the resident had resided at the facility since 2019 and had diagnoses which included but were not limited to hypertension (high blood pressure), acquired absence of right lower leg below knee, acquired absence of left toes, COVID-19, and heart failure. A review of the facility's CMS Submission Report for Resident #22 indicated that the target date for the resident's quarterly MDS was 09/02/22 and the quarterly MDS was submitted to CMS late on 12/19/22. The MDS is a comprehensive federal mandated process for clinical assessment of all residents that must be completed and submitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. After transmitting of the MDS, it will generate a quality measure to enable a facility to monitor the residents decline and progress. On 12/20/22 at 1:46 PM, the surveyor informed the facility's Administrative staff of the MDS transmission error. NJAC 8:39-11.1

Based on observation, interview, and record review, it was determined that the facility failed to remove an expired controlled medication (Oxycodone) from the active back up supply for one (1) of three (3) medication storage rooms that were inspected for proper medication storage. The deficient practice was evidenced by the following: On 12/20/22 at 11:48 AM, the surveyor observed a Registered Nurse/Unit Manager (RN/UM) and a Licensed Practical Nurse (LPN) perform an inventory count for the controlled medications stored in the electronic back up supply machine for the facility. During the inventory count the RN/UM stated that there were eight (8) Oxycodone Immediate Release (IR) tablets in inventory and that was an accurate count. The surveyor, with the RN/UM and LPN, observed an expiration date of 11/19/22 for two (2) of the eight (8) tablets. The RN/UM stated that the two (2) tablets were expired and would need to be removed and destroyed appropriately. The RN/UM further stated that she was responsible for any discrepancies in the electronic back up supply machine for the controlled medications and that the expiration dates should be checked when an inventory was completed. The RN/UM added that the controlled medications in the back up supply machine were counted every shift by two (2) nurse supervisors. The RN/UM also stated that the two (2) expired Oxycodone IR tablets were missed during the inventories that had been done. A review of the November and December 2022 facility Control Inventory Record reflected that the controlled medications in the electronic back up supply machine had been counted every shift. The records reflected two (2) nurses signed every shift that the controlled medications were counted. The records had not reflected any discrepancies or expired medications. On 12/20/22 at 1:05 PM the surveyor was provided a facility policy for Storage of Medications by the Chief Operating Officer (COO). A review of the undated facility policy for Storage of Medications reflected that Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. On 12/20/22 at 1:30 PM, the survey team met with the facility administrative team. The COO stated that the undated facility policy for the Storage of Medications was the current policy. NJAC: 8:39-29.4(g)(h)

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that Certified Nursing Aides (CNA) received 12 hours of mandatory annual in-service training that included abuse training for 1 of 5 CNA files reviewed (CNA #1). The deficient practice was evidenced by the following: On 12/20/22 at 12:30 PM, the surveyor reviewed the in-service education hours for five randomly selected CNA files, which were provided by the facility. The Nursing Education Record and Transcripts provided showed the following: CNA #1 had a hire date of 11/20/19. According to the Nursing Education Record and Transcript provided by the facility, CNA #1 had completed 6.5 hours of training from 11/20/21 to 11/20/22 which did not include training on abuse and the additional 5.5 hours of the required 12. On 12/20/22 at 1:05 PM, the surveyor interviewed the Nurse Educator (NE) regarding the education provided. The NE stated that the education provided was everything that she could find for each person. On 12/20/22 at 1:13 PM, the surveyor interviewed the NE regarding CNA #1's education. The NE confirmed that CNA #1 had 6.5 hours in the time frame from 11/20/21 to 11/20/22. The NE also confirmed that CNA #1 did not have training on abuse in that time frame. On 12/21/22 at 12:08 AM, in the presence of the survey team, the Chief Operating Officer confirmed that CNA #1 did not have the appropriate training and confirmed that CNA #1 should have had the training. On 12/21/22 at 12:52 PM, in the presence of the survey team, the NE stated that staff should have had 12 hours of education including abuse training within their anniversary year. The facility could not provide any documented evidence that CNA #1 had completed the mandatory 12 hours training including abuse training. Review of the facility provided policy titled, In-Service Training with a revised date of 12/21/22, included the following: Under Policy Statement All nursing assistant personnel shall participate in regularly scheduled in-service training classes. Under Policy Interpretation and Implementation 1. All personnel are required to attend regularly scheduled in-service training classes . 3. Annual in-services must: a. Ensure the continuing competence of the nursing assistant b. Be no less than 12 hours per employment year c. Address areas of weakness as determined by the performance reviews d. Include training that addresses the care of the residents, as determined by facility staff e. Include training that addresses the care of the residents with cognitive impairment f. Include training in dementia management and abuse prevention . 6. All training classes attended by the employee shall be recorded on the respective employee's Education File by the staff educator. N.J.A.C. 8:39-43.17 (b)

Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice following a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/17/21 at 9:30 AM, the surveyor observed Resident #56 in bed. The resident was quiet and lying comfortably in bed. A review of the resident's Face Sheet (A one-page summary of important information about a patient) indicated that Resident #56 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/22/21 at 9:15 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medication for administration to Resident #56 on unit 1 East. The surveyor noted an order documented on the Electronic Medical Record (EMAR) for Resident #56, [MEDICATION(S)] 2.5 mg daily for Hypertension, Hold for Systolic Blood Pressure (SBP) less than 110. The LPN informed the surveyor that the resident's previously checked SBP, documented on the daily Vital Sign Worksheet, was 108/70. She said she would not administer the medication to Resident #56 because the SBP was below 110. The surveyor asked the LPN if she had checked the resident's SBP. The LPN responded that the SBP and all vitals are checked at the beginning of the shift by the Certified Nursing Assistant (CNA). The surveyor then requested that the LPN recheck Resident #56's SBP, which resulted in an SBP of 112/70. The LPN then administered the [MEDICATION(S)] 2,5 mg to Resident #56. On 2/22/21 at 9:40 AM, the surveyor interviewed the Registered Nurse (RN) responsible for administering medications on unit 1 West. The RN informed the surveyor that if by chance, she encounters a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN stated that the vitals are all checked at the beginning of the morning shift by the CNA on the unit. On 2/22/21 at 10:20 AM, the surveyor interviewed the RN responsible for administering medication on unit 2 West. The RN informed the surveyor that she does not refer to the Vital Sign Worksheet documented with vitals information checked by the CNA at the beginning of the shift. The RN stated that before administering any medication that has hold parameters ordered by the Physician, she checks the vitals herself prior to administering the medication. On 2/22/21 at 10:25 AM, the surveyor interviewed the RN responsible for administering medication on unit 2 East. The RN informed the surveyor that she does not refer to the Vital Sign Worksheet documented with vitals information checked by the CNA at the beginning of the shift, approximately 7:30 AM. The RN stated that before administering any medication that has hold parameters ordered by the Physician, she checks the vitals herself prior to administering the medication. On 2/22/21 at 10:32 AM, the surveyor interviewed CNAs responsible for checking vitals on unit 1 East. Both CNAs informed the surveyor that vitals are checked on unit 1 East between 7:00 and 7:30 AM. On 2/22/21 at 11:00 AM, the surveyor discussed the discrepancy with the facility's Direct of Nursing, who stated that the medication administration nurses should check vitals prior to administering medications with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/22/21 at 2:00 PM, the surveyor reviewed the facility Medication Administration Guidelines, which explained, Medication orders that have parameters, the nurse will obtain the appropriate vital sign prior to administering the medication (at minimum 30 minutes prior to). NJAC 8:39-27.1(a)

Based on the documentation, interview, and record review, it was determined that the facility Consultant Pharmacist (CP) failed to identify the contraindication of an opioid-dependent resident's use of as-needed opioid pain medication. This deficient practice was identified for 1 of 16 residents sampled and reviewed for CP evaluation, Resident #62, and was evidenced by the following: On 2/17/19 at 9:40 AM, the surveyor observed Resident #62 in bed in the resident's room, watching television. A review of Resident #62's Face Sheet (A one-page summary of important information about a patient established upon admission) revealed that the resident had diagnoses that included but were not limited to Opioid dependence, Generalized anxiety disorder, and Chronic Pain Syndrome. A review of the current Physician's Orders for Resident #62 documents an order for [MEDICATION(S)] 10 mg ([MEDICATION(S)]) 6 tablets (60 mg) by oral route for Opioid dependency ordered soon after admission on 1/15/2021, and [MEDICATION(S)] 10 mg-325 mg 1 tablet every 6 hours as needed for pain ordered on admission on 1/11/21. The medication [MEDICATION(S)] is a combination of [MEDICATION(S)] 10 mg and Acetaminophen 325 mg. [MEDICATION(S)] is an opioid with an abuse liability similar to [MEDICATION(S)]. A review of the February 2021 Electronic Medical Record (Emar) establishes that Resident #62 received 14 doses of [MEDICATION(S)] 10 mg - 325 mg from 2/1-2/19/2021. The documentation on the Emar revealed pain levels ranging from 5 to 9 (level 1 mild to level 10 severe). A review of the Consultant Pharmacist's Medication Regimen Review dated 1/12/2021 and 2/15/2021 did not mention any information related to the contraindication of use with an opioid pain medication ([MEDICATION(S)] 10 mg-325 mg) or the resident's history of opioid dependency. On 2/24/21 at 1:20 PM, the surveyor interviewed the resident's Medical Doctor (MD), who stated that he is the resident's physician in the community and has treated the resident with [MEDICATION(S)] for pain, as well as the resident's heroin addiction. The surveyor identified that there was a contraindication between [MEDICATION(S)] and [MEDICATION(S)], an opioid. The MD stated, I can increase the dose of the [MEDICATION(S)]. On 2/25/21 at 10:50 AM, the surveyor interviewed the facility Consultant Pharmacist (CP). The CP could not explain why there was no mention in her recommendations to the facility that it is was contraindicated to treat an opioid-dependent person with [MEDICATION(S)], classified as an opioid, or why on both occasions where the CP reviewed the resident's medications, there was no mention of the contraindication of [MEDICATION(S)] (Opioid) used in an opioid-addicted person. Futhermore, the CP could not explain why [MEDICATION(S)] was ordered for as-needed pain relief for a resident treated with [MEDICATION(S)] for opioid dependency. The CP responded that the resident received [MEDICATION(S)] during the resident's hospital admission prior to coming to the facility. The CP could not provide any further information. On 2/25/21 at 11:00 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the CP reviews every resident's medication regimen for any discrepancies on admission and monthly. The DON added that the CP provides the facility a report that identifies any discrepancies used for follow-up. The DON informed the surveyor that the issue involving Opioid-dependent Resident #62's treatment with [MEDICATION(S)] (an opioid) and the combination of [MEDICATION(S)] and [MEDICATION(S)] was never identified to the facility by the CP. 8:39-29.3(a), (b)

Based on observation, interview, record, and policy review, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and the potential for the development of foodborne illness. This deficient practice was evidenced by the following: On 2/24/21 at 10:12 AM, the surveyor, in the Dietary Director's (DD) presence, observed a bristle hairbrush fall to the floor from the top of the condiment station (metal shelf storing salt, pepper, ketchup, mustard, mayonnaise, and other condiments). The dietary aide, who was mopping the floor, then picked up the hairbrush from the floor and placed it back on top of the condiment shelf. The surveyor observed that along with the bristle hairbrush (having evident hair strands in between the bristles) was a head bandana and cellphone placed on the condiment shelf. The DD instructed the dietary aide to remove all his personal belongings from the condiment shelf and put it in the office for storage. On 2/24/21 at 10:30 AM, the surveyor interviewed the DD in the presence of another surveyor. The DD stated to the surveyors that the condiment station must always be kept clean and free from any contaminated items. The DD explained that the condiment station is used during tray line food preparation, and personal items placed on the shelf will contaminate the area. The DD informed the surveyor that all employee personal items are to be kept in lockers supplied by the facility. The DD further stated that the condiment shelf would be completely sanitized. On 2/24/21 at 2:00 PM, the surveyor informed the Administrator (Admin) and Director of Nursing (DON) about the above concerns in the kitchen area. The Admin and DON acknowledged the deficient practice and added that the facility provides all employees lockers for their personal items. They added that the dietary aide should not have had his personal items placed on any part of the kitchen area. NJAC 8:39-17.2(g)

Based on observation and interview, it was determined that the facility failed to properly dispose and maintain waste in the garbage compactor area as evidenced by the following: On 2/24/21 at 10:10 AM, in the presence of the Dietary Director (DD), the surveyor observed the garbage compactor area to be littered with old cardboard boxes, old milk cartons, soiled plastic gloves, and soiled incontinence pad. The DD stated to the surveyor that the maintenance department of the facility was responsible for the cleaning of their garbage area. On 2/24/21 at 10:43 AM, the surveyor interviewed the Maintenance Director (MD) of the facility in the presence of another surveyor. The MD stated that the landlord of the facility's building was the one responsible for maintaining the garbage area clean. The surveyor requested a copy of a written agreement between the facility and the landlord that would indicate that the landlord of the building will be the one responsible for maintaining the garbage area clean. The surveyor also requested a copy of the facility's policy related to cleaning of the garbage area. On 2/24/21 at 11:30 AM, the Administrator spoke to the surveyor and stated that there was no written policy nor an agreement regarding who was responsible on the clean up of the garbage disposal. On 2/24/21 at 2:00 PM, the surveyor informed the Administrator, and the Director of Nursing regarding the above concern. NJAC 8:39-31.5(a)1

Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 8:16 to 9:03 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. A cleaned and sanitized meat slicer on top of a counter in the prep area was not in use and not covered. When interviewed at that time, the FSD stated, Our policy is to cover it up and bag when not in use. I'm gonna cover it up now. On the same shelf a cleaned and sanitized [NAME]ot Coupe (a type of food processor) was uncovered and exposed. The FSD stated generally we don't cover that. 2. On a middle shelf in the walk-in refrigerator, a ,[DATE] pan was labeled homemade icing and dated ,[DATE]. The FSD stated, I'm gonna throw that away. It should have a use by date. The FSD threw it in the trash. On the same shelf an opened can of Whipped Light Cream had Best By [DATE] stamped on the bottom of the can. The FSD stated, I'm throwing that out, it's expired. 3. On a middle shelf in the walk-in freezer, two separate plastic bags contained frozen waffles and were removed from their original container. The waffles had no dates. The FSD stated, I'm gonna toss them out. They are not in the original box and they are not dated. On the same middle shelf, a 5 gallon paper container of vanilla ice cream was ripped in the middle of the container and the contents were exposed. The FSD stated, we just opened this yesterday. I'm gonna throw it in the trash its been exposed. In addition, an opened bag of frozen blueberries had a manufacturer's use by date of (MONTH) 23 (YEAR). The FSD stated, I'm gonna throw them out. The surveyor witnessed all products to be thrown in the trash by the FSD. 4. On [DATE] from 10:05 AM to 10:25 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN) observed the Second Floor Resident Pantry. The surveyor observed the HACCP/Food Safety - Refrigeration/Freezer Monitoring Tool attached to the freezer door. The temperature log was inconsistently documented. Observation of the log revealed that staff failed to document the temperatures of the refrigerator for the following dates: (MONTH) 3, 8, 9, 14, 17, 22, and 23 of 2019. There were no temperatures recorded for the freezer for the month of (MONTH) 2019. The LPN stated, Dietary is responsible for documenting refrigerator temperatures twice daily. The surveyor observed the instructions on the top of the temperature log, which stated: Document equipment temperature when department opens & in evening prior to closing. 5. Adjacent to the refrigerator, the second and fourth drawers below the counter contained an unidentified substance on the bottom of the drawers. The surveyor interviewed the LPN who stated, I believe it's between the kitchen staff and the Certified Nursing Assistants (CNA's) to maintain the pantry. I'm not sure but I can clarify it. On [DATE] from 11:52 AM to 12:04 PM, the surveyor, accompanied by the FSD observed the following in the kitchen: 1. The surveyor observed a Dietary Aide (DA) perform handwashing at the designated handwashing sink. The DA wet their hands, applied soap, and performed vigorous handwashing for 22 seconds. The DA then turned off both faucets with their bare hands and then proceeded to obtain a hand towel form the dispenser above the sink and dry their hands. The DA then threw the hand towel into the trash receptacle. The surveyor reviewed the facility policy titled, Hand Washing, Policy #: 1012. The policy stated at 2. How to Wash Hands: Dry hands with paper towel. Turn the facet off with the towel. The surveyor reviewed the job duties for the PM Diet Aide F Position, PM Diet Aide F 10:30 AM-7PM. Observation of the job duties revealed that at 2:30 the Diet Aide F is to: Deliver Nourishments to the pantry, clean cooler as needed, or every weekend Record temps once daily, report anything unacceptable to managers. The surveyor reviewed the facility policy titled Food Storage, Policy #: 4006. Under Procedure 7 the policy stated, Leftover food is stored in covered containers or wrapped carefully and securely, clearly labeled, and dated before being refrigerated. Leftover food is used within 48 hours. Only NSF approved containers are used. (No single service containers are to be used to store food). NJAC 8:,[DATE].2(g)

Based on observation, interview and review of documentation provided by the facility it was determined that the facility failed to maintain acceptable standards of maintenance in the kitchen. This deficient practice was evidenced by the following: ¿@ On 7/17/16 at 8:00 a.m. during the initial tour of the kitchen and in the presence of the Dietary Supervisor (DS) the surveyor observed the following: ¿@ 1. A control knob was missing from one of two ovens in the kitchen. ¿@ 2. There was built up ice around the water pumps in both of the walk-in freezers. ¿@ 3. The was no light or ventilation in a small storage area in the kitchen. ¿@ 4. Two of four ceiling mounted light fixtures in the main dry storage room were cracked. ¿@ 5. The floor and both the black and yellow floor mats around the second floor ice machine were wet, heavily soiled with black debris and discarded gloves, tissues, napkins and debris. ¿@ 6. The wall and molding around the wall of the ice machine was in poor repair. The molding and the lower section of the wall directly in front of the ice machine was missing with exposed plaster and sheet rock. ¿@ The Director of Maintenance (DOM) stated the inside of the ice machine was cleaned every month by an outside vender and the house keeping department cleaned the floor outside the machine and the area around it. ¿@ He acknowledged that the area around the ice machine was dirty and in poor repair. ¿@ Review of the facility's Dry Storage Room Policy and Procedure (P&P) stated there must be adequate space on all sides of stored items to permit ventilation. Store rooms must be swept clean at all times, mopped at least weekly, well lighted and must have good ventilation and the temperature should be 50 degrees Fahrenheit (F) to 70 degrees F. A thermometer is present in the storeroom, and is monitored on a regular basis. ¿@ Review of the facility's Production, Storage and Dispensing of Ice Policy and Procedure (P&P) stated ice will be produced, stored and dispensed in a manner to avoid contamination. Inside and outside of the machine are cleaned and the area around the machine is also cleaned. ¿@ Compliance with the above stated P&P's was not observed by the surveyor. ¿@ NJAC 8:39 31.4(a)

C/O# NJ , NJ Based on interviews, review of medical records and facility documentation, it was determined that the facility failed to assure that 1 of 3 sampled Residents (Resident#2) identified as being at risk for elopement, was properly supervised and/or monitored to prevent elopement. Resident #2 eloped from the facility on 7 separate occasions, 9/1/14, 9/6/14, 9/14/14, 9/15/14, 9/16/14, 9/17/14 and 9/18/14. On each elopement, Resident #2 was observed by facility staff ambulating on city streets and on one occasion attempted to board a city bus. As per Director of Nursing (DON) on 9/19/14 at 9:50 AM, "staff are instructed to follow the Resident for one to two blocks because it is not safe and places their life at risk." The facility's failure to adequately supervise a resident identified as a risk for elopement which placed Resident #2 in an immediate jeopardy (IJ) situation. The DON was notified of the IJ on 9/19/14 at 10:20 AM. The immediate jeopardy began on 9/1/14 whereby Resident #2 left the facility premise unsupervised and was lifted the day of the survey, 9/19/14, when an acceptable plan of correction was submitted to the surveyor. This deficient practice was evidenced by the following: Medical records were reviewed and interviews conducted on 9/19/14, unless otherwise noted. The surveyor reviewed the medical record of Resident #2 on 9/19/14 at 10:40 AM. The "Resident Face Sheet" revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 9/3/14 did not indicate a Brief Interview for Mental Status (BIMS) score. Review of MDS indicated as per section C0100 that the Resident was not interviewable secondary to "resident is rarely/never understood." In section C1000, staff Assessment for Mental Status, indicated that Resident #2's cognition was moderately impaired. According to the MDS, Resident #2 required staff supervision for Activities of Daily Living (ADL's). The Resident's Interdisciplinary Plan of Care initiated 8/25/14, identified a potential for elopement with Active Status. Intervention dated 8/25/14 included: "Roam alert device to (Resident's #2's) wrist." Interview with the Security Supervisor revealed that when residents go out to smoke, "Security Officer (S/O) asks where they are going and why. For those that have a bracelet, we shut off alarm." Interventions dated 8/26/14 included: "Staff will monitor (Resident #2) while smoking to ensure safety. Staff will redirect resident as needed. Frequent monitoring for safety with orientation to unit." On 9/1/14, after Resident #2's first elopement, care plan interventions included: "Staff will continue to re-direct (Resident #2) as necessary. Notify police if resident should leave facility grounds without escort." On 9/6/14, after Resident #2's second elopement, care plan interventions included: "Behavior health referral, family meeting." On 9/8/14 care plan intervention included: "Family members will have tracking device activated on Resident (#2's) cell phone to help find resident should she elope again." On 9/18/14 after Resident #2's seventh elopement, care plan interventions included: " Resident (#2) will be escorted by staff when she leaves the facility without authorization until it is evident she will not return to facility. Area Hospital ER'S (emergency room 's) called Q2H (every 2 hours) to inquire if resident had been brought to ER." The care plan failed to include any new interventions after the elopements on 9/14/14, 9/15/14, 9/16/14 and 9/17/14. The surveyor conducted an interview with RN (#1) (Registered Nurse) on 9/19/14 at 1:11 PM. RN #1 indicated that, "the residents do not need to tell us they go outside. If they elope, security can locate a Resident immediately on the camera. Security watches everyone who is on elopement risk and will follow/go to where the parking lot ends. If resident does not come back, we call the police. If elopement the RN immediately updates the care plan." The surveyor conducted an interview with RN #2 on 9/19/14 at 1:17 PM. RN #2 indicated that, "security watches them outside. Security calls us to inform us when she (Resident #2) eloped. If they elope the DON, Supervisor and the Police are called. We can not follow her (Resident #2), because the person who follows her puts their life at risk as well. The unit manager and RN update the care plan." A facility "Reportable Event Record/ Report", faxed to the Department of Health and Senior Services on 9/17/14 at 3:59 PM, indicated that that on 9/16/14 at 7:30 AM, Resident #2 "left the facility grounds unauthorized. Staff tried to re-direct her but were unsuccessful. At 8:45 AM (Resident #2) returned to the facility with a staff member who was able to convince her to return. This is a recurrent pattern of behavior with this Resident." The Resident's Interdisciplinary Progress Notes dated 8/29/14 at 5:18 PM indicated "that resident (#2) made 2 attempts to elope but attempts were unsuccessful. On 9/1/14 nurses note stated: "Resident alert and oriented but confused. Resident is pacing up and down the corridor engaged in a very loud conversation. She is verbally abusive when approached with cueing/supervision." At 6:20 PM, a nurses note indicated, "Received a call from security the Resident (#2) has eloped while staying outside for smoke time. Security also informed the police and a picture identity provided to them." At 8:50 PM "Resident (#2's) brother and boyfriend escorted her (Resident #2) back into the facility." On 9/6/14 at 4 PM, "Received call from security resident left facility. S/O (security officer) notified the police but they never came." At "6:15 PM Resident (#2) returned to facility." On 9/11/14 at 5:30 PM, "Received a call from S/O resident is about to leave the facility. Supervisor notified, went to talk to the resident. CNA (Certified Nursing Assistant) was with resident talking to her at the gate, and resident came back to facility. Resident kept moving around, sitting down one second getting up. Ativan 0.5 mg (milligrams) PO (by mouth) administered for anxiety." A nurses note dated 9/12/14 at 4 PM, indicated the following: "Resident observed pacing back and forth on first floor and then attempting to leave facility as per Security Supervisor. Resident noted to have lingerie (bra) tied around waist on top of clothing." At 6:50 PM "Received a call from S/O to sent (Sic) (send) a CNA for resident she wants to leave the facility. Two minutes later S/O called back and stated they were bringing resident up. Resident again try (Sic} (tried) to leave but was redirected by the CNA." On 9/14/14 a nurse documented at 1:15 PM, "called by security notified that resident was attempting to leave grounds. When I arrived outside informed by security that resident was walking down Broadway street. I rode around the block and did not see resident but when I returned she was sitting at the picnic table out front. I informed client (Resident #2) that if she left the grounds I will call the police. Client did not respond." On 9/15/14 at 6:50 PM a nurses note documented, "(Elopement)- writer informed by Security Officer that Resident (#2) has left facility grounds via (a neighboring facility) driveway while being monitored and followed by Security. As per S/O (#1), partner S/O (#2) while following Resident, attempted to dissuade her from leaving grounds, however to no avail, she then turned left on the street of Broadway." On 9/16/14 at 7:45 AM a nurses note documented, "Security notified me of resident leaving facility. At 8:45 AM Resident was returned to facility by a staff member who saw her in the rain." On 9/16/14 at 1 PM "Constantly walking on/off unit since return this AM." On 9/17/14 at 9:45 PM nurses note indicated the following: "Elopement - Approximately 9:15 pm writer received a call from security that resident was attempting to leave facility grounds. Writer immediately proceeded outside to redirect resident, supervisor was made aware in passing. As writer proceeded out of (facility) parking lot writer was met by security guard and resident which continued to leave facility grounds and could not be redirected at the time. Writer proceeded for a full block to redirect resident back to facility resident adamantly refused and proceeded down the block." At 9:46 PM, "Received a call from security stating that resident returned back to facility." At 9:48 PM, "resident returned back to unit." The surveyor conducted an interview with Security Supervisor on 9/19/14 at 4:15 PM. Security Supervisor indicated that the "Security is outside with smoking residents and monitor and check for any residents who may wonder off. Security Officer (S/O) asks where they are going and why. S/O uses radio to desk (indicating that they call, via walkie talkie to the security in the building stationed at the desk in the lobby) and desk calls nursing station if anyone elopes. Security is outside and watch while resident is out. Instructions are given to all security guards to walk for no more than 2 blocks with any eloping resident and notify desk, call police with their (residents) location and direction of area they are going to." On 9/18/14 a nurse note indicated the following information: At 11:00 am - (Resident #2) "has been restless all morning, walking back and forth on and off unit. Attempted to leave facility earlier this am but was persuaded to come inside facility." At 12 pm, Requires constant redirection. Remains non verbal." As per Psych/Mental Health note at 1:32 PM, "Pt (patient) continues to leave facility multiple times a day. When spoken to this morning, she was unable to answer questions coherently. At 1:49 PM, "Pt continues to leave facility multiple times a day. Pt is unable to sit or stand in one place for any length of time. When spoken to this morning, she was unable to answer questions coherently." She mumbled incoherently, neologisms and word salad present. Per SW (Social Worker), she knocked on his door repeatedly today and when he opens the door, she walks away without saying anything. Will increase Seroquel XR, will add Haldol and Cogentin. Start Klonopin for anxiety." At 3:05 PM, "This writer was contacted a number of times today when the resident left the premises. Twice this writer went to the parking lot and located the resident who was accompanied by a security guard and calm. On the first occasion, the security guard had been able to persuade the resident to walk back and this writer accompanied them. The resident was irritable with disorganized speech and cursed randomly. On the second occasion in the afternoon the resident was calmer and she was persuaded to return by this writer offering her a piece of birthday cake." As per nurses note at 3:15 PM, "Resident observed sitting outside on a bench next to Security. At 3:30 pm Received a call from Security stating that resident was leaving the grounds and Security was with her at the time but resident could not be persuaded to return to the facility. 3:33 pm Security called and stated resident boarded a #13 Bus headed towards downtown and they were trying to get her to get off of Bus. 3:34 pm- Newark Police were notified by Security Guard at desk of resident's elopement. 3:45 pm Security Supervisor returned to facility and reported resident did get off of bus after the bus driver did not move and she was asked to exit bus and threw her clothes at the bus. She was cursing and started to become aggressive. She was asked to return to facility but she kept walking." At "8:45 pm Newark police called again concerning Police report by Security Officer. Informed they will send out another unit as first unit did not find (facility address). Called sister who stated resident was seen about 1 hour ago in the area of 18th Ave, in the area she was familiar with. 11 PM Resident still out of facility at change of shift." On 9/19/14 at 10:20 AM the surveyor was informed by DON, that Resident (#2) eloped yesterday at 3:30 PM and was with her sister. Within the next five minutes the DON informed the surveyor that Resident (#2) eloped yesterday at 3:30 PM but the facility was not sure where she was and that Resident (#2) has not yet returned to the facility. At 11:45 AM, as per Social Worker, Resident (#2) was being escorted by the police to the crisis center. At 2:45 PM the DON informed the surveyor that Resident (#2) was with her case worker at hospital in the crisis center. At 3:05 PM the DON informed the surveyor that Resident (#2) was in the ER (emergency room ) and being admitted by the facility physician. The surveyor conducted an interview with the Social Worker on 9/19/14 at 11:45 AM. The Social Worker stated that "Resident (#2) needs a lock down unit. Resident (#2's) sister was looking into (another facility) with a locked unit." The Social Worker failed to indicate further ongoing reassessments and safe alternative placement for Resident #2. The immediate jeopardy to Resident #2's health and safety, which began on 9/1/14 was identified by the surveyor, who notified the DON and the ADON on 9/19/14 at 10:20 AM. The facility reported the elopement of 9/16/14 to Department of Health on 9/17/14. During the entrance conference on 9/19/14, the DON informed the surveyor of another elopement, which occurred on 9/18/14 at 3:30 PM, whereby Resident #2 had not returned to the facility. In further review of Resident #2's medical record, it was determined that Resident #2 had five previous elopements, which were not reported by the facility to the Department of Health. The immediate jeopardy, however, continued ongoing until an acceptable Plan of Correction was received by the surveyor at 4:50 PM on 9/19/14. The Plan of Correction included: 1. The Resident was transferred and subsequently admitted to the hospital on [DATE] at 2 PM. 2. Measures or systemic changes to ensure that the deficiencies will not occur. a) Policy review/revisions for Elopement policy and the Admission Policy on 9/19/14. b) Staff inservices on the policy changes started on 9/19/14. c) Policy revisions on 9/19/14: 1. "If a resident leaves the facility grounds, staff shall maintain visual contact which may require following the resident in a motor vehicle until the police intercede. One staff member will maintain visual surveillance while the other obtains the vehicle." 2. "Staff members engaged in visual monitoring of a resident who has left the facility grounds shall possess a cell phone to communicate with the facility and law enforcement." 3. Maintain current listing of residents at risk for elopement. 4. Review/revise elopement risk assessments and behaviors. 5. Revise the admission chart review process. 6. LTC consultant review policy/procedure policy changes for appropriateness. 7. The safety committee chair will oversee the monitoring process of all residents identified as elopement risks. The Security Department is responsible for managing the 24 hour electronic monitoring system which provides information regarding those Residents entering and exiting the main doors. All data will be reported at least quarterly to the Quality Improvement Committee and safety committee meets three times per week to review new cases. This will begin starting this current 3rd quarter until 2015 4th quarter. All items will be addressed as of today - 9/19/14, and on going, until the designated completion date of 10/10/14 NJAC 8:39-27.1(a)

C/O# NJ , NJ Based on interviews and review of medical records and other facility documentation, it was determined that the facility failed to follow their policies on: "Management of Missing Resident, Accident Incident Reporting, and Abuse Policy." The Facility failed to report 5 Elopements (elopement occurs when a resident leaves the premises or safe area without authorization and/or any necessary supervision to do so), on the following dates: 9/1/14, 9/6/14, 9/14/14, 9/15/14, 9/17/14, to the New Jersey Department of Health (NJDOH ) for 1 of 3 sampled residents (Resident # 2 ). The facility also failed to report a Resident to Resident altercations, as defined in the facility policy, involving 3 residents, (Resident #1 and 2 unsampled residents) to the New Jersey Department of Health. This deficient practice is evidenced by the following: A review of facility policy on "Management of Missing Resident", indicated under subtitle, "Policy Interpretation and Implementation 5 d. Notify the Department of Health and Senior Services. 5 F. All interventions implemented shall be documented in the interdisciplinary notes." A review of facility policy on "Accident and Incident Reporting", Indicated under subtitle, "Procedure: 4. An investigative report will be initiated, if warranted to include written statements of witness. In addition, the department (Department) of Health shall be notified immediately of any suspected resident abuse. The Office of the Ombudsman will be notified of any incidents involving resident abuse, which require medical treatment, for residents over age (60)." A review of facility policy on "Abuse", indicated under subtitle, "Policy Statement". "All forms of abuse including resident to resident abuse must be reported immediately to the nursing supervisor (Nursing Supervisor), Director of Social Services, DON/ADON and to the administrator (Administrator). Under subtitle Policy Interpretation and Implementation, 1. l Report incidents, findings and corrective measures to appropriate agencies." 1. The surveyor reviewed the medical record of Resident #2 on 9/19/14 at 10:40 AM. The "Resident Face Sheet" revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 9/3/14 did not indicate a Brief Interview for Mental Status (BIMS) score. Review of MDS indicated as per section C0100 that the Resident was not interviewable secondary to "resident is rarely/never understood." In section C1000, staff Assessment for Mental Status, indicated that Resident #2's cognition was moderately impaired. According to the MDS, Resident #2 required staff supervision for Activities of Daily Living (ADL's). A review of the nurses notes dated 8/25/14 documented "Resident is at risk for elopement." A nurses note dated 8/26/14 documented "Resident put on an Elopement Risk Alert facility wide." The care plan initiated 8/25/14, "Active Status," identified an elopement risk. Documented interventions, included: "Security and staff made aware of Resident (# 2) Facility Wide Alert of Residents Elopement status effective 8/25/14. Frequent monitoring for safety, with reorientation to unit. Call bell kept within reach effective 8/26/14, Roam alert device applied to (Resident #2's) wrist effective 8/25/14." A nurses note dated 9/1/14 at 6:20 PM documented that nursing received a call from security indicating that resident 206 A (Resident #2's Room Number), has eloped while staying outside for smoke time. Resident returned to facility at 8:50 PM as documented on the "Accident" report. The nurses note documented that the physician and family were notified. A review of the medical record and the facility "Accident" report failed to document that the NJDOH was notified of the elopement. The surveyor conducted a telephone interview with the Director of Nursing ( DON ) on 9/24/14 at 1:40 PM, questioning the DON if this elopement was reported to NJDOH. The DON stated that the facility did not report the 9/1/14 elopement. A nurses note dated 9/6/14 at 4PM, documented, "Received call from security resident left the facility, walked up summer avenue. Sisters notified. S/O (Security Officer) notified the police." Resident returned to facility at 6:15 PM as documented on the facility "Accident" report. A review of the medical record and the facility "Accident" report failed to document that the NJDOH was notified of the elopement. The surveyor conducted a telephone interview with the Director of Nursing ( DON ) on 9/24/14 at 1:40 PM, questioning the DON if this elopement was reported to NJDOH (New Jersey Department of Health). The DON stated that the facility did not report the 9/6/14 elopement. A nurses note dated 9/14/14 timed at 1315 (1:15 PM) documented, "called by security that resident was attempting to leave grounds. When I (nurse) arrived outside informed by security that resident was walking down Broadway street. I (nurse) rode around the block and did not see resident but when I (nurse) returned to the facility resident was sitting at the picnic table out front. I (nurse) informed the resident if she left the grounds I (nurse) will call the police." The nurses note failed to document that family, physician or police notification was completed. Resident #2 returned to the facility at 1:35 PM, as documented on the facility "Accident" report. A review of the medical record and the facility "Accident Report" failed to document that the NJDOH was notified of the elopement. The surveyor conducted a telephone interview with the Director of Nursing ( DON ) on 9/24/14 at 1:40 PM, questioning the DON if this elopement was reported to NJDOH. The DON stated that the facility did not report the 9/14/14 elopement. A nurses note dated 9/15/14 timed at 6:50 PM documented "(Elopement) Writer informed by Security Officer (S/O) that resident has left the facility grounds via driveway while being monitored and followed by Security Officer. As per SO (S/O) while following resident attempted to dissuade her from leaving grounds, however to no avail, resident then turned left on the street of Broadway. Family, physician, and police were notified." Resident returned to facility within 20 minutes as documented on the facility "Accident" report. A review of the medical record as well as the facility "Accident" report failed to document that the NJDOH was notified of the elopement. The surveyor conducted a telephone interview with the Director of Nursing ( DON ) on 9/24/14 at 1:40 PM, questioning the DON if this elopement was reported to NJDOH. The DON stated that the facility did not report the 9/15/14 elopement. A nurses note dated 9/17/14 timed at 9:15 PM documented "Resident was attempting to leave the grounds and could not be redirected." Resident returned to the facility at 9:46 PM as documented on the facility "Accident" report. A review of the medical record and the facility "Accident" report failed to document that the NJDOH was notified of the elopement. The surveyor conducted a telephone interview with the Director of Nursing ( DON ) on 9/24/14 at 1:40 PM, questioning the DON if this elopement was reported to NJDOH. The DON stated that the facility did not report the 9/17/14 elopement. The surveyor conducted an interview with RN #1 (Registered Nurse) on 9/19/14 at 1:11 PM. RN #1 indicated that, "The residents do not need to tell us they go outside. If they elope, security can locate a Resident immediately on the camera. Security watches everyone who is on elopement risk and will follow/go to where the parking lot ends. If resident does not come back, we call the police." The surveyor conducted an interview with RN #2 on 9/19/14 at 1:17 PM. RN #2 indicated that, "Security watches them outside. Security calls us to inform us when she (Resident #2) eloped. If they elope the DON (Director of Nursing), Supervisor and the Police are called. We can not follow her (Resident #2), because the person who follows her puts their life at risk as well." The surveyor conducted an interview with Security Supervisor on 9/19/14 at 4:15 PM. Security Supervisor indicated that "Security is outside with smoking residents and monitor and check for any residents who may wonder off. Security Officer (S/O) asks where they are going and why. S/O uses radio to desk (indicating that they call, via walkie talkie to the security in the building stationed at the desk in the lobby) and desk calls nursing station if anyone elopes. Security is outside and watch while resident is out. Instructions are given to all security guards to walk for no more than 2 blocks with any eloping resident and notify desk, call police with their (residents) location and direction of area they are going to." The surveyor conducted a telephone interview with the Director of Nursing ( DON ) on 9/24/14 at 1:40 PM, questioning the DON if the previous 5 elopements were reported to NJDOH. The DON stated "No we did not report the other ones. We should have reported it before. We know that, but we reported this one because of increased risk of elopement. She was not going to stop going to her boyfriend's house." The Facility Reportable Record/ Event dated 9/17/14 for elopement of 9/16/14 was faxed to NJDOH on 9/17/14. On 9/19/14, the day of the survey, the DON gave the surveyor a Reportable Event Form for the elopement of 9/18/14. The facility failed to notify NJDOH of the previous 5 elopements. The surveyor reviewed the facility's policy, received on 9/19/14, which was last reviewed and revised on 2/14, entitled "Elopement/ Missing Residents Policy" documents Purpose: "To Provide guidelines to follow whenever the facility staff are unaware of a resident's whereabouts outside of the facility." It further documents under the Policy Interpretation and Implementation "5 d. Notify the Department of Health & Senior Services, and the Ombudsman for resident." 2. The surveyor reviewed the medical record of Resident #1 on 9/19/14 at 11:30 AM. The "Resident Face Sheet" revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 9/13/14 indicated a Brief Mental Status assessment (BIMS) score of 9 indicating that Resident #1 was moderately impaired. According to the MDS, Resident #1 required staff supervision for Activities of Daily Living (ADL's). A review of Resident #1's care plan for "Cognitive Loss/Behavior problems" indicated that Resident #1 had "Verbal and Physical altercation" with 3 Peers, which the facility failed to report to the New Jersey Department of Health on the following dates: "6/16/14 Verbal altercation with (an unsampled Resident #1) over the weekend on (6/15/14). Resident #1 hit the Unsampled Resident #1 with his cane. On 6/30/14 Physical altercation with an (unsampled Resident #2). Resident (#1) "appears to have initiated the aggression." On 8/28/14 physical altercation in Activities room with an (Unsampled Resident #3). A review of facility documentation revealed that the facility failed to provide nursing documentation regarding the Resident to Resident altercations on 6/15/14, 6/30/14 and 8/28/14. A review of facility "Accident" report for unsampled Resident #1, indicated "Accident Reason: Abuse." On 6/15/14 at 7 PM, (Unsampled Resident #1) "had a verbal altercation with Resident (#1). Security officer intervened and resident was redirected to her unit." According to the "Accident" report form, it was noted that the Administrator, Director of Nursing (DON), Physician and one other named staff member were notified on 6/16/14 at 7:30 AM. The Nurse Supervisor was notified on 6/15/14 at 7:00 PM. Review of facility "Accident" report for Resident (#1), indicated, "Accident Reason: Other." On 6/15/14, (Resident #1) "stated they hit each other with their canes." Under "Description: (Resident #1) was involved in verbal altercation with resident (Unsampled Resident #1)." According to the "Accident" report form, it was noted that the Administrator, Director of Nursing (DON), Physician, nurse and two other named staff members were notified on 6/19/14 at 11:30 AM. Review of Security documentation regarding the incident on 6/15/14, indicated that Resident #1 and the Unsampled Resident #1 had a verbal altercation which resulted in a physical altercation whereby the Unsampled Resident #1 hit Resident #1 with her cane. Resident #1 hit the Unsampled Resident #1 with his cane. As per Resident #1's statement, "She (unsampled Resident #1) hit me with her cane, I had to defend myself. I hit her with my cane." In a review of Progress Notes, a nurse documented that on "6/15/14 at 7 PM as reported by security. Resident (#1) and resident (Unsampled Resident #1) into a verbal altercation, and before it got physical, security staff intervene, and separated them." A review of facility "Accident" reports indicated, on 6/30/14 at 4:10 PM, "resident (unsampled) was hit in the mouth by Resident" (#1). Resident (#1) "was asked what happened, resident states "He tried to sneak me and I wasn't going down like that." According to the "Accident" report form, it was noted that Resident #1's contact was informed of the incident on 6/30/14 at 5:45 PM. The Administrator, Director of Nursing (DON), Physician and one other named staff member were notified on 7/8/14 at 10:53 AM. The nurse was notified on 7/8/14 at 10:54 AM. The facility staff when requested failed to provide nursing progress notes documentation regarding the Resident to Resident physical altercation. A review of facility "Accident" report indicated, on 8/28/14 at 3:30 PM, an unsampled Resident hit Resident (#1) in the activity room during art group. According to the "Accident" report, the Administrator, ADON(Assistant Director of Nursing), Physician and Mental Health staff were notified on 9/4/14. Facility staff failed to provide, to the survey team on the day of the survey 9/19/14, nursing progress notes or documentation regarding the resident to resident physical altercation. A review of Facility Abuse Policy Number G-1, last reviewed February 2014, indicated that, "All forms of abuse including resident-to-resident abuse must be reported immediately to the nursing supervisor, the Director of Social Services, DON/ADON and to the administrator." A review of the Facility "Accident And Incident Reporting," last reviewed on 2/26/14, indicated that, "An investigation report will be initiated, if warranted to include written statements of witness. In addition, the department (Department) of Health shall be notified immediately of any suspected resident abuse." NJAC 8:39-13.4(c)2(v)

C/O # NJ , NJ Based on interview and record review, it was determined that the facility failed to revise a care plan to address continual elopements for 1 of 3 sampled residents (Resident #2). Resident #2 eloped from the facility on 7 separate occasions, 9/1/14, 9/6/14, 9/14/14, 9/15/14, 9/16/14, 9/17/14, 9/18/14 and the care plan was not revised on 9/14/14, 9/15/14, 9/16/14 and 9/17/14. The deficient practice was evidenced by: The surveyor reviewed the medical record of Resident #2 on 9/19/14 at 10:40 AM. The "Resident Face Sheet" revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 9/3/14 did not indicate a Brief Interview for Mental Status (BIMS) score. A review of the MDS indicated as per section C0100 that the Resident was not interviewable secondary to "resident is rarely/never understood." In section C1000, staff Assessment for Mental Status, indicated that Resident #2's cognition was moderately impaired. According to the MDS, Resident #2 required staff supervision for Activities of Daily Living (ADL's). A review of the "Care Plan Activity Report" indicated that the facility failed to implement new interventions to prevent further elopements for the following: On 9/14/14 a nurse documented at 1:15 PM, "called by security notified that resident was attempting to leave grounds. When I arrived outside informed by security that resident was walking down Broadway street. I rode around the block and did not see resident but when I returned she was sitting at the picnic table out front. I informed client (Resident #2) that if she left the grounds I will call the police. Client did not respond." There was no new intervention added to the care plan to prevent future elopements. On 9/15/14 at 6:50 PM a nurses note documented, "(Elopement) - writer informed by Security Officer that Resident (#2) has left facility grounds via (a neighboring facility) driveway while being monitored and followed by Security. As per S/O (#1), partner S/O (#2) while following Resident, attempted to dissuade her from leaving grounds, however to no avail, she then turned left on the street of Broadway." There was no new intervention added to the care plan to prevent future elopements. On 9/16/14 at 7:45 AM a nurses note documented, "Security notified me of resident leaving facility. At 8:45 AM Resident was returned to facility by a staff member who saw her in the rain." On 9/16/14 at 1PM "Constantly walking on/off unit since return this AM." There was no new intervention added to the care plan to prevent future elopements. On 9/17/14 at 9:45 PM nurses note indicated the following: "Elopement - Approximately 9:15 PM writer received a call from security that resident was attempting to leave facility grounds. Writer immediately proceeded outside to redirect resident, supervisor was made aware in passing. As writer proceeded out of (facility) parking lot writer was met by security guard and resident which continued to leave facility grounds and could not be redirected at the time. Writer proceeded for a full block to redirect resident back to facility resident adamantly refused and proceeded down the block." At 9:46 PM, "Received a call from security stating that resident returned back to facility." At 9:48 PM, "resident returned back to unit." There was no new intervention added to the care plan to prevent future elopements. On 9/19/14 at 10:20 AM during an interview with the DON (Director of Nursing), the surveyor was informed that the resident eloped yesterday at 3:30 PM and was with her sister. Within the next five minutes the DON informed the surveyor that the resident eloped yesterday at 3:30 PM but the facility was not sure where she was and that the resident has not yet returned to the facility. At 11:45 AM, as per Social Worker, resident was being escorted by the police to the crisis center. At 2:45 PM the DON informed the surveyor that the resident was with her case worker at the hospital in the crisis center. At 3:05 PM the DON informed the surveyor that the resident was in the ER (emergency room ) and being admitted by the facility physician. The surveyor conducted an interview with RN (#1) (Registered Nurse) on 9/19/14 at 1:11 PM. RN #1 indicated that, "the residents do not need to tell us they go outside. If they elope, security can locate a Resident immediately on the camera. Security watches everyone who is on elopement risk and will follow/go to where the parking lot ends. If resident does not come back, we call the police. If elopement the RN immediately updates the care plan." The surveyor conducted an interview with RN #2 on 9/19/14 at 1:17 PM. RN #2 indicated that, "security watches them outside. Security calls us to inform us when she (Resident #2) eloped. If they elope the DON, Supervisor and the Police are called. We can not follow her (Resident #2), because the person who follows her puts their life at risk as well. The unit manager and RN update the care plan." A review of Resident #2's current care plan for elopements revealed that the facility failed to implement any new interventions after the elopements on 9/14/14, 9/15/14, 9/16/14 and 9/17/14 to include measures that would prevent future elopements. NJAC8:39-11.2(i)

Based on observation, interview and record review, it was determined that the facility failed to provide appropriate supervision and assistive devices to prevent falls. This deficient practice was observed for 1 of 6 residents reviewed for falls, Resident #2. The evidence was as follows: On 8/25/14 at 8:01 a.m. the surveyor observed Resident #2 in bed sleeping in his/her room. There was no safety mat on the floor adjacent to his/her bed. There were no anti-roll bolsters applied in the bed. At approximately 8:15 a.m. a Certified Nurses Assistant (CNA#1) transferred Resident #2 from bed to the wheel chair by herself. At 8:40 a.m. CNA #1 left Resident #2's bedroom while the resident started to eat breakfast independently while seated in his/her wheel chair without staff presence. At 9:01 a.m. CNA #1 walked back into Resident #2's room briefly and then walked out again leaving the resident still in his/her wheel chair eating breakfast without staff presence. At 9:11 a.m. Resident #2 was still in his/her room seated in his/her wheel chair without staff presence when the surveyor left the area. On 8/25/14 the surveyor reviewed Resident #2's fall incident and investigations for 4 falls that occurred on 3/21/14, 4/7/14, 6/1/14, and 7/2/14. Review of the 3/21/14 fall investigation indicated that Resident #2 was in his/her wheel chair at the nurse station feeding him/herself and slid out of the wheel chair onto the floor without injury. Further review indicated interventions added to prevent recurrence of falls from the wheel chair included for the application of an anti-slip pad for prevention of sliding. Review of the 4/7/14 fall investigation indicated that Resident #2 fell from the wheelchair and landed on his/her buttocks without injury. Further review indicated that the resident stated that one wheel chair wheel was unlocked and he/she fell . Additional review indicated that the non-slip pad was not applied at the time of the fall as it was removed for cleaning the wheelchair and was not replaced afterwards. Review of the 6/1/14 fall investigation indicated that Resident #2 was observed on the floor trying to take items out of the lower part of his/her night stand. Staff last observed the resident to be seated in his/her wheelchair 45 minutes prior to discovering the resident on the floor. The resident had no apparent injury. Interventions added to prevent recurrence of falls included that staff will refrain from leaving Resident #2 in the wheelchair unattended when in room or other area where staff were not present. Review of the 7/2/14 fall investigation indicated that Resident #2 was seated in his/her wheelchair with meal tray eating in his/her room. Additional review indicated that Resident #2 got up from wheelchair to get something and slipped on the wet floor. No apparent injury. Interventions added to prevent the recurrence of falls included to monitor Resident #2 during meals to make sure he/she has no spill of any drinks on tray or table. On 8/26/14 the surveyor reviewed the current plan of care that addressed falls and Activities for daily living (ADL) tasks which indicated that Resident #2 had a history of [REDACTED]. The resident was unaware of his/her safety. Resident #2 attempted to ambulate without assistive device and had lower extremity weakness. Additional review indicated interventions to continue with floor mat while in bed; provide anti-roll bolster to prevent rolling out of bed; Resident #2 will not be left in wheelchair without monitoring; and extensive one person assist for transfer. On 8/26/14 the surveyor reviewed the most current Minimum Data Set (MDS), an assessment tool dated 6/14/14 which indicated that the Interdisciplinary Team (IDT) assessed that Resident #2 needed extensive assistance with two person assist for transfers. On 8/27/14 the surveyor reviewed Resident #2's fall risk assessment for 12/12/13 and 3/14/14 which indicated that the IDT assessed that Resident #2 was at high risk for falls. On 8/26/14 at 9:26 a.m. the surveyor interviewed Nurse #1 and asked her to review the fall investigation of 6/1/14 that indicated that staff will refrain from leaving Resident #2 in the wheelchair unattended when in room or other area where staff were not present. She stated that her interpretation of this intervention was staff was to provide 1:1 monitoring of Resident #2 while the resident ate meals. The surveyor also asked Nurse #1 to review the care plan which called for one person assist for transfers and the MDS which called for two person assist for transfers and asked Nurse #1 to explain the discrepancy. Nurse #1 stated that in her opinion, Resident #2 needed to be transferred with two person assist for the safety of Resident #2. NJAC 8:39-27.1(a)

Based on observation, interview and record review it was determined that the facility failed to ensure that all medications were administered without errors totaling 5% or more. On the morning medication pass of 8/25/14 the surveyor observed 2 nurses administer medications to 8 residents. There were 34 opportunites observed with 2 errors, which calculated to a 5.8% error rate. This deficient practice was identified for Resident #5 and #16. The evidence was as follows: 1. On 8/25/14 at 8:29 a.m. the surveyor observed Nurse #1 administer a [MEDICATION NAME] 150mg tablet by mouth (po) to Resident #16. At that time the surveyor observed the electronic Medication Administration Record [REDACTED].' On 8/25/14 at 11 a.m. the surveyor interviewed Nurse #1 who acknowledged the EMR for the order [MEDICATION NAME] 150mg po included instructions to administer before a meal. Nurse #1 stated that Resident #16 had eaten breakfast prior to the medication administration, between 8 a.m. and 8:30 a.m. since several of the medications for Resident # 16 were required to be administered with food. Nurse #1 acknowledged that the [MEDICATION NAME] 150mg po order was timed for 8 a.m. while the other medications that were administered on the medication pass were timed for 9 a.m. On 8/27/14 the surveyor reviewed the 'Medication Administration Guidelines' policy provided by the Director of Nursing (DON) which stated "Medications can be administered an hour before or an hour after unless otherwise indicated." 2. On 8/25/14 at 9:13 a.m. the surveyor observed Nurse #2 administer a [MEDICATION NAME] 325mg tablet po to resident #5. At that time, Resident #5 was in the room eating breakfast. At that time, the surveyor observed the EMR for the order [MEDICATION NAME] 325mg which included a statement with the order "Best taken on an empty stomach, one hour before meals or two hours after meals." On 8/25/14 at 11:40 a.m. the surveyor interviewed Nurse #2 who acknowledged the [MEDICATION NAME] order included the statement "Best taken on an empty stomach" and the resident was eating breakfast when the [MEDICATION NAME] was administered. The nurse further stated that the [MEDICATION NAME] was timed for 9 a.m. and would need to be changed to accommodate the instructions. N.J.A.C. 8:39-11.2(b), 29.2(d)