Every finding on record at Cambridge Rehabilitation and Healthcare Center

Based on interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident's plan of care was followed and communicated to all facility staff to prevent falls. Resident #2 fell and sustained head trauma with a laceration to the head with active bleeding which required transferring Resident #2 to the hospital. This deficient practice was identified for one of three residents (Resident #2) reviewed for accidents and incidents. This deficient practice was evidenced by the following:On 11/6/25 at 10:15 AM, the surveyor reviewed Resident #2's closed electronic Medical Record (EMR).A review of the Face Sheet (an admission summary) reflected that Resident #2 was admitted to the facility with diagnoses which included but were not limited to; Parkinson's disease, need for assistance with personal care, hemiplegia unspecified affect, muscle wasting and atrophy and unspecified dementia.A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 7/21/25, reflected that Resident #2 scored 7 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severe cognitive impairment.Section GG of the MDS addressed Functional Abilities and indicated that Resident #2 was assessed as being totally dependent on staff for care. Resident #2 received a score of 01 which indicated that the helper completed the activity or the assistance of 2 or more helpers were required for the resident to complete the activity.Section GG 0115 of the MDS referred to Functional Limitation in Range of Motion and indicated that Resident #2 had impairment on both upper and lower extremities. A review of the interdisciplinary comprehensive care plan (ICCP) initiated on 1/21/2025, revealed a focus area that Resident #2 was at risk for falls related to deconditioning, weakness, impaired mobility and incontinence. The ICCP goal was that Resident #2 would be free of fall related injury through the next review date of 10/15/2025.The 1/21/2025 ICCP interventions included; to assist and /or remind the resident to change position and get up from sitting or lying slowly due to orthostatic blood pressure problems. Be sure call light is within reach and provide reminders to use call light for assistance as needed. Create a safe environment, floors clear of clutter, clean up spills, adequate lighting. Educate resident, involved family members, and caregivers about safety reminders, fall prevention, and what to do if a fall occurs. Monitor for safety due to dizziness, lethargy, and poor safety awareness. Document findings and interventions. The ICCP was revised on 9/5/25, after a fall and included the following: Determine and address causative factors of the fall.Review of the ICCP for ADL (Activities of Daily Living) Self Care Performance Deficit related to Activity Intolerance, impaired mobility, Parkinson's disease, initiated on 10/15/2024, revealed that the resident was dependent on staff for bathing, used a Geri-chair when out of bed, required staff assistance with grooming/personal hygiene, a total mechanical lift with two person assistance with transfers, and to educate resident, involved family members, and caregivers about safety reminders. A review of the Certified Nursing Assistant (CNA) plan of care revealed that Resident #2 was dependent on staff for all care. Resident #2 had impairments on both upper and lower extremities. Review of the nursing progress notes (PN) dated 09/05/25 timed 20:16 (4:16) PM, indicated the following: Writer notified by Aide at 16:00 PM (4:00 PM) that Resident #2 was on the floor, resident noted lying on the floor on their left side, able to respond to commands, eyes open, blood noted on the floor to the left side of head, Unit Manager notified, Resident Representative notified. Resident transferred to emergency room for further evaluation.An additional PN dated 09/06/25 at 6:52 AM, revealed, admitted for observation. Large hematoma (collection of blood outside the blood vessels similar to a bruise) and laceration to the back of the head. Bleeding stopped and controlled. Remains conscious .A review of the nursing PN dated 09/15/ 25 and timed 13:02 (1:02 PM), indicated the following: Resident Representative reported that Resident #2 had a decline since hospitalization in the trauma unit. Resident #2 was not eating, not responding verbally to others and had bruises, and stated, she is black and blue all over.On 11/06/25 at 10:30 AM, the surveyor requested all investigations for Resident #2 for the past six months and their ICCP from the Director of Nursing (DON).On 11/06/25 at 11:15 AM, the DON provided an incident report (IR) dated 9/5/25 at 4:00 PM, which revealed that Resident #2 sustained a fall during incontinence care. The following details were included: Resident #2 was found on the floor in the room. Resident #2 sustained a head trauma with laceration to the scalp and a hematoma. First Aid initiated; vital signs obtained. No neuro checks initiated; 911 called emergently. The physician and the Resident Representative were notified. Resident #2 was transferred to the hospital for evaluation and treatment The facility's IR conclusion revealed, that during incontinent and linen change, Resident #2 rolled out of bed, which caused a fall. The nurse was notified by the assigned Certified Nursing Assistant (CNA) that the resident had a witnessed fall. Upon entering the room, Resident #2 was noted to be on the floor laying on their left side with a laceration with active bleeding noted. Bleeding controlled with occlusive dressing and firm pressure. MD (medical doctor) ordered the resident to be sent out via 911 to the Trauma Center. Interdisciplinary Team met and reviewed the event details. Concluded: CNA performed tasks properly per protocol. Resident #2 moved their arm which shifted their weight and they loss trunk balance, landing on the floor.The Root Cause section of the IR revealed: Resident rolled out of bed, which caused a fall during incontinent care and linen change while in bed. The investigation provided by the facility contained the following statements: A statement from CNA #1, revealed, I was finishing up their care and was fixing the bed sheet as their previous sheets were soiled. As I was straightening out the sheets toward the bottom of the bed, the resident rolled over before I could grab their back. I followed the plan of care and received report from the other aides and nurses. A statement from CNA#2 who was present in the room indicated the following: I was behind the curtain, giving care to the roommate. We were working together to get changes throughout our assignment done. She (referring to CNA#1 provided care to Bed 1, and I (CNA #2) provided care to Bed 2. CNA #1 stated that Resident #2 did not have bedrails on the bed.The surveyor requested and reviewed the assignment sheet of 9/5/25 for the 3:00 PM-11:00 PM shift, and confirmed that CNA #1 was assigned to Resident #2.On 11/16/25 at 12:15 PM, the surveyor interviewed the DON regarding Resident #2's plan of care. The DON stated that although the resident was immobile, she was able to hold onto the bedrail and assist with turning. The surveyor then requested the bedrail assessment that was completed for Resident #2. None was provided.On 11/6/25 at 12:40 PM, the surveyor conducted a telephone interview with the Licensed Practical Nurse (LPN) who cared for Resident #2 after the fall. The LPN stated that she observed the resident on the floor, bleeding. She notified the Nursing Supervisor and remained with the resident until paramedics arrived. The LPN was informed by CNA #3 that Resident #2 rolled out of bed. When asked about the resident's functional mobility, the LPN stated that Resident #2 was totally dependent on staff and unable to assist with care. On 11/06/25 at 1:22 PM, the surveyor interviewed the MDS Coordinator (MDSC) regarding Resident #2's coding assessment, specifically Section GG (functional mobilities). The MDSC stated that the data for the assessment was obtained from nursing staff communication and the CNA plan of care. The surveyor in the presence of the MDSC reviewed the CNA plan of care and coded data, which confirmed that Resident #2 was unable to roll from side to side during care. The Roll left and right activity under section GG was coded as helper does ALL the effort; Resident does none of the effort to complete the activity. Further required the assistance of 2 or more helpers to complete the task. Resident #2 was totally dependent on care and demonstrated impaired upper and lower extremities.On 11/6/25 at 1:26 PM, the surveyor interviewed CNA #3 assigned to the unit where Resident #2 resided. CNA #3 stated that she was familiar with the resident's care routine and confirmed that Resident #2 got out of bed only for hair care and was completely dependent on staff and required two persons physical assist for care and transfers. The surveyor asked CNA #3 where the resident's care documentation could be located, and she stated it was entered into the electronic plan of care system. CNA #3 showed the surveyor the Plan of care and confirmed that Resident #2 was dependent on staff for all care needs and was unable to assist with turning/rolling from side to side. CNA #3 further stated that she had provided care for Resident #2 for the past two years. The CNA #3 explained that Resident #2 was bedbound and required two persons assist with care and could not turn on their own as they were immobile. She stated that she cared for the resident with her hallway partner. She reported that the day of the fall, she was about to leave the unit when she observed the resident on the floor, bleeding, and observed CNA#1 and CNA #2 in the room. She Immediately went to the nursing station and retrieved the nurse.On 11/6/25 at 1:50 PM, the DON stated that she could not provide the bedrail assessment. In the presence of the survey team, the DON stated that Resident #2 did not have siderails. The surveyor then asked about the MDS Coding for Section GG0115 (Functional Limitation in Range of Motion) and 0170 (Mobility), the DON declined to comment. The DON stated that she did not review the MDS coding yet.On 11/6/25 at 2:00 PM, the surveyor interviewed the DON regarding the plan of care implemented for Resident #2. The DON stated again that she did not look at the MDS coding yet and could not comment on the plan of care.On 11/6/25 at 2:05 PM, the surveyor reviewed the MDS coding with the DON and asked if CNA #1 should have followed the plan of care. In the presence of the survey team, the DON stated, yes the CNAs should follow the plan of care.The DON could not comment on the discrepancy noted on the fall investigation. The investigation concluded that Resident #2 rolled out of bed and CNA #1 followed the plan of care. However, the MDS, the assessment tool used by the facility to prioritize care for Resident #2 reflected that CNA #1 did not follow the plan of care. The CNA's Plan of Care generated by the facility reflected that Resident #2 was dependent on staff and could not complete the activity of rolling from side to side. Resident #2 had impairment on both upper and lower extremities and could not turn or maintain a log roll position during care. Resident #2 required two-person physical assist with care.On 11/6/25 at 2:18 PM, the surveyor conducted a telephone interview with CNA #1 who cared for Resident #2 on 9/5/25. CNA #1 stated that she was asked to assist on the 3:00 -11:00 PM shift. When she went to Resident #2's room, Resident #2 was soaked with urine, the bedding including the mattress were saturated with urine. She adjusted the bed to her height to provide care, she proceeded to change the resident and wiped the bed at the same time to remove the excess of urine on the mattress. She turned the resident to the side and the resident landed on the floor. The CNA #1 stated, When Resident #2 hit the floor, I screamed, I was panicked.The surveyor then asked CNA #1 if she reviewed the resident plan of care prior to provide care. CNA #1 stated, it was chaotic that day, she did not read the plan of care or get report from the 7:00 AM-3:00 PM shift regarding the level of assistance required by Resident #2. CNA #1 further stated that she reviewed the plan of care after she was called in the office by the DON and noted that Resident #2 was dependent on staff and required two persons assist with care. CNA #1 stated she received an in-service education that same day from the DON. On 11/6/25 at 2:45 PM, during the exit conference with the administrative staff, no additional information was provided for Resident #2's fall.A review of the facility's policy titled Accidents and Incidents-Investigation and Reporting undated and last revised July 2017, included the following:Policy Statement- All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and implementation- The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/ Accident. The data and time. The nature of the injury/illness (e.g., bruise, fall) .The circumstances surrounding the accident or incident. Follow up information, other pertinent data as necessary or required. The administrator and /or director of nursing will determine the need for further action and follow-up, as deemed appropriate based on the results of the investigation.The Care Plans Comprehensive Person-Centered policy, last revised 2/2022, revealed the following:Policy Statement- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation-The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. NJAC 8:39-27.1(a), NJAC 8:39-11.2(e) 1 .

Based on interview, record review and review of pertinent documents it was determined that the facility failed to ensure a thorough investigation was conducted to identify the causal factor of a fall for a severely cognitively impaired resident who was found lying on the floor in a pool of blood, that resulted in a hematoma and laceration to the head, and required emergent transfer to the hospital on 9/5/25. This deficient practice occurred for 1 of 3 residents (Resident #2) reviewed for accidents and incidents, and was evidenced by the following:On 11/6/25 at 11:30 AM, the surveyor reviewed the closed medical record (Electronic and Paper) for Resident #2.According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to; Parkinson's disease, need for assistance with personal care, hemiplegia unspecified affect, muscle wasting and atrophy, unspecified dementia.A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/21/25, revealed that Resident #2 scored 07 out of 15 on the Brief Interview for Mental Status (BIMS), indicative of severe cognition. Further review of the MDS indicated that Resident # 2 was totally dependent on staff for care, required a Hoyer mechanical lift transfer with 2 or more people assist. Had impairments on both upper and lower extremities. A review of the QAPI Report dated 9/5/25, provided by the facility, reflected that Resident #2 sustained a fall with injuries which included, hematoma, and laceration to the scalp and required an emergent transfer to the hospital for treatment.The investigation concluded that the resident rolled out of bed. The CNA performed tasks properly according to protocol.On 11/6/25 at 11:15 AM the surveyor reviewed the MDS assessment dated [DATE] which revealed that Resident #2 was totally dependent on staff for care, had limitation on both upper and lower extremities and required two persons physical assist with care.On 11/6/25 12:15 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident although immobile was able to hold onto the bedrails and assist with turning during care. That same day at 1:30 PM the DON informed the survey team that Resident #2 did not have bedrails in use. On 11/6/25 at 12:40 PM, during a telephone interview with the Licensed Practical Nurse (LPN) who cared for Resident #2 at time of the fall, she stated that Resident #2 was fully dependent on staff, required two-persons assist with care.On 11/6/25 at 1:22 PM, the surveyor interviewed the MDS coordinator regarding the MDS coding. She explained to the surveyor that the data to complete the MDS was obtained from communication from the nursing staff and the CNA Plan of Care. The MDS Coordinator provided the Plan of Care for Resident #2. The Plan of Care revealed that the resident was unable to perform the activity (Roll from side to side) the helper does the work. Or 2 or more assists were required to perform the activity. On 11/6/25 at 1:26 PM, the surveyor interviewed a random CNA (CNA #3) on the unit where Resident #2 resided. Upon inquiry, CNA# 3 stated that she was familiar with the resident's care routine. The CNA stated that Resident #2 got out of bed only for hair care. Resident #2 was fully dependent on staff and required 2 persons physical assist for care and transfer. The surveyor asked the CNA where the documentation regarding the care required by Resident #2 could be located. The CNA stated that the care was entered on the Plan of care. CNA #3 showed the resident the Kardex and verified that Resident #2 was dependent on staff for care, the resident could not assist with turning/rolling from side to side. CNA #3 informed the surveyor that she had been taking care of the resident for the last three years. The CNA stated that Resident #2 was a FULL complete. When asked to elaborate she stated, Resident #2 was bedridden, she required 2 persons assist with care. Resident #2 could not turn on their own as they were immobile. She cared for the resident with her hallway partner daily. The CNA further stated that the day of the fall she was about to leave the unit when she observed the resident on the floor bleeding and both CNA #1 and CNA #2 were in the room. She went to the nursing station and informed the nurse.The facility did not provide any statement from CNA #3.On 11/6/25 at 2:00 PM, the surveyor interviewed the DON regarding the plan of care implemented for Resident #2. The DON stated again that she did not look at the MDS coding yet and could not comment on the plan of care.On 11/6/25 at 2:05 PM, the surveyor reviewed the MDS coding with the DON and asked if the CNA should have followed the plan of care. In the presence of the survey team, the DON stated, yes. The CNAs should have followed the plan of care.The facility concluded that CNA #1 performed tasks properly per protocols. Resident #2 moved their arm which shifted their weight and they loss trunk balance, landing on the floor. Root Cause: Resident rolled out of bed, which caused a fall during incontinent and linen change while in bed. On 11/6/25 at 2:18 PM, during a telephone interview with CNA #1 who cared for Resident #2 on 9/5/25, she stated that Resident #2 did not have siderails in use. CNA #1 stated that she did not check the plan of care prior to provide care to Resident #2. She was not aware that Resident #2 required two-persons physical assist with care. CNA #1 further stated that she did not get report from the 7:00 AM-3:00 PM shift regarding Resident #2's plan of care. However, the investigation was completed and closed on 9/18/25. 62 days had elapsed, and the facility could not comment on the plan of care required by Resident #2. Based on the assessment provide and dated 7/21/25, Resident #2 required 2 persons physical assist with care. On 11/6/25 at 2:45 PM, the DON did not provide the in-service education that was done following the incident. The DON provided an in-service education dated 8/22/25 regarding ADL. The CNA involved with the fall of 9/5/25 was not in attendance.NJAC 8:39-9.4(f)

Based on interview, record review and review of other pertinent facility documentation it was determined that the facility failed to treat and manage a resident's pain consistent with professional standards of practice. This was identified for 1 of 4 residents (Resident #1) reviewed for pain and was evidenced by the following:A review of the resident admission Record (admission summary) indicated that Resident #1 was admitted to the facility with the diagnoses which included but was not limited to Alzheimer's Disease, chronic obstructive pulmonary disease (COPD-a group of lung diseases that cause airflow obstruction and breathing difficulty) and osteoporosis (causes bones to become thinner, weaker and more likely to fracture). A review of the quarterly Minimum Data Set (MDS)-an assessment that facilitates a resident's care) dated 9/10/25, indicated that Resident #1 scored a 3 (three) out of 15 on the Basic Interview for Mental Status (BIMS) which indicated that the resident had severe cognitive impairment. The MDS also reflected that Resident #1 required maximum assistance with all aspects of activities of daily living (ADLs).A review of the Facility Reportable Event (FRE) dated 8/25/25 revealed that on 8/23/25, Resident #1's responsible party (RP) informed the nursing staff that the resident had pain in the right shoulder. The physician was notified, and an x-ray was obtained on 8/24/25 which showed that the resident had osteopenia and a non-displaced humerus fracture. The physician was updated, and the resident had a history of pathological fractures. Further review of the Situation, Background, Assessment and Recommendation (SBAR-change of condition) form dated 8/23/25 at 6:44 PM, reflected that Resident #1's complained of right shoulder pain rated 8 out of 10 (with 10 being the worst). The nurse documented noted tenderness and limited range of motion in the affected shoulder. However, there was no follow-up documentation which indicated that any pain medication or intervention was administered at that time to address or manage the resident's pain.A review of the facility summary and conclusion indicated the resident was medicated with Tylenol for pain and that the medication was effective. The surveyor reviewed Resident #1's nursing progress notes and the Medication Administration Record (MAR) and there was no documentation that the resident had received any pain medication.The surveyor reviewed the MAR dated 8/24/25 which indicated that Resident #1's pain was being monitored each shift. On the night shift documentation reflected that the resident complained of pain at a rate of 5 out of 10 on the pain scale. However, there was no follow-up documentation to indicate whether the resident was administered pain medication or interventions to address or manage the resident's discomfort.On 11/6/25 at 10:20 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who reviewed Resident #1's MAR in the presence of the surveyor. The ADON confirmed that on 8/23/25 at 6:44 PM and again on 8/24/25 during the night shift, when the resident had complained of pain, there was no documentation that pain medication was administered. The ADON stated that the nursing staff did not appear to administer any pain medication or implement interventions to manage the resident's pain. The ADON stated that the physician should have been notified, and appropriate pain medication should have been provided.On 11/6/25 at 12:46 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who cared for the resident on 8/23/25 at 6:44 PM. The LPN stated that she could not recall whether she administered pain medications to Resident #1 at that time. She reported that she may have given the resident Tylenol but may have failed to document the administration. She acknowledged that she should have notified the physician and obtained an order for pain medication, administered the prescribed medication and then documented both the administration and effectiveness of the medication.On 11/6/25 at 1:20 PM, the surveyor interviewed the Director of Nursing (DON) simultaneously with the Licensed Nursing Home Administrator (LNHA) who were both in agreement that when a nurse assessed a resident for pain, the nurse would be responsible to document the level of pain, location and description of the pain. The DON stated that the nurse would also be responsible to call the provider to obtain an order for pain medications. The DON continued to explain that nurses were expected to follow-up with the provider for further interventions to manage the pain and to document the effectiveness of the interventions.The facility policy titled, Pain Assessment and Management dated April 2025 indicated that the purpose of this procedure were to help staff identify pain in the resident, development of interventions and address the underlying cause of pain. General guidelines indicated that staff were to identify underlying causes, intensity, duration, type and characteristics of pain and to address the underlying cause of pain. The policy reflected that non-pharmacological interventions may be appropriate alone or in conjunction with medications. The medication regimen is implemented as ordered and results of the interventions are documented and communicated to the provided when appropriate.NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness.This deficient practice was evidenced by the following:On 7/25/2025 from 09:49 AM to 10:14 AM the surveyor accompanied by the Food Service Director (FSD), observed the following in the kitchen:1. In the walk-in freezer a frozen lasagna was wrapped in plastic wrap with a use by date of 7/25/25. When asked if lasagna should be used, the FSD replied No, I'm going to take it out right now. The expired food was removed by FSD.2. In the walk-in refrigerator a container of chicken noodle soup wrapped in plastic wrap with a use by date of 7/28/25. The expired food was removed by FSD.On 7/30/2025 at 10:36 AM on the [NAME] unit in the pantry 11 plastic cups labeled for 7/30 7-3 were seen stacked facing up and exposed to the air. Licensed Practical Nurse, (LPN) #1 accompanied surveyor to the [NAME] unit pantry to ask about the cups. LPN #1 said she did not know what the cups were for and they shouldn't be out, they should be in a container for infection control reasons. LPN #1 discarded the cups which were left open to air in unsanitary manner. On 7/31/2025 at 09:51 AM on the Laurel Creek unit in the panty a sleeve of plastic cups were seen laying on their side open to air and one cup in the cabinet facing upward open to air in an unsanitary manner.On 8/01/2025 at 12:17 PM The surveyor interviewed Licensed Nursing Home Administrator (LNHA) who said Cups should be contained in a sleeve when not in use.to prevent any food-born illness. The surveyor asked if outdated food should be in the refrigerator or freezer and the LNHA replied No and the importance is To prevent food born illness. A review of an undated facility policy titled Refrigerators and Freezers, revealed under Policy Interpretation and Implementation that 7. All food is appropriately dated to ensure proper rotation by expiration dates. The policy further reveals 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers, are not past use by or expiration dates. N.J.A.C. 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documents, the facility failed to ensure that food brought to residents by family and other visitors were stored, handled, and consumed in a safe and sanitary manner. This deficient practice was identified for 4 of 6 residents (Resident # 9, Resident # 13, Resident # 26 and Resident # 51) who had personal refrigerators in their bedrooms.The deficient practice was evidenced by the following:On 07/31/2025 at 10:23 AM, the surveyor observed that Resident # 26's personal refrigerator, located in room [ROOM NUMBER]-W temperature log had not been filled out since July 18th.On 07/31/2025 at 10:24AM, the surveyor observed that Resident # 9's personal refrigerator, located in room [ROOM NUMBER]-W, was missing temperature log entries for the whole month of July.On 07/31/2025 at 10:42 AM, the surveyor observed that Resident #51's personal refrigerator, located in room [ROOM NUMBER]-D had no temperature log was on the refrigerator for the month of July.On 07/31/2025 at 10:35 AM the surveyor observed that Resident # 13's personal refrigerator, located in room [ROOM NUMBER]-W temperature log had not been filled out since July 18th.07/31/2025 at 10:44 AM, during an interview with the surveyor, the Registered Nurse (RN) said that nursing staff was responsible for cleaning, checking and documenting the personal refrigerators in residents' rooms. The RN was unsure how often the temperatures needed to be check and said the 11-7 shift was responsible to that.07/31/2025 at 12:14 AM, during an interview with the surveyor, the Licensed Nursing Home Administrator said personal refrigerator temperatures should be checked daily to prevent food born illnesses.A review of the facility's dated policy September 2022, titled, Refrigerators and Freezers-Resident Personal, revealed, Designated employees will check and record refrigerator and freezer temperatures daily. NJAC 8:39-17.2(g)

Number of residents sampled:Number of residents cited:This deficient practice was evidenced by the following:A review of Resident # 14's admissions record revealed that, Resident # 14 was admitted with but not limited to Heart Failure, and Peripheral Vascular Disease (a condition in which narrowed arteries reduce blood flow to the arms or legs).A review of Resident #14's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 06/27/2025 revealed under section N that the resident was ordered an anticoagulant (a medication that helps thin the blood).A review of Resident #14's Electronical Medical Record revealed a physician's order with a state date of 05/26/2025 for apixaban (a medication that helps thin the blood) 5 milligrams to be given every twelve hours. A review of the current Care Plan (CP) for Resident #14 did not include documentation of a CP focus area or interventions for the use of an anticoagulant.During an interview on 08/01/2025 at 09:58 AM with the surveyor the Unit Manger Registered Nurse (UMRN)# 1 said that care plan consists of focus areas for falls, wounds, catheters, certain medications and diagnoses. When asked if Resident #14 should be care planned for oxygen the UMRN replied, Yes, but it's not in there. I must have missed it.During an interview on 08/01/2025 at 12:14 PM with the surveyor the Director of Nursing stated, there should be a focus or an intervention on use of an anticoagulant on the resident's care plan.A review of a facility provided policy titled Care Plans, Comprehensive Person-Centered revealed under section Policy Statement that, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. NJAC 8:39-27.1(a)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living specifically by not turning the resident in bed every two hours to prevent skin deterioration. The deficient practice was identified for 2 of 5 residents (Resident # 179, 152) investigated for Activities of Daily Living. The deficient practice was evidenced by the following: A review of Resident # 179’s Minimum Data Set (MDS; an assessment tool) dated 9/15/2024 revealed under section “GG” that he/she has lower extremity impairment on both sides. Further, the MDS revealed under section, “M” that he/she is at risk of pressure ulcers/injury. A review of Resident # 179’s Care Plan revealed a focus of an Activity of Daily Living (ADL) Self Care Performance deficit related to deconditioned status post hospitalization, pain, and weakness. The Care Plan revealed an intervention for “Bed Mobility” that Resident # 179 requires the assistance of one staff member and a sheet for turning and repositioning. The intervention was dated 4/14/2025. A review of the Physician’s Orders located in the Electronic Medical Record (EMR) revealed an order to, “Turn every 2 hours for turning schedule” with a start date of 4/01/2024. A review of the Treatment Administration Record (TAR) located in the EMR revealed blanks in the documentation area for the order to turn every two hours. The blank areas were identified for the following dates and times: 4/5/2024 – 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM. 4/13/2024 – 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM 4/20/2024 – 12:00 PM, 2:00 PM, 6:00 PM, 8:00 PM, 10:00 PM On 8/01/2025 at 12:05 during an interview with the surveyor, the Director of Nursing (DON) replied, “After investigation and following up with the nurse, I would make that determination.” After the surveyor asked if there are blanks on the Treatment Administration Record and no progress notes referring to the administrations, would you consider that completed. The DON said rotating residents in bed is important because it helps with skin integrity prevention or maintenance. A review of the facility policy titled, “Activities of Daily Living (ADL), Supporting” revised April of 2025 revealed that, Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.” NJAC § 8:39-27.1 (a) A review of Resident # 152’s Minimum Data Set (MDS) an assessment tool dated 05/07/2025 revealed in the Brief Interview for Mental Status (BIMS) that the resident scored a 15 indicating that the resident is cognitively intact. The MDS also revealed in section GG that the resident has bilateral lower extremity impairment and requires substantial/maximum assist with showering. A review of Resident # 152's Care Plan revealed a focus for Activity of Daily Living (ADL) Self-Care Performance deficit related to activity intolerance. The Care Plan revealed an intervention for “Bathing” that Resident # 152 requires the assistance of1 staff with bathing. The intervention was dated 10/15/2024. A review of the ADL record documentation sheet located in the Electronic Medical Record (EMR) revealed blanks in the documentation area for showering evening shift. The blanks were identified for: 07/14/2025 3-11 07/17/2025 3-11 07/21/2025 3-11 07/28/2025 3-11 A review of Resident # 152’s grievances revealed that on 05/10/2025 the resident filed a grievance regarding his/her shower schedule. The resolution was a shower schedule hung on the residents closet door. On 07/01/25 at 9:30 A.M. during an interview with the Administrator regarding blanks on the ADL record regarding showers and would they be considered performed. The Administrator stated that the resident “may have refused it.” A review of the facility policy titled, “Bathing and showering” revised February 19, 2024, revealed that “the interdisciplinary team will develop bathing/showering schedules with resident and/or representative,” It further revealed that “Provision of refusal of showers and/or tub baths will be documented in the medical record by the certified nursing assistant and/or licensed nurse.” A review of the facility policy titled, “Activities of Daily Living (ADL), Supporting” revised April of 2025 revealed that “Residents are provided with care, treatment, and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out services of daily living independently received the services necessary to maintain good nutrition, grooming, and personal and oral hygiene, NJAC 8:39-27.1(a)

Based on interview, record review, and other pertinent facility documents, it was determined that facility to failed to ensure residents received the appropriate pain management by administering pain medications according to the physician's ordered pain level parameters. This deficient practice was identified in 2 of 4 residents reviewed for pain (Resident #7 and #49) and was evidenced by the following: 1.On 7/29/2025 at 10:47 AM, during the initial tour Resident #7 was in the room in bed. The resident's left leg was elevated on pillows and the resident appeared comfortable to the surveyor. The surveyor reviewed the medical record for Resident #7.A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; fracture of the lower extremity, diabetes (high blood sugar), and depressive disorder.A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 7/11/25, section C for cognitive patterns revealed the resident had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. Section J of the MDS, health conditions indicated the resident was receiving a pain management regime. The pain assessment indicated pain was present and frequently affected sleep and therapy activities.A review of the physician orders showed the following orders related to pain management. Oxycodone (narcotic analgesic) 15 milligrams (mg) one tablet every four hours as needed for severe pain (7-10 on numeric pain scale). Acetaminophen (Tylenol, a non-narcotic analgesic) 325 mg Give 2 tablets by mouth every 6 hours as needed for Pain.A review of Resident #7 individualized comprehensive care plan (ICCP) included a focus area of acute pain related to left ankle fracture with surgical repair. Interventions included administering pain medication as ordered by the physician and evaluate the effectiveness of the pain management.A review of the Medication Administration Record (MAR) indicated that Resident #7 received 92 doses of Oxycodone in the month of July. Nine of the doses were given outside of the pain parameter as ordered by the physician.7/11/25-pain level zero7/11/25-pain level six7/12/25-pain level two7/16/25-pain level three7/17/25-pain level three7/19/25-pain level six7/23/25-pain level three7/25/25-pain level six7/30/25-pain level fiveOn 07/30/2025 at 11:13 AM, the surveyor interviewed the resident regarding pain. Resident #7 told surveyor they fractured ankle and required surgery. The resident stated they were receiving pain medication with relief. 2. 7/31/25 at 10:15 AM, Resident #49 was in bed with eyes closed, the resident appeared comfortable at the time of the observation.The surveyor reviewed the medical record for Resident #49.A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to asthma (airways become inflamed causing difficulty breathing), opioid dependence, hypertension (high blood pressure), and fracture of one rib.A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 6/25/25, section C for cognitive patterns revealed the resident had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. Section J of the MDS, health conditions indicated the resident was receiving a pain management regime. The pain assessment indicated pain was present and occasionally affected sleep and day to day activities.A review of the physician orders showed the following orders related to pain management. Oxycodone (narcotic analgesic) Extended release 40 mg one tablet every 12 hours and Oxycodone 20 mg every four hours as needed for severe pain (8-10 pain scale).A review of Resident #49 individualized comprehensive care plan (ICCP) included a focus area of pain and/or potential for pain related to arthritis, chronic pain, depression, and impaired skin integrity. Interventions included administering pain medication as ordered by the physician and evaluate the effectiveness of the pain management and notify physician if interventions are unsuccessful.A review of the Medication Administration Record (MAR) indicated that Resident #49 received 93 doses of Oxycodone in the month of July. Twelve of the doses were given outside of the pain parameter as ordered by the physician.7/3/25-pain level 67/4/25-pain level 67/5/25-pain level 57/6/25-pain level 67/10/25-pain level 67/10/25-pain level 77/13/25-pain level 77/15/24-pain level 7 7/20/25-pain level 77/26/25-pain level 77/29/25-pain level 67/29/25-pain level 6On 7/31/25 at 11:25 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding pain medication and pain scales. The LPN told the surveyor the numeric pain scale was 1 to 3 for mild pain, 4 to 7 for moderate pain, and 8 to 10 for severe pain. The surveyor asked what if a resident had pain outside of the parameters that a physician ordered and the LPN stated she would have to call the physician to have either a onetime dose of a medication or an order for a medication for a less severe pain.On 8/5/25 at 9:15 AM, the surveyor reviewed the policy titled, Pain-Clinical Protocol. The policy had a revision date of 4/2025. Under the section Treatment and Management, the policy read that the lowest possible effective dose was prescribed for the shortest time possible with ongoing staff monitoring for effectiveness.NJAC 8:39-27.1 (a)

Complaint # NJ00172812Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide access to the call system while a resident was in bed. The deficient practice was identified for 2 of 8 residents investigated under the Environment Task. (Resident # 2 and Resident # 77)On 07/29/2025 at 10:29 AM, during the initial tour of the facility, the surveyor observed Resident # 2 asleep in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On the same date at 10:37 AM, the surveyor observed Resident # 77 awake in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On 07/30/2025 at 10:29 AM, the surveyor observed Resident # 77 wake in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On 07/31/2025 at 09:40 AM, the surveyor observed Resident # 2 asleep in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On the same date at 09:42 AM, the surveyor observed Resident # 77 wake in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On 07/31/2025 at 09:43 AM, during an interview with the surveyor, the Certified nursing assistant (CNA) # 1 said that when residents are in bed the handheld call device should be attached to their sheet within their reach.On 08/01/2025 at 09:58 AM, during an interview with the surveyor, the Registered Nurse Unit Manager (RNUM) #1 said that the handheld call system should be clipped to the resident's blanket and within reach when residents are in their bed. The RNUM #1 replied, no when asked if the handheld call device should be on the floor.On 08/01/2025 at 01:01 PM, during an interview with the surveyor, the Director of Nursing (DON) replied, No when asked if the handheld call device should be on the floor when residents are in bed.A review of the facility policy titled, Answering the Call Light dated April 2016 revealed under General Guidelines number 5., When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. N.J.A.C. S 8:39-31.8

Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed a.) conduct quarterly Interdisciplinary Care Plan (ICP) meetings and b.) to consistently maintain documentation showing that the resident's representative (RR) was invited or attended ICP meetings in accordance with the facility practice and policy. This deficient practice was identified for two (2) of 36 residents (Resident #67, #81) reviewed, and was evidenced by the following: On 01/22/23 at 10:30 AM, the surveyor reviewed the Admission Record (AR) for Resident # 67 which reflected that the resident was admitted to the facility with diagnoses that included but was not limited to dementia with mood disturbances, major depressive disorder, recurrent and cognitive communication deficit. It further reflected that resident had a Power of Attorney (POA) with contact information listed on the AR. The surveyor reviewed Resident #67's medical record which revealed the following information: A review of Resident #67's Care Plan Meeting Review (CPMR) form dated 01/31/23, reflected that the Resident Representative/Power of Attorney (RR/POA) did not attend the care plan meeting on this date. The CPMR dated 10/24/23, indicated that Resident #67's RR/POA attended the care plan meeting. The facility could not provide the surveyor with any additional CPMRs. There was no documentation found in the medical record that the POA was contacted, invited, refused, or attended the care plan meeting on 01/31/23. The surveyor could not find any other care plan meetings that were conducted in 2023. A further review revealed that the care plan meetings should have been conducted in April of 2023 and July of 2023 for Resident #67. On 01/23/23 at 9:14 AM, the surveyor reviewed the AR for Resident # 81 which reflected that the resident was admitted to the facility with diagnoses that included but was not limited to unspecified dementia, behavioral disturbances, depression, and cognitive communication deficit. It further reflected that resident has a POA with contact information listed on the AR. The surveyor reviewed Resident #81's medical record which revealed the following information: A review of the CPMRs for Resident #81 dated 06/05/23 and 07/17/23 indicated that both were conducted for a comprehensive (Annual, Admission, and Significant (Sig) change) care plan meeting. The surveyor could not locate any other care plan meeting documentation that was completed that year. Further record review revealed that the care plan meetings should have been conducted in March of 2023 and October of 2023 for Resident #81. On 01/23/24 at 10:50 AM, the surveyor interviewed the Director of Nursing (DON) regarding care plan meetings and the process on how the meeting were conducted and who was in attendance. The DON stated that care plan meetings were to be completed quarterly and attendance was documented on either the CPMRs or in a separate progress note in the electronic medical record (EMR). The DON further stated she did not know why the care plan meetings were not completed quarterly on Resident #67 and Resident #81 and confirmed that there was no documentation showing that either resident POA/RR were consistently contacted or invited to attend care plan meetings. On 01/23/24 at 11:40 AM, the surveyor interviewed the Social Worker (SW) regarding the facility process when conducting care plan meetings. The SW stated that care plan meeting were to be completed quarterly. The SW also stated that family, RR and POA were to be contacted to attend and to arrange a time and date for the meetings. The SW stated that multiple attempts were made to contact resident representatives, and this was documented under progress notes in the EMR system. He explained that if the RR or POA attended meetings it would be documented under the evaluation's tab/care plans in the EMR. The SW elaborated further to include that care plan meetings were important in facilitating communication, making sure that the residents' families were informed from a holistic approach by keeping them up to date of any resident changes. Reference: New Jersey Statutes Annotated, Title 8. Chapter 39 Subchapter 12(a)(b). Advisory resident Assessment and care plans states:(a) The resident care plan is developed at a meeting held by an interdisciplinary team that includes professional and/or ancillary staff from each service providing care to the resident. (b) The facility makes care planning meetings available at mutually agreeable times, including evenings and weekends, for the convenience of families and significant others. Reference: New Jersey Statutes Annotated, Title 8. Chapter 39 Subchapter 13.2(a) Mandatory resident communication services states: Residents and their families shall be given the opportunity to participate in the development and implementation of the care plan, and their involvement shall be documented in the resident's medical record. The facilities undated policy labeled Resident Rights with a reference number of 483.10 under 1(k) indicated that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: appoint a legal representative of his or her choice, in accordance with state law. The policy specified that residents were to be informed of and participate on his or her care plan meeting. The facility policy statement labeled Care Plans, Comprehensive Person -Centered version October 2022, indicated under item #5 that the resident is informed of his or her right to participate in his or her treatment and is provided advance notice of care planning conferences. Under item #6 it further indicates, that the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. Item #12 of the policy, indicates that the interdisciplinary team reviews and updates the care plan; (a) when there has been a significant change in the resident's condition;(b) when the desired outcome is not met;(c) when the resident has been readmitted to the facility from the hospital stay; and (d) at least quarterly, in conjunction with the required quarterly MDS assessment. Item #13 of the facility policy, indicated that the resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. NJAC 8:39 -12(a)(b) NJAC 8:39-13.2(a)

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain the resident's environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for one (1) of four (4) units ([NAME] Glen) was evidenced by the following: The surveyor conducted a tour of the [NAME] Glen Unit on 1/10/24 at 9:52 AM. The surveyor interviewed Registered Nurse/Unit Manager (RN/UM #1) who explained that the [NAME] Glen Unit was comprised of dementia (cognitively impaired) residents and some residents that had behavioral disturbances related to dementia. RN/UM #1 informed the surveyor that Housekeeping was responsible for cleaning/maintaining the resident rooms and daily touch surfaces and the certified nursing assistants (CNAs) were responsible for making beds, changing bed linens, and general cleanliness of the rooms. During the tour the surveyor identified the following: 1.) In room [ROOM NUMBER], beneath the window, brown drippings/splatter was observed on the wall. 2.) Towards the end of Hallway B, near the fire exit, brown smudges, which presented as handprints, was observed on the handrail. 3.) Hallway C's linen cart, located in between rooms [ROOM NUMBERS], had brown stains/residue/drippings on the sides and debris across the top of the blue mesh cart cover. The handrail next to the linen cart was observed to have brown residue. 4.) In room [ROOM NUMBER], the bottom of the radiator unit was broken open and exposed. In the bathroom, the toilet was observed to have dried brown brown substance, which appeared as feces, on the toilet seat. On 1/12/24 at 11:31 AM, the surveyor interviewed CNA#1 who stated that unit cleanliness was approached as a team and everyone was responsible to ensure that the unit was clean/sanitary. CNA#1 reported that the housekeepers each take a hallway and were responsible for cleaning the resident rooms and high touch surfaces. If unknown substances were observed, they would use disinfectant to clean the area. On 1/17/24 at 11:18 AM, the surveyor interviewed Housekeeper (HSK#1) who stated that their general responsibilities included dusting, cleaning the walls, taking out trash, sweeping the floor, and mopping. HSK#1 reported that they were to use disinfectant on high touch surfaces because they did not know what was contagious. HSK#1 further confirmed that they cleaned the resident bathrooms, including the toilet, and all common areas of the unit. When asked the process of reporting broken items in resident rooms, HSK#1 confirmed that they then notify the Director of Housekeeping upon discovery of the item. On 1/18/23 at 11:04 AM, the surveyor interviewed RN/UM#1, who reported that housekeeping would complete their thorough cleaning in the morning and continuously spot check throughout the remainder of the day. RN/UM#1 confirmed that housekeeping was responsible for the resident rooms, bathroom, walls, and railings. The surveyor and RN/UM#1 together observed the brown residue on the handrail at the end of Hallway B by the fire exit; Hallway C linen cart with the brown residue on the sides of the cover; and the exposed underside of the radiator in room [ROOM NUMBER]. In addition, the surveyor showed RN/UM#1 pictures of the brown residue on the handrail in between room [ROOM NUMBER] and 526; dried brown residue of toilet seat in room [ROOM NUMBER]; and the drip/splatter marks beneath the window in room [ROOM NUMBER]. RN/UM#1 confirmed these areas should have been cleaned and acknowledged that the radiator in room [ROOM NUMBER] should have been reported and repaired. On 1/18/24 at 11:29 AM, the surveyors interviewed the Director of Housekeeping (DOH) who stated that the housekeepers have regular assignments and are guided in their tasks by a daily checklist. The DOH acknowledged that housekeepers were responsible for the common areas, resident rooms, including bathrooms, and hand rails. The DOH confirmed that housekeeping was to clean and disinfect any touchable surface daily. When asked about splatters or drippings on the walls, the DOH reported that this was to be wiped and cleaned. The DOH stated that on the [NAME] Glen Unit, housekeeping was expected to go back and forth and monitor the floor for cleaning. Upon reviewing the pictures obtained from the [NAME] Glen Unit, the DOH confirmed that the pictured areas should have been cleaned. The DOH also confirmed that the radiator unit in room [ROOM NUMBER] should have been reported and maintenance work order submitted. The DOH acknowledged that the linen carts covers are able to be cleaned. On 1/18/24 at 12:08 PM, surveyors interviewed the Maintenance Director (MD), who confirmed that they were not made aware of the radiator's condition in room [ROOM NUMBER]. The MD further stated that it was not acceptable and it should have been reported upon its discovery. On 1/23/24 at 12:03 PM, surveyors interviewed the Director of Nursing (DON) who stated that the soiled areas should have been reported and were to be cleaned as soon as it is noticed. The DON stated that nursing can start to clean any area, but housekeeping was to be notified for proper cleaning and disinfecting of the area. The DON advised that all the linen carts were wipeable and expected to be cleaned. Upon review of the pictures, the DON confirmed that all areas should have been cleaned and that the radiator should not have been in that condition. A review of the facility provided undated Homelike Environment policy included . Residents are provided with a safe, clean, comfortable, and homelike environment [ .] 2. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment. NJAC 8:39-4.1 (a), 11, 12, 21.3 (a) (b), 27.2 (j), 31.2 (a-e), 31.3, 31.4 (a-f)

Complaint NJ#: 165482 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to a.) ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 6 residents (Residents #65, #84, #89) observed for incontinence care on 1 of 2 units ([NAME] Glen and Laurel Creek units) and b.) provide nail care to a resident who required extensive assistance from the staff for activities of daily living (ADLs) for 1 of 5 residents, (Resident #114) reviewed for ADLs. a.) ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 6 residents (Residents #65, #84, #89) observed for incontinence care on 1 of 2 units ([NAME] Glen and Laurel Creek units). This deficient practice was evidenced by the following: 1. On 01/12/24 at 12:30 PM, the [NAME] Glen Unit Manager (UM) provided the surveyors with a list of incontinent residents on the unit. On 01/18/23 at 07:38 AM, the surveyor met with the Certified Nursing Assistant (CNA#1) on [NAME] Glen unit to complete an incontinence tour. CNA #1 stated she was awaiting her assignment. On 01/18/24 at 07:41 AM, the surveyor and CNA #1 commenced an incontinence tour, per the list provided on 01/12/24 by the UM, and observed the following: On 1/18/24 at 07:46 AM, CNA #1 and the surveyor greeted Resident #84 in their room, and CNA #1 informed the resident she was going to check his/her diaper. The diaper was observed to be saturated with urine. A folded blanket under the resident had a dried yellow stain and the fitted sheet on the bed had a dried yellow stain. CNA #1 stated, it should not be like that. During an interview at that time, CNA #1 was asked what it meant when the blanket and sheet under an incontinent resident had dried stains and CNA #1 stated, They haven't been touched. We do have heavy wetters, but if there is a yellow or brown ring it means they haven't been changed and it seeped through. The CNA stated that it was important to do incontinence checks every 2 hours, and to check the heavy wetters in between, to prevent skin break down or wounds from forming. She further stated that it was important to know your resident's needs. A review of Resident #84's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's disease, epilepsy (seizure disorder), pneumonia, and primary osteoarthritis (degenerative joint disease). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 11/24/23, revealed Resident #84's cognitive skills for daily decision-making were severely impaired. The MDS further assessed that the resident required assistance from staff for personal hygiene and was always incontinent of bowel and bladder. On 01/18/24 at 07:49 AM, CNA #1 and the surveyor greeted Resident #65 in their room, and CNA #1 informed the resident she was going to check his/her diaper. The diaper was observed to be saturated with urine. The resident was observed to have an open wound on their right buttocks with a moist and dried white substance on the area. There was a fitted sheet under the resident with a wet ring. CNA #1 stated that the wet ring was urine. A review of Resident #65's Admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's disease, hypertension (high blood pressure), and hyperlipidemia (elevated level of fat in the blood). The Quarterly MDS dated [DATE], revealed Resident #65's cognitive skills for daily decision-making were severely impaired. The MDS further assessed that the resident required assistance from staff for personal hygiene and was always incontinent of bowel and bladder. On 01/18/24 at 08:00 AM, CNA #1 and surveyor greeted Resident #89 in their room, and CNA #1 informed the resident she was going to check his/her diaper. The diaper was observed to be dry. A folded blanket under the resident was observed to have a dried tan stain and there was a blue fitted sheet with a wet ring. CNA #1 stated that the sheet should not have been wet. A review of Resident #89's Admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's disease, muscle wasting and atrophy, and major depressive disorder. The Quarterly MDS, dated [DATE], revealed Resident #89 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated the resident had severe cognitive deficits. The MDS further assessed that the resident required assistance from staff for personal hygiene and was always incontinent of bowel and bladder. On 01/18/24 at 08:04 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that it was the CNA and nurse's responsibility to provide incontinence care to the residents. LPN #1 stated the residents were changed every one to two hours if they were wet, and if they were not that they were asked if they needed to use the bathroom. LPN #1 stated that the staff constantly checked for incontinence and that they knew which residents used the bathroom more often. LPN #1 stated that she expected the CNA to make sure the residents were taken care of, diapers were dry, that the bed was not soiled, and that the residents were toileted. She further stated that a resident should not have been lying on soiled linens and that if the CNA found a resident with soiled linens, that she would have expected them to have changed them. LPN #1 was informed of the surveyor's incontinence rounds observations. LPN #1 acknowledged that the residents should not have had soiled diapers and linens and that it was important to make sure the residents were clean and dry to maintain dignity and to avoid skin breakdown. On 01/18/24 at 08:12 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that she expected the incontinent resident's diapers to have been changed every two hours, on every shift, and for any soiled linens to also have been changed. The RN/UM was informed of the surveyor's incontinence rounds observations. The RN/UM acknowledged that the resident's linens should not have been soiled and stated that it was important to make sure the residents were clean and dry for the prevention of skin breakdown. On 01/23/24 at 12:07 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses and CNAs were responsible for incontinence care and that if a resident was identified as being incontinent, that the protocol was for the staff to change them every two hours. The DON was informed of the surveyor's incontinence rounds observations. The DON stated that she would not have expected the residents to be wet like that but if they were, that they should have received incontinence care and the dirty linens should have been changed. The DON further stated it was important for residents to have clean linens and to stay clean and dry for overall skin health. A review of the facility policy, Urinary Incontinence-Clinical Protocol, revised April 2018, does not speak to incontinence care. On 01/23/24 at 12:31, the surveyor inquired from the DON any additional policies on incontinence care. The DON stated there were no other incontinence policies. A review of the facility documentation, Certified Nursing Assistant/Geriatric Nursing Assistant job description, provided on 01/18/24 at 08:42 AM by the DON, revealed Duties and Responsibilities, Personal Nursing Care Functions: Keep residents dry (i.e., change gown, clothing, linen, etc., when it becomes wet or soiled). Change bed linens. 36419 Complaint NJ #: 168814 b.) provide nail care to a resident who required extensive assistance from the staff for activities of daily living (ADLs) for 1 of 5 residents, (Resident #114) reviewed for ADLs. This deficient practice was evidenced by the following: 2. On 1/10/24 at 11:00 AM, the surveyor observed Resident #114 in bed. The surveyor observed the resident's fingernails to be long, jagged and soiled underneath. Resident #114 stated they would like to have their nails cleaned and trimmed. On 1/18/24 at 11:04 AM, the surveyor observed Resident #114 in bed. The surveyor observed the resident's fingernails to be long, jagged and soiled underneath. The resident stated that they still needed their nails cleaned and trimmed. According to the Admission Record, Resident #114 had diagnoses which included, but were not limited to diabetes mellitus, peripheral vascular disease, depression and the need for assistance with ADL care. Review of Resident #114's MDS, dated [DATE], reflected the resident had a BIMS score of 8 out of 15 which indicated the resident had a moderate cognitive impairment. The MDS further assessed that Resident #114 required assistance with ADLs. On 1/18/24 at 11:10 AM, the surveyor interviewed LPN#2 who stated that nail care should have been provided by the CNAs on shower days and acknowledged that it was obvious that it had not been done since Resident #114's nails were observed to be soiled, long and unfiled. On 1/18/24 at 11:17 AM, in the presence of the RN/UM, the surveyor interviewed CNA #2 who stated that the CNAs were responsible for providing nailcare every two weeks. CNA #2 stated that she had not cleaned, clipped, or filed resident #114's fingernails but acknowledged that it should have been done as part of the resident's Activities of Daily Living (ADL) care daily. The RN/UM acknowledged that the resident's nails had not been cleaned or trimmed and stated that fingernails should be assessed daily and nail care should be provided as needed. A review of the facility's policy, Activities of Daily Living (ADLs), Supporting, with a revised date of 3/2018, reflected .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal care. On 1/23/24 at 1:30 PM, the survey team met with the Licensed Nursing Home Administrator, DON, Regional Nurse, and Regional Director of Operations to discuss the above observations and concerns. On 1/24/24 at 9:46 AM, the DON stated that the facility had no set schedule for providing nail care but that it was part of the residents daily ADL care and that nurses and CNAs were responsible for providing residents with nail care. NJAC 8:39-27.1 (a), 27.2 (g, h, j)

Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to meet the professional standards of practice related to pain management. Specifically not a.) obtaining a physician's order for severe pain and administering pain medication according to the appropriate pain level, b.) administering pain medications as ordered by a physician and c.) appropriately assessing, monitoring, and recognizing verbal and non-verbal signs and symptoms of pain during a wound care treatment. This deficient practice was identified for three (3) of 3 residents (Resident #52, #114 and #200) reviewed for pain management. The deficient practice was evidenced by the following: a.) On 01/10/24 at 11:07 AM, during the initial tour, the surveyor observed Resident #52 lying in bed watching the television. When asked if they had any concerns, Resident #52 stated that he/she did not feel like their pain was managed well. Resident #52 stated they had a standard oxycodone (pain medication) low dose ordered for every 12 hours and a prn (as needed) medication as well but that it took a long time before it was administered. The surveyor reviewed the medical record for Resident #52. A review of the Admission Record (AR) face sheet (an admission summary) indicated that the resident had the diagnoses which included chronic pain syndrome, cognitive communication deficit, rheumatoid arthritis (immune system attacks healthy cells in your body by mistake, causing inflammation [painful swelling] in the affected parts of the body), difficulty in walking and pressure ulcer of sacral region (located below the lumbar spine and above the tailbone). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 12/30/23, reflected the resident had a Brief Interview for Mental Status (BIMS) score 15 out of 15, which indicated a fully intact cognition. A further review indicated the resident received routine scheduled pain medications and as needed pain medications in the last five days. It also revealed that frequent pain limited day-to-day activities, and the intensity of the worst pain was severe. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 5/11/23, for I have pain and/or potential for pain r/t [related to] chronic pain syndrome and rheumatoid arthritis. Interventions included to administer analgesia (pain relieving medication) as per orders, observe for effectiveness and signs and symptoms of side effects; anticipate my need for pain relief and respond to reports and signs and symptoms of pain; encourage me to use non-pharmacological interventions for pain relief as applicable; evaluate the effectiveness of pain management interventions; monitor and record the presence of pain daily and as needed. A further review of the ICCP included a focus area dated 1/10/24, for I am on pain medication therapy. Interventions included to administer medication as ordered and monitor for effectiveness and adverse effects; monitor for altered mental status, anxiety, constipation, depression .observe for adverse reactions with every interaction with the resident; monitor safety due to potential increased risk for falls; and opioids, Narcan/naloxone can rapidly reverse opioid overdose, have available in case of emergency. A review of the December 2023 and January 2024 Medication Administration Record (MAR), reflected the following: -Start date 5/11/23: Pain evaluation every day shift for monitoring of patient's pain level. -Start date 5/11/23: Oxycodone ER (extended release) 12 hour abuse deterrent 40 milligrams (MG). Give one (1) tablet by mouth every 12 hours for pain. -Start date 9/28/23: Acetaminophen tablet 325mg. Give two (2) tablets by mouth every 6 hours as needed for mild pain. -Start date 5/11/23: Oxycodone oral tablet 20mg. Give 1 tablet by mouth every four (4) hours as needed for pain. Discontinued 1/11/24. -Start date 1/11/24: Oxycodone oral tablet 20mg. Give 1 tablet by mouth every 4 hours as needed for moderate pain. A further review revealed that the resident had a documented pain level of seven (7) to nine (9) and was administered the oxycodone for moderate pain. There were no as needed pain medications ordered for severe pain. On 01/17/24 at 10:37 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who stated that Resident #52 was alert and complained about pain and requested pain medication every 4 hours on the dot and had a standard pain medication oxycodone 40 mg every 12 hours. LPN #1 further stated that the resident's prn pain medication was oxycodone 20mg every 4 hours for moderate pain and that the resident would tell you the time of the medication. At that time, LPN #1 and the surveyor reviewed the electronic medical record (EMR) together. LPN #1 confirmed she did not see anything for severe pain. The surveyor asked what was the numerical pain scale? LPN #1 stated that the pain scale level was moderate is anything over 4 and mild was 1 to 4. The surveyor asked was there a numerical number for severe pain? She then clarified and stated, mild pain is 1 to 2, moderate is 3 to 4 and severe pain is anything over 4. LPN #1 stated she administered the prn medication based on the pain level that the resident would tell her. She further stated the prn Oxycodone 20mg every 4 hours was for pain and was not specific on the pain level but that it now was indicated for moderate pain. On 01/17/24 at 10:44 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) for the Hartford Glen unit who stated that the numerical pain level was mild, 1 to 3; moderate, 4 to 7; and severe, 8 to10. She stated that if the order was for moderate pain, but the resident was complaining of severe pain then the nurse would call the doctor to get a medication for severe pain. The RN/UM stated that it was important to get the appropriate medication for the type of pain because everyone was different, and it should be individualized based on that resident. At that time, the RN/UM and the surveyor reviewed the EMR together which indicated a physician's order for oxycodone 40mg every 12 hours, pain patches, Tylenol 325mg 2 tablets every 6 hours for mild pain, oxycodone 20mg every 4 hours for moderate pain. She then confirmed she did not see anything for severe pain. The RN/UM and the surveyor review the MAR together which revealed the nurses documented 8 and 9 and the oxycodone 20mg for moderate pain was administered. The RN/UM acknowledged that based on those numerical numbers, that the nurses should have notified the physician and there should have been an order for severe pain. The RN/UM then stated that Resident #52 was always on the call light every 4 hours for their pain medication and for someone like that they should have a medication for severe pain. The RN/UM concluded she just texted the physician to get an order for severe pain. On 01/17/24 at 10:59 AM, the RN/UM informed the surveyor that the physician called back and stated they would keep the oxycodone 20mg every 4 hours for moderate pain but would now add oxycodone 20mg every 3 hours for severe pain. A further review of the January 2024 Medication Administration Record (MAR), reflected the medications listed above and the following: -Start date 5/11/23: Oxycodone oral tablet 20mg. Give 1 tablet by mouth every four (4) hours as needed for pain. Discontinued 1/11/24. - Start date 1/11/24: Oxycodone oral tablet 20mg. Give 1 tablet by mouth every 4 hours as needed for moderate pain. - Start date 1/17/24: Oxycodone oral tablet 20mg. Give 1 tablet by mouth every 3 hours as needed for severe pain. A further review revealed that the oxycodone order did not specify if it was for severe pain until after surveyor inquiry. On 01/17/24 at 11:16 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the numerical pain scale was mild pain, 1 to 3; moderate pain, 4 to 7; and severe pain, 8 to10. The surveyor inquired if a resident had a pain level of 9 and only had an order for moderate pain, what should be done? The DON stated that the nurses should call the physician and inform them that the resident's pain level was a 9 and that they needed to give them something else for severe pain. When asked what was the importance of following the numerical pain scale? The DON stated it was important to give in the parameters for effectiveness and to see if there were any adverse effects. On 01/17/24 at 11:21 AM, the DON and the surveyor reviewed the MAR together. The DON acknowledged that there should have been an order for severe pain prior to surveyor inquiry. On 01/17/24 at 01:46 PM, the DON stated in the presence of the survey team that the facility did not have any type of numerical pain scale for the nurses to follow and that they utilized the pain assessment tool which was completed quarterly or when there was a significant change. A review of the Order Summary Report (OSR), indicated the following active orders as of 1/22/24: - Acetaminophen tablet 325mg. Give 2 tablets by mouth every 6 hours as needed for mild pain 1-3. - Oxycodone ER oral tablet 12 hours abuse deterrent 40mg. Give 1 tablet by mouth every 12 hours for chronic pain syndrome. - Oxycodone 20mg. Give 1 tablet by mouth every 4 hours as needed for moderate pain 4-6. - Oxycodone oral tablet 20mg. Give 1 tablet by mouth every 3 hours as needed for severe pain 7-10. On 01/24/24 at 09:56 AM, the DON stated in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, that a pain management in-service was started. The DON concluded since the changes of the pain medication that it had been effective for the resident. 33106 b.) According to Resident #200's AR, the resident was admitted with the diagnoses which included, but was not limited to, effusion of the right knee, pain in the right knee and osteoarthritis. The admission MDS, an assessment tool dated 01/04/24, indicated that Resident #200 scored a 4 out of 15 on the BIMS which indicated that the resident had severe cognitive deficits. The MDS also indicate that the resident required maximum assistance with activities of daily living (ADL's) and had occasional complaints of pain. On 01/10/24 at 10:17 AM, the surveyor observed Resident #200 in bed. The resident was observed to have tears coming from his/her eyes and facial grimacing. The surveyor interviewed the resident at this time and the resident stated that he/she had pain in the left hip. The Resident stated that he/she did not have any pain medications since yesterday. He/she stated that he/she did not know if any routine pain medication were provided to manage his/her pain. The surveyor reported the residents' complaints of pain to the nurse. On 01/10/24 at 11:00 AM, the surveyor reviewed Resident #200's medical record which revealed the following documentation: The Physician Order Summary (POS) sheet indicated that Resident #200 had the following medications ordered for pain: -Order dated 12/29/23, for Acetaminophen oral Tablet 325 MG (Acetaminophen) Give 2 (two) tablets by mouth every 4 (four) hours as needed for as needed for mild pain (1-3). -Order dated 12/29/23, for Lidocaine Patch 4 % Apply to right low back topically in the morning for pain for 12 hours then remove and remove per schedule. -Order dated 12/29/23, for Tramadol hydrochloride (HCl) oral Tablet 50 MG *Controlled Drug* Give 1 tablet by mouth every 8 (eight) hours as needed for as needed for severe pain (8-10) According to the documentation on the Medication Administration Record (MAR) Resident #200 had a physicians order for: Acetaminophen 325 mg give two tablets by mouth as needed for mild pain (1-3) on the pain scale. The MAR indicated that on 01/03/24 and 01/05/24, Resident #200 complained that his/her pain was at a pain level of 5 (five) on the pain scale. The MAR indicated that the resident was administered Acetaminophen 325 mg two tabs by mouth as needed for mild pain (1-3) on the pain scale. This medication was administered out of the physician ordered parameters and was given when the resident complained of pain at a level of 5. According to the MAR, Resident #200 had a physician's order for Tramadol 50 mg tab to be given every 8 (eight) hours as needed for severe pain (8-10) on the pain scale. The MAR indicated that on 01/08/24, Resident #200 complained that his/her pain was at a level 7 (seven) on the pain scale. The MAR indicated that the resident was administered Tramadol 50 mg. The medication was ordered to be given when the resident complained of pain (8-10) on the pain scale. The surveyor reviewed Resident #200's ICCP, dated 01/09/24, that indicated the resident had potential for pain. The ICCP interventions included the following: Administer analgesia as per ordered. On 01/11/24 at 10:48 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #2) who stated that she had been employed in the facility for approximately 1 (one) year. LPN #1 stated that if a resident had complaints of pain, she would have asked the resident what their pain level was using a pain scale of 0-10 (0 being no pain, and 10 being excruciating pain). She stated that she would question the resident on how much pain they were having, the description of the pain, and where the pain was located. LPN #2 continued to explain that a 1-3 pain level was mild pain, 4-7 was moderate pain level and 8-10 on the pain scale indicated that the resident had severe pain. She explained that when a resident complained of pain that it would have been documented on the MAR and on the pain monitoring section of the MAR. LPN #2 stated that if the resident had complaints of mild pain (1-3) on the pain scale, then the nurse would have administered the pain medication that was ordered for that pain level. If the resident had moderate pain (4-7) on the pain scale, then the nurse would have administered the pain medication that was ordered for that pain scale. If the resident had severe pain (8-10) the nurse would have then administered the pain medication associated with that pain scale and followed the physician's order. LPN #2 reviewed Resident #200's prn pain medications in the presence of the surveyor and the LPN stated that the nurse should have called the primary care physician (PCP) when the resident complained of moderate pain (4-7) and gotten an order for medication for moderate pain. LPN#2 confirmed that the resident was administered pain medication out of the physician ordered parameters on 01/03/24, 01/05/24 and 01/08/24. She continued to add that if a nurse administered the medication out of parameters that would have indicated that the nurse was not following physician orders. On 01/17/24 at 09:31 AM, the surveyor interviewed the RN/UM #2 on the [NAME] Unit (sub-acute rehab) who stated that if a resident's pain levels were higher than the mild level of pain on the pain scale (1-3) and only had a mild level pain medication ordered, then the nurse should reach out to the PCP to find out if the they wanted a different pain medication given to that resident. She stated that this should have also been done with moderate pain and severe pain level ordered medications. She stated that the nurses should have followed physicians' orders and should not give medication out of the physician ordered parameters. She stated that the nurse should have notified the PCP to get a different pain medication ordered if the resident was complaining of pain at a level higher than what the current medication order was to be used for. On 01/17/24 at 09:48 AM, the surveyor interviewed LPN #3, on the [NAME] Glen Unit, regarding administration of pain medications. LPN #3 stated that if a resident companied of pain above the pain level that a medication was ordered for that the nurse should have called the PCP and should have written it in the progress notes. LPN #3 confirmed that the nurse should not have given any medication out of the physician ordered parameter and should have called the PCP if a resident complained of pain out of the physician ordered parameters. On 01/17/24 at 12:39 PM, the Pharmacy Consultant (PC) stated that she came in monthly to review resident medications. The PC stated that if nurses gave pain medication out of the physician ordered parameters that the nurse would not be following physicians' orders. On 01/17/24 01:43 PM, the surveyor interviewed the DON who stated that the facility did not have a standardized pain scale that the staff could have utilized when they assessed the resident's pain. The DON stated that she could not provide any policy regarding the type of pain scale that the nursing staff used to assess a resident's pain. A review of the facility's policy, Pain Assessment and Management, revised October 2022, included, Assessing pain 5. During the pain assessment gather the following information as indicated from the resident .(2) intensity of pain (as measured on a standardized pain scale). Defining goals and appropriate interventions 1. The pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. Implementing pain management strategies 1. Establish a treatment regimen that is specific to the resident based on consideration of the following: b. current medication regimen; d. nature, severity, and cause of the pain. 36419 c.) On 1/10/24 at 11:00 AM, the surveyor observed Resident #114 in bed. The resident told the surveyor that he/she had a wound on their backside that hurt especially when they put the stuff on to heal it. On 1/11/24 at 11:05 AM, during an interview with the surveyor, LPN#5 stated that she had completed a wound treatment to Resident #114's stage 2 sacral wound that morning. The surveyor asked LPN#5 if she had medicated Resident #114 for pain. LPN #5 replied that the resident had not complained of pain so she did not administer pain medication before the treatment. The surveyor asked LPN #5 if she had assessed the resident's pain level and documented it. LPN #5 reviewed Resident #114's Medication Administration Record (MAR) and Treatment Administration Record (TAR) with the surveyor and replied she had not assessed or documented the resident's pain level. On 1/18/24 at 11:04 AM, the surveyor observed Resident #114 in bed. The resident told the surveyor that he/she had pain in their pelvic area and continued to have pain in their backside. The surveyor asked Resident #114 if he/she had informed the staff that they had pain. Resident #114 replied that they could not remember. On 1/22/24 at 10:00 AM, the surveyor observed the RN/UM #1 on the Hartford Glen unit perform a wound treatment to Resident #114's stage 2 sacral wound. LPN #6 was the assigned nurse for the resident and stated that she would be assisting with the Resident's positioning during the treatment. LPN #6 further stated that she had pre-medicated the resident for pain at approximately 8:00 AM, for a pain level of 8 which indicated the resident was in severe pain. LPN #6 stated that she usually did a pain assessment and medicated the residents before they received wound treatments. The surveyor reviewed the resident's MAR which reflected that LPN #6 was assigned to Resident #114 on 01/09/24, 01/11/24, 01/19/24, and 01/22/24 and had not documented that a pain assessment had been completed, and had not administered any pain medication prior to the wound treatments on any of those dates. LPN#6 could not speak to why she had not conducted a pain assessment or administered pain medication on those days. On that same date, at that same time, during the wound treatment, the surveyor observed Resident #114 in a side-lying position with eyes closed; the resident appeared comfortable. When RN/UM #1 began cleaning the wound, the resident moaned and made a jerking motion forward which indicated she may have experienced pain. The RN/UM #1 removed her gloves and went to wash her hands. The surveyor asked RN/UM #1 if she thought Resident #114 had experienced pain when she cleaned the wound. RN/UM #1 stated that the resident had already been medicated with morphine and continued the treatment. The surveyor observed that RN/UM #1 had not assessed the resident for pain throughout the entire wound treatment. On 1/22/24 at 10:20 AM, during an interview with the surveyor, RN/UM #1 stated that she did not hear Resident #114 moan but did notice he/she winced during the treatment. RN/UM #1acknowledged that she should have assessed the resident for pain during the treatment. On 1/23/24 at 10:50 AM, during an interview, the surveyor asked the RN/UM #1 if she believed that Resident #114's pain was being managed appropriately since the January MAR reflected that Resident #114 had only received two doses of pain medication during the entire month of January. RN/UM #1 replied that she believed the resident needed routine pain medication and had discussed it yesterday with Resident #114's primary care physician and obtained an order. According to the admission record, Resident #114 had diagnoses which included, but were not limited to diabetes mellitus, peripheral vascular disease, depression, and the need for assistance with ADL care. Review of Resident #114's Annual Minimum Data Set (MDS), an assessment tool, dated 05/06/23, reflected the resident had a BIMS score of 8 out of 15 which indicated the resident had a moderate cognitive impairment. The MDS further assessed that Resident #114 required assistance with ADLs. Review of the January 2024 Physician Order Summary reflected a physician's order (PO), with a start date of 11/1/23, for Tramadol HCL 50mg tablet, give 1 tablet by mouth every 6 hours as needed for moderate pain (level 4-7) and a PO for Morphine Sulfate Concentrate oral solution 100mg/5ml, with a start date of 12/27/23, give 0.25 ml by mouth every 3 hours as needed for pain. This order did not indicate the pain level at which this medication should have been administered. The surveyor observed that before the surveyor's inquiry, Resident #114 had not been administered any Tramadol HCL from 01/01/24-01/19/24 nor had Resident #114 been administered Morphine from 01/01/24-01/17/24. Review of the resident's current MAR reflected an order for Morphine Sulfate Concentrate Oral Solution 100mg/5 ml Give 0.25ml by mouth every 3 hours as needed for pain, document pain level with a start date of 12/27/23. There were no initials from 01/01/24-01/11/24 which indicated that the resident had not been evaluated for pain and had not received any Morphine for pain. Review of Resident #114's ICCP for pain reflected administering analgesia as per orders, anticipating the need for pain relief responding to any complaint of pain, and monitoring and recording the presence of pain daily and when needed. On 1/23/24 at 1:30 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing (DON), Regional Nurse, and Regional Director of Operations to discuss the above observations and concerns. NJAC 8:39-27.1 (a)

Based on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 01/10/24 at 09:43 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD#1) for the Assisted Living unit and the Regional Director of Dining Services (RDDS). FSD#1 stated that the FSD#2 for the Long-Term Care unit would be on site shortly. The tour commenced and the following was observed: 1. At handwashing sink #1, there was a step-lid trashcan with no plastic trash bag, with trash and debris observed inside the can. During an interview at that time, FSD#1 acknowledged the unlined trashcan and stated that there should have been a plastic bag in the can. FSD#1 stated that a plastic bag would have made it easier for the trash to have been removed, the inside of the can would not have been contaminated and the trash would have been easier to dispose of. 2. In the walk-in refrigerator, on a rolling metal rack, there was an uncovered metal half pan that contained tan and cream colored gelatinous material, with no label or dates. FSD#1 identified it as cream gravy and stated that it should have been covered with clear plastic wrap and dated when it was made. The pan was removed. 3. On the same rolling metal rack, there were two sealed boxes of bacon with no dates observed on the box. FSD#1 stated she did not know when the bacon was pulled from the freezer and that it should have had a pulled date and a use by date. 4. On the cooked and raw meat rack, resting on a sheet pan, was one defrosted 10 pound (lb) pan roasted turkey breast in a manufacturer's sealed package with no sticker or dates. FSD#1 stated that it should have had a sticker when it was received. 5. On the bottom shelf of the same rack, resting in a four-inch half pan, was one unsealed, opened clear plastic bag with the tan meat visible and exposed to air. The meat was soft and resting in red liquid. There was no label nor dates. FSD#1 identified the meat as chicken thighs and acknowledged that the meat was not sealed correctly. FSD#1 stated that the meat should not have been exposed to air and that the bag should have had a label with a use by date, and dated when it was pulled from the freezer so staff would have known when it should have been discarded. The RDDS stated that the meat would get discarded and removed the chicken from the refrigerator. 6. On the vegetable rack, there was one large clear plastic bin containing five red peppers. The peppers were wrinkled and had visible black spots. The sticker on the bin was marked received 12/28/23 and FSD#1 stated that they were good for a month. The surveyor inquired as to whether the peppers were still good to eat and FSD#1 stated, no and discarded the peppers. 7. On the same rack, there was one plastic bin containing asparagus. On the bin there was one sticker marked received 1/10/24 and one sticker marked received 12/19/23. The asparagus was thin, wrinkled and dried out. FSD#1 stated the asparagus should not have looked dried out and that they should have lasted for a month or longer. FSD#1 stated it was important to inspect produce to prevent spoilage. On 01/10/24 at 10:19 AM, FSD#2 joined the tour and observed the asparagus with the surveyor and staff. 8. On a metal rack, there were three sheet pans of defrosted, soft to touch, salmon. Each pan was covered with clear plastic wrap, and each had a sticker marked, seafood raw/frozen, prep/open on 12/14/23, use by 3/12/24. FSD#1 stated that she prepped them on 12/14/23 when they came in fresh, and then she covered them and put them into the freezer. The surveyor inquired as to when the salmon was pulled from the freezer. FSD#1 stated that she was the one who pulled them, acknowledged there was no pulled sticker, and stated that there should have been a sticker when they were pulled because it would have told the length of time that the salmon could have been used. RDDS told FSD#1 to discard the salmon. FSD#1 left the tour. 9. On a rack in the deep freezer, there were six large, frozen, undated manufacturer sealed packages marked pork. FSD#2 acknowledged the packages of meat were not stickered with any dates and stated that they should have been marked the date that they were received. The RDDS stated that it was important to make sure the food items were marked with a received or use by date so staff would have known when the food was received and when it should have been discarded. 10. There was one frozen, manufacturer sealed package, marked beef bologna, with a manufacturer's stamp marked sell by 6/21/23. There were no received or use by dates. FSD#2 stated, it ain't got no label and acknowledged that it should have had a received date. The surveyor inquired as to how old the bologna was and FSD#2 stated that it was a couple months but that we would have known if there was a received date. At that time, the [NAME] President (VP) joined the tour and told FSD#2 to discard the bologna in the trash. 11. There was one opened 10 lb box marked precooked breaded flounder filets, with an opened, clear plastic bag inside the box with the filets visible and exposed to air. FSD#2 acknowledged that the filets should not have been visible and that there should have been a received and use by date marked. She stated it was important to have a use by date so that the staff would have known when to use them, to use the first in and first out method, and that if they were no good that they would have been thrown away. 12. There was one opened box marked cornstarch that contained five individual clear bags of baked dough, that FSD#2 identified as hoagie rolls, with no labels on the bags and no dates. FSD#2 acknowledged that the bags should have had a label and use by date. The VP told FSD#2 to discard the rolls. 13. There was one metal tray that contained four unwrapped, unlabeled cooked pies. FSD#2 identified them as cherry pies and acknowledged that they were not covered correctly and that they should have been labeled with a use by date. The RDDS told FSD#2 to discard the pies. 14. There was one sealed clear plastic bag containing frozen tan pieces of meat, that FSD#2 identified as chicken thigh pieces, with no label and no dates. FSD#2 stated that the bag should have been labeled chicken and had an expiration date because it was important to use the chicken before the expiration date. The VP told FSD#2 to discard the chicken. 15. On a metal table in the kitchen, there was a slicer covered with a black plastic bag. FSD#2 stated that when the equipment was cleaned that it was then covered with the plastic bag. [NAME] debris was observed on the base of the slicer and white debris was observed on the back of the slicer blade. FSD#2 acknowledged the debris and stated that it should not have been there. FSD#2 stated it was important that the equipment was cleaned correctly so the residents were not exposed to bacteria. 16. On a rack under a metal table was one purple handled, white cutting board with black smudges, one blue handled, white cutting board with gouges and brown debris, one green handled, white cutting board with brown stains and black smudges, and one red handled, white cutting board with gouges and brown smudges. FSD#2 stated that the black smudges were, not mold, it's from the stove, like something burned. The VP stated, Sometimes the bottom of pans with the black char can get on there. The VP told FSD#2 to order new ones and the cutting boards were removed and discarded. 17. In the coffee area, there were four stacked metal trays containing upright coffee cups. The top row of cups were uncovered and exposed to air, and the remaining rows of cups were exposed to the metal underside of the tray. The VP acknowledged that the cups were exposed to air, and stated it was important to store them correctly to prevent debris exposure. The VP told a dietary aide to remove and rewash the cups and store them upside down on parchment paper. 18. Handwashing sink #2 was observed with no trash can in the area. FSD#2 acknowledged there was no trash can and stated it was important to have a trashcan because they need to throw the napkin out. A review of the facility policy, Food Receiving and Storage, revised November 2022, revealed, Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. A review of the facility policy, Food Preparation and Service, revised November 2022, revealed, General Guidelines: 2. Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces . Food Preparation Area: 4.d. cleaning and sanitizing work surfaces (including cutting boards) and food contact equipment between uses, following food code guidelines. A review of the facility policy, Sanitization, revised November 2022, revealed, Policy Interpretation and Implementation: 2. All utensils, counters, shelves and equipment are kept clean .3.All equipment, food contact surfaces and utensils are cleaned and sanitized .4. Cutting boards are washed and sanitized between uses. 8. When cleaning fixed equipment (e.g., mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are: a. washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution .b. the equipment is reassembled and any food contact surfaces that may have been contaminated during the process are re-sanitized .14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained . NJAC 8:39-17.2(g)

Complaint NJ #: 168814 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a.) follow appropriate hand hygiene practices during a wound treatment observation by One (1) of two (2) nursing staff observed for 1 of 1 resident reviewed for wound treatments (Resident # 114); b.) follow isolation precautions for a resident who was on Enhanced Barrier Precautions by 1 of 3 nursing staff for 1 of 2 Residents (Resident #102) reviewed for transmission-based precautions c.) follow facility policy regarding not wearing gloves in the hallway by 2 of 2 nursing staff observed transporting soiled linens and trash on the Hartford Glen Unit and d.) clean and disinfect multiuse medical equipment prior to resident use for 1 resident (Residents #38) by 1 of 2 nurses on 1 of 2 nursing units observed during medication pass. This deficient practice was evidenced by the following: 1.) On 1/22/24 at 10:00 AM, the surveyor observed the Registered Nurse/ Unit Manager (RN/UM) on the Hartford Glen Unit perform a wound treatment for Resident #114. The RN/UM stated that the resident had been medicated with Morphine for pain sometime between 8:00-8:30 AM. The RN/UM stated that the Licensed Practical Nurse (LPN#1) would be assisting with the resident's positioning. LPN#1 washed her hands for 20 seconds using acceptable technique and then donned (put on) a pair of gloves. The surveyor observed the RN/UM preparing to wash her hands. The RN/UM turned on the faucet, wet her hands with water, applied soap, lathered her hands for 10 seconds outside the running water, then dried her hands with a paper towel and used the same paper towel to turn off the faucet. The surveyor observed the RN/UM applied gloves and cleaned the overbed table with bleach wipes. The RN/UM removed her gloves applied soap to her hands, lathered for eight (8) seconds outside of the running water then dried her hands with a paper towel and used the same paper towel to turn off the faucet. The RN/UM applied a clean barrier to the overbed table, gathered all supplies which included a small bottle of Normal Saline (NSS), Medi honey (reduces bacteria/debridement), Calcium Alginate (absorbes wound exudate), Collagen particles (stimulates healing), zinc oxide (heals and protects skin), a foam border dressing, and placed them onto the overbed table. The RN/UM wet her hands, applied soap and lathered her hands for 8 seconds outside of the running water, dried her hands and used the same paper towel to turn off the faucet. The RN/UM donned a pair of gloves and removed the resident's soiled dressing which she described as having a moderate amount of serosanguineous exudate (combination of serous fluid and blood indicating wound healing). The RN/UM removed her gloves, applied soap, lathered her hands outside of the running water for 12 seconds, dried her hands, and used the same paper towel to turn off the faucet. The RN/UM applied gloves but then stated that she had forgotten the gauze. The RN/UM removed her gloves, washed her hands for seven (7) seconds outside of the running water, dried her hands and used the same paper towel to turn off the faucet. The RN/UM obtained the gauze from the treatment cart, moistened it with NSS and cleansed Resident #114's wound using a circular motion cleansing from the inside to the outside. At that time, the surveyor heard the resident moan softly and observed the resident's body jerked forward indicating she may have experienced pain. The RN/UM removed her gloves and went to the bathroom to wash her hands. The surveyor asked the RN/UM if she thought the resident had experienced pain when she was cleaning the wound. The RN/UM stated that the resident had already had morphine. The surveyor observed the RN/UM applied soap to her hands and lathered outside of the running water for nine (9) seconds; dried her hands and used the same paper towel to turn off the faucet. The RN/UM returned to the resident's bedside but did not assess the resident for pain. The RN/UM applied the Medi honey, Collagen Particles, and Calcium Alginate to the resident's wound, then applied a foam dressing that was not initialed or dated. The RN/UM did not assess the resident for pain at all during the treatment. The RN/UM discarded all the supplies, removed her gloves, and washed her hands for 12 seconds outside of the running water. The RN/UM left the water running for LPN #1 who washed her hands for 22 seconds and used acceptable technique. The RN/UM stated that she had completed Resident #114's wound treatment and brought the trash to the soiled utility room. The RN/UM did not disinfect the overbed table after she completed the treatment. On 1/22/24 at 10:20 AM, after the wound treatment was completed the surveyor discussed the breaks in technique with the RN/UM. The RN/UM stated that she had not heard the resident moan, but had observed that she had winced during the treatment. The RN/UM further stated that she should have assessed the resident for pain during the treatment. The RN/UM acknowledged that she should have washed her hands for 20 seconds outside of running water and used a clean paper towel to turn off the faucet as that was the facility's policy. The RN/UM stated that she should have dated and initialed the dressing but that she had forgotten her sharpie. The RN/UM acknowledged that she should have disinfected the overbed table after she completed the treatment. 2.) On 1/10/24 at 11:30 AM, the surveyor observed room [ROOM NUMBER] had signage on the door indicating that Resident #102 was on Enhanced Barrier Precautions; the signage instructed that everyone who entered the room must clean their hands including before entering and when leaving the room. The signage further instructed that Providers and Staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use; central line, urinary catheter, feeding tube, tracheostomy; wound care: any skin opening requiring a dressing; do not wear the same gown and gloves for the care of more than one person. On 1/12/24 at 11:28 AM, the surveyor observed the Licensed Practical Nurse (LPN #2) entered room [ROOM NUMBER] without performing hand hygiene. The surveyor observed the LPN organized items on the resident's bedside table. The LPN exited the room and without sanitizing or washing her hands, went and removed items from the linen cart. At that same time, during an interview with the surveyor, the LPN#2 acknowledged that she should have sanitized her hands before she entered the resident's room and when she left. 3.) On 1/12/24 at 11:15 AM, the surveyor observed the Hospice Aide in the hallway on the Hartford Glen unit wearing gloves and carrying two plastic bags which contained soiled linens and trash. The surveyor observed the Hospice Aide touched the key pad lock with the soiled gloves and entered the soiled utility room. At that same time, during an interview with the surveyor, the hospice aide acknowledged that she should have removed her gloves inside the resident's room. On 1/12/24 at 11:48 AM, the surveyor observed the Nursing Assistant (NA) in the hallway on the Hartford Glen unit wearing gloves while carrying two plastic bags which contained soiled linens and trash. The surveyor observed the NA touched the key pad lock with the soiled gloves and entered the soiled utility room. At that time, during an interview with the surveyor, the NA acknowledged that she should have removed her gloves inside the resident's room. On 1/12/24 at 11:54 AM, during an interview with the surveyor, the RN/UM stated that all staff were aware of the facility's policy that no gloves were to be worn in the hallway. On 1/23/24 at 1:30 PM, the surveyor informed the Director of Nursing (DON) of the above observations and concerns. The DON stated handwashing was expected to be performed for at least 20 seconds; the resident should have been assessed for pain throughout the treatment; the wound dressing should have been dated and initialed and the table should have been disinfected after the treatment was completed. The DON further stated that the LPN should have sanitized her hands before she entered and when she exited Resident #102's room as they were on Enhanced Barrier Precautions. A review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. A review of the facility's policy titled Handwashing/Hand Hygiene with a revised date of August 2019, instructs .Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers .rinse hands with water and dry thoroughly with a disposable towel .use a towel to turn off the faucet. A review of the facility's policy titled, Enhanced Barrier Precautions dated August 2022, reflected .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents .signs are posted in the door or wall outside the resident room indicating the type of precautions and Personal Protective Equipment required. NJAC 8:39-27.1 (a) 19.4 (a) (n) 41260 3). On 01/18/24 at 8:05 AM, the surveyor observed the Licensed Practical Nurse (LPN) check Resident #301's blood pressure (BP) using a wrist BP cuff. Afterwards, the LPN placed the BP cuff on the medication cart, dispensed the resident's medications, and administered the medications to the resident. The LPN did not clean the BP cuff after using it on Resident #301. At 8:23 AM, the surveyor observed the LPN take the same BP cuff that was used on Resident #301 to check Resident #38's BP. Afterwards, the LPN placed the BP cuff on the medication cart, dispensed the resident's medications, and administered the medications to the resident. The LPN did not clean the BP after using it on Resident #38. The LPN then stated she was going to another unsampled resident's room to administer medications and pushed her medication cart in front of the unsampled resident's room. At that time, at 8:40 AM, the surveyor stopped the LPN to interview her. When asked about medical equipment used on multiple residents, the LPN stated she was supposed to clean and disinfect the BP cuff with disinfectant wipes between use and acknowledged that she did not do so during the surveyor's medication pass observation. The LPN further stated that it was important to clean the BP cuff between use to prevent the spread of infection. During an interview with the surveyor on 01/22/24 at 10:52 AM, the Registered Nurse/Unit Manager (RN/UM) stated that re-usable medical equipment was disinfected between resident use to prevent the spread of infection between residents. During an interview with the surveyor on 01/22/24 at 1:07 PM, the Director of Nursing (DON) stated that re-usable medical equipment was cleaned before and after use with disinfectant wipes in order to prevent the spread of infection. Review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, undated, included, Re-usable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). NJAC 8:39-19.4

Based on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of abuse to the New Jersey Department of Health (NJDOH) for 1 of 2 residents (Resident #103) reviewed for abuse. This deficient practice was evidenced by the following: On 01/16/24 at 10:25 AM, the surveyor observed Resident #103 ambulate into the day room and begin conversing with the other residents. At that time, the Assistant Director of Nursing (ADON) entered the day room and redirected the resident. According to the Admission Record, Resident #103 had diagnoses which included, but were not limited to, encephalopathy (condition that causes brain dysfunction), unspecified dementia with agitation, depression, cognitive communication deficit, anxiety, and insomnia. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/08/23, included the resident had a Brief Interview for Mental Status score of 6, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident exhibited wandering behavior daily. Review of the Care Plan, initiated 08/17/23, included a focus of, I have a behavior problem. I like to go 'shopping in other resident's rooms.' I like to wander in and out of resident's rooms. I believe another male resident is my husband and initiated oral sex with him, with an intervention to, intervene as necessary to protect the rights and safety of others. Review of a Progress Note, written by Licensed Practical Nurse (LPN) #1 on 01/06/24 at 12:19 AM, revealed, Resident was observed by staff kissing another resident on the lips, while that resident was asleep out in community requiring [Resident #103] to be redirected earlier in shift. The kiss was reported to manager. An hour or so later [Resident #103] was observed attempting to kiss resident again by this nurse and coworker but was able to interseed [sic]. Resident continues to be bizarre, confused, forgetful with inappropriate behaviors and with very poor safety awareness. Wanderguard in place to LLE [left lower extremity] and functioning well. The surveyor requested all Facility Reportable Events (FRE) related to Resident #103. On 01/16/24 at 10:59 AM, the Director of Nursing (DON) provided FRE's dated 08/21/23 and 10/07/23 and stated there were no additional FRE's for Resident #103. During an interview with the surveyor on 01/16/24 at 12:31 PM, the Certified Nursing Assistant (CNA) stated Resident #103 was a wanderer and that staff monitor and redirect the resident. During an interview with the surveyor on 01/16/24 at 12:35 PM, LPN #2 stated Resident #103 had a history of sexually inappropriate behaviors and that staff frequently monitor and redirect the resident. LPN #2 further stated that when abuse was witnessed or suspected, staff reported the incident to the nursing supervisor and the DON. During an interview with the surveyor on 01/16/24 at 12:38 PM, LPN #3 stated Resident #103 had sexually inappropriate tendencies and that staff monitor and redirect the resident. LPN #3 further stated that when abuse was witnessed or suspected, staff immediately reported the incident to the nursing supervisor and the DON who then report it to the NJDOH in a timely fashion. During an interview with the surveyor on 01/16/24 at 12:47 PM, the Registered Nurse/Unit Manager (RN/UM) stated Resident #103 had a history of being sexually inappropriate and that staff monitor and redirect the resident. The RN/UM further stated that when abuse was witnessed or suspected, staff notify the UM, the ADON, the DON, and the Licensed Nursing Home Administrator (LNHA). On 01/16/24 at 1:52 PM, the surveyor attempted to call LPN #1 who wrote the Progress Note on 01/06/24. The surveyor left a message for the LPN to call the surveyor back. During an interview with the surveyor on 01/16/24 at 2:14 PM, the DON stated that sexual abuse included any sexual act that the resident reports was ill intent, including intercourse, kissing, and inappropriate touching. The DON explained that when abuse was witnessed or suspected, the facility ensures the residents are safe and staff report the incident to the immediate supervisor, the DON, and the LNHA. The DON further stated that the incident was reported to the NJDOH within two (2) hours. When asked about the incident documented in Resident #103's Progress Notes on 01/06/24, the DON stated she recently came across that progress note today (01/16/24) and was planning to report the allegation to the NJDOH, Long Term Care Ombudsman, and the police. The DON further stated that the incident should have been reported to the NJDOH on 01/06/24 when the incident was documented. During an interview with the surveyor on 01/16/24 at 3:25 PM, LPN #1 stated that on 01/05/24, she worked the 3:00 PM to 11:00 PM shift and that at the beginning of her shift, she overheard LPN #2 report to the RN/UM that Resident #103 kissed Resident #23 who was seated in front of the nurse's station. LPN #1 further stated that about an hour after that, LPN #1 witnessed Resident #103 approach Resident #23 and bend over towards the resident, but that she was able to intervene before Resident #103 touched Resident #23. When asked about reporting the incident, LPN #1 stated she reported the incident to the RN/UM and was instructed to monitor the resident and document the incident in a progress note. LPN #1 further stated the Progress Note was dated 01/06/24 at 12:19 AM, because she documented the incident at the end of her 3:00 PM - 11:00 PM shift. During a follow-up interview with the surveyor on 01/17/24 at 9:38 AM, the DON, in the presence of the LNHA, stated the RN/UM should have reported the incident to the DON and the LNHA who would then make the final decision on reporting the incident to the NJDOH. During a follow-up interview with the surveyor on 01/17/24 at 10:30 AM, LPN #2 stated she did not recall the incident on 01/05/24. During a follow-up interview with the surveyor on 01/17/24 at 10:49 AM, the RN/UM stated that on 01/05/24, LPN #2 reported to her that Resident #103 kissed Resident #23 on the cheek. The RN/UM further stated she should have reported the incident to the DON and the LNHA because Resident #23 had a diagnosis of dementia and was unable to consent to the kiss from Resident #103. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated October 2022, included, Investigate and report any allegations within timeframes required by federal requirements. NJAC 8:39-9.4 (f)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to thoroughly investigate an allegation of abuse for 1 of 2 residents (Resident #103) reviewed for abuse. This deficient practice was evidenced by the following: On 01/16/24 at 10:25 AM, the surveyor observed Resident #103 ambulate into the day room and begin conversing with the other residents. At that time, the Assistant Director of Nursing (ADON) entered the day room and redirected the resident. According to the Admission Record, Resident #103 had diagnoses which included, but were not limited to, encephalopathy (condition that causes brain dysfunction), unspecified dementia with agitation, depression, cognitive communication deficit, anxiety, and insomnia. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/08/23, included the resident had a Brief Interview for Mental Status score of 6, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident exhibited wandering behavior daily. Review of the Care Plan, initiated 08/17/23, included a focus of, I have a behavior problem. I like to go 'shopping in other resident's rooms.' I like to wander in and out of resident's rooms. I believe another male resident is my husband and initiated oral sex with him, with an intervention to, intervene as necessary to protect the rights and safety of others. Review of a Progress Note, written by Licensed Practical Nurse (LPN) #1 on 01/06/24 at 12:19 AM, revealed, Resident was observed by staff kissing another resident on the lips, while that resident was asleep out in community requiring [Resident #103] to be redirected earlier in shift. The kiss was reported to manager. An hour or so later [Resident #103] was observed attempting to kiss resident again by this nurse and coworker but was able to interseed [sic]. Resident continues to be bizarre, confused, forgetful with inappropriate behaviors and with very poor safety awareness. Wanderguard in place to LLE [left lower extremity] and functioning well. The surveyor requested all incident/accident investigations related to Resident #103. On 01/16/24 at 10:59 AM, the Director of Nursing (DON) provided incident reports dated 08/21/23 and 10/07/23 and stated there were no additional incident reports for Resident #103. During an interview with the surveyor on 01/16/24 at 12:31 PM, the Certified Nursing Assistant (CNA) stated Resident #103 was a wanderer and that staff monitor and redirect the resident. The CNA further stated that when abuse is witnessed or suspected, the staff are required to fill out a written statement. During an interview with the surveyor on 01/16/24 at 12:35 PM, LPN #2 stated Resident #103 had a history of sexually inappropriate behaviors and that staff frequently monitor and redirect the resident. LPN #2 further stated that when abuse is witnessed or suspected, staff complete an incident report and obtain written statements from the staff. During an interview with the surveyor on 01/16/24 at 12:38 PM, LPN #3 stated Resident #103 had sexually inappropriate tendencies and that staff monitor and redirect the resident. LPN #3 further stated that when abuse is witnessed or suspected, staff complete an incident report and obtain written statements from the staff. During an interview with the surveyor on 01/16/24 at 12:47 PM, the Registered Nurse/Unit Manager (RN/UM) stated Resident #103 had a history of being sexually inappropriate and that staff monitor and redirect the resident. The RN/UM further stated that when abuse is witnessed or suspected, staff complete an incident report which opens up an investigation that the DON and Licensed Nursing Home Administrator (LNHA) are involved in. The RN/UM added that staff statements are also collected and a summary of investigation is written. On 01/16/24 at 1:52 PM, the surveyor attempted to call LPN #1 who wrote the Progress Note on 01/06/24. The surveyor left a message for the LPN to call the surveyor back. During an interview with the surveyor on 01/16/24 at 2:14 PM, the DON stated that sexual abuse includes any sexual act that the resident reports is ill intent, including intercourse, kissing, and inappropriate touching. The DON explained that when abuse is witnessed or suspected, the facility ensures the residents are safe and staff report the incident to the immediate supervisor, DON, and Licensed Nursing Home Administrator (LNHA). The DON further stated that the nurse completes an incident report and the DON and LNHA obtain statements from staff and residents. The DON added that the investigation should be completed within five days. When asked about the incident documented in Resident #103's Progress Notes on 01/06/24, the DON stated she recently came across that progress note today (01/16/24) and was currently in the process of investigating the incident. The DON further stated that since the Progress Note was written on 01/06/24, investigation into that incident should have been started the same day the note was written. During an interview with the surveyor on 01/16/24 at 3:25 PM, LPN #1 stated that on 01/05/24, she worked the 3:00 PM to 11:00 PM shift and that at the beginning of her shift, she overheard LPN #2 report to the RN/UM that Resident #103 kissed Resident #23 who was seated in front of the nurse's station. LPN #1 further stated that about an hour after that, LPN #1 witnessed Resident #103 approach Resident #23 and bend over towards the resident, but that she was able to intervene before Resident #103 touched Resident #23. LPN #1 added that she reported the incident to the RN/UM and asked if she should complete an incident report, however, the RN/UM instructed her to monitor the resident and document the incident in a progress note. LPN #1 stated she was never instructed to complete an incident report or provide a written statement. LPN #1 further stated the Progress Note was dated 01/06/24 at 12:19 AM, because she documented the incident at the end of her 3:00 PM - 11:00 PM shift. During a follow-up interview with the surveyor on 01/17/24 at 9:38 AM, the DON, in the presence of the LNHA, stated the RN/UM should have reported the incident to the DON and LNHA who would then make the final decision regarding the incident. During a follow-up interview with the surveyor on 01/17/24 at 10:30 AM, LPN #2 stated she did not recall the incident on 01/05/24. During a follow-up interview with the surveyor on 01/17/24 at 10:49 AM, the RN/UM stated that on 01/05/24, LPN #2 reported to her that Resident #103 kissed Resident #23 on the cheek. The RN/UM further stated she should have reported the incident to the DON and LNHA because Resident #23 had a diagnosis of dementia and was unable to consent to the kiss from Resident #103. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated October 2022, included, Investigate and report any allegations within timeframes required by federal requirements. Review of the facility's Accidents and Incidents - Investigating and Reporting policy, dated July 2017, included, All accidents and incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator, and, The nurse supervisor/charge nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. Further review of the policy included, The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. NJAC 8:39-4.1(a)(5)

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified resident behavior and preferences. This deficient practice was identified for 1 of 36 residents (Resident #45) reviewed for care plans and evidenced by the following: On 1/10/24 at 10:44 AM, the surveyor observed the resident lying in bed, but permitted the surveyor to enter. The surveyor observed the bottom of the room's radiator unit broken, open and exposed. The surveyor located the resident's call bell in the bottom, closed nightstand drawer. The surveyor also observed a sign that depicted a call bell on Resident #45's closet door that stated, press the red button for help from nurse. On 1/11/24 at 11:08 AM, the surveyor observed Resident #45's call bell in the bottom, closed nightstand drawer and the bottom of the radiator was broken, open and exposed. On 1/12/24 at 11:22 AM, the surveyor observed Resident #45's call bell in the bottom, closed nightstand drawer and the bottom of the radiator was broken, open and exposed. On 1/12/24 at 11:31 AM, the surveyor interviewed the Certified Nursing Assistant (CNA#1) and brought them to room [ROOM NUMBER]. The surveyor inquired about the radiator and call bell. CNA#1 described Resident #45 as a fixer and that they like to put things away. On 1/17/24 at 11:43 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1), who described a resident's individualized comprehensive care plan (ICCP) as an outline of the basic needs for the resident. LPN#1 stated that nurses could review the ICCP but could not access it. LPN#1 reported that the RN Supervisor or Unit Manager were in charge of the ICCP, but nursing staff could monitor the care plan for accuracy and updates. LPN#1 also confirmed that the care plan should have identified resident preferences and any behaviors that the resident may have exhibited. On 1/18/24 at 11:04 AM, the surveyor interviewed the Registered Nurse Unit Manager (RNUM#1), who stated that the purpose of an ICCP was to make everyone aware of the areas a resident may have needed help. RNUM#1 further stated that a care plan should have been personalized to the resident. When asked what type of things should be identified on a ICCP, RNUM#1 stated, falls, room preferences, dietary needs, and behaviors. When asked if Resident #45's care plan should have identified their preference to have the call bell stored in the nightstand drawer and the Resident's tendency to disassemble equipment, RNUM#1 confirmed. On 1/23/24 at 12:03 PM, the surveyor interviewed the Director of Nursing (DON), who confirmed that the expectation for Resident #45 was that the care plan identified the behavior to take apart items and the preference to have the call bell in the drawer. The surveyor reviewed the medical record for Resident #45: A review of the Admission Record face sheet (an admission summary) reflected that the resident had diagnosis that included, but was not limited to, unspecified dementia, major depressive disorder, and unspecified mood disorder. A review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 12/15/23, reflected a brief interview for mental status (BIMS) score of 99, which indicated that the resident was unable to complete the assessment. A review of Resident #45's individualized comprehensive care plan (ICCP) had focus areas that identified behaviors but did not identify the Resident's behavior of taking items apart or their preference to keep the call bell in a closed drawer of the nightstand. A review of the facility's undated policy, Homelike Environment included . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change. NJAC8:39-11.2(e) thru (i); 27.1(a), (d)

Complaint NJ #: 168814 Based on interview, record review, and review of facility documents, it was determined that the facility failed to address recommendations from the Wound Care Consultant (WCC) in a timely manner for 1 of 5 residents (Resident #502) reviewed for pressure ulcers. This deficient practice was evidenced by the following: According to the Admission Record, Resident #502 had diagnoses which included, but were not limited to, COVID-19, diabetes mellitus, and dementia with anxiety. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/12/23, included the resident's Brief Interview for Mental Status score was 14, which indicated the resident's cognition was intact. Further review of the MDS included the resident had three unstageable - deep tissue injury (DTI) pressure ulcers that were present upon admission to the facility. Review of the Care Plan, initiated 10/12/23, included a focus of, the resident has a pressure ulcer development r/t [related to] immobility, with an intervention for, Nutrition/Dietitian consult as needed. Review of the WCC report, dated 10/18/23, included the resident was seen for an initial evaluation of a DTI to the left buttock and an unstageable pressure ulcer to the right buttock. Further review of the WCC report included nutrition recommendations of, Recommend increasing dietary protein intake, and, Recommend obtaining prealbumin, albumin, and Vitamin D-25 level. The WCC added, Will suggest increase in protein intake to improve healing and BW [bloodwork] to evaluate protein levels (albumin/prealbumin/vitamin d/total protein). Review of the resident's Electronic Medical Record (EMR) revealed there were no evaluations or progress notes completed by the Dietician or labs results for prealbumin, albumin, and Vitamin D-25 level for the time period of 10/18/23 through 10/25/23. Review of the WCC report, dated 10/25/23, included the resident was seen for a follow-up evaluation for the left and right buttock pressure ulcers which were improving. Further review of the WCC report included nutrition recommendations of, Recommend Dietician consult, Recommend increasing dietary Protein intake, and, Recommend obtaining prealbumin, albumin, and Vitamin D-25 level. The WCC added, Will again suggest increasing protein intake to improve healing and BW to evaluate protein levels (albumin/prealbumin/vitamin d/total protein) - will consult RD [Registered Dietician]. Review of the resident's EMR revealed there were no evaluations or progress notes completed by the RD or labs results for prealbumin, albumin, and Vitamin D-25 level for the time period of 10/25/23 through 11/01/23. Review of the WCC report, dated 11/01/23, included the resident was seen for a follow-up evaluation for left and right buttock pressure ulcers which were improving. Further review of the WCC report included chemistry recommendations for prealbumin, albumin, and Vitamin D-25. Review of the resident's EMR revealed there were no evaluations or progress notes completed by the RD after the WCC report dated 11/01/23, but there were lab results, dated 11/03/23, for albumin, prealbumin, and Vitamin D-25. Review of a progress note, dated 11/04/23, revealed the resident was discharged from the facility. During an interview with the surveyor on 01/22/24 at 10:43 AM, the Licensed Practical Nurse (LPN) stated that the WCC visited the facility once a week and submited the WCC report to the Unit Manager (UM). The LPN further stated that the any recommendations made by the WCC should be implemented as soon as they were received to ensure the wounds are getting better. During an interview with the surveyor on 01/22/24 at 10:52 AM, the Registered Nurse/Unit Manager (RN/UM) stated that she started working at the facility in November 2023. When asked about the WCC, the RN/UM stated the WCC emailed her the WCC report with any recommendations and that the RN/UM put the orders in that night. The RN/UM further stated that if there was a nutrition recommendation, she would email the Dietician to let her know. The RN/UM added that WCC recommendations should be implemented within 24 hours to promote wound healing. During an interview with the surveyor on 01/22/24 at 11:42 AM, the Dietician stated that the WCC visited the facility weekly and if there were any recommendations related to nutrition, the UM would put in for a nutrition consult that same week. The Dietician further stated that after she evaluated a resident, she would either document under the progress notes or evaluations in the resident's EMR. When asked about Resident #502, the Dietician stated that she started working at the facility the last week of October 2023 and did not recall the resident because she was not involved with the WCC reports until November 2023. The Dietician added that if there was a nutrition recommendation made on 10/18/23, the Dietician at that time should have been notified by the UM and followed-up with the resident. During an interview with the surveyor on 01/22/24 at 1:07 PM, the Director of Nursing (DON) stated that the WCC visited the facility weekly and emailed the WCC report within 12 to 24 hours after the visit to the UMs and DON. The DON further stated the UM reviewed the WCC report, notified the physician, and implemented the recommendations once approved by the physician. The DON added that she was unsure of the timeframe that recommendations from the WCC should have been implemented, but that it was important to follow-up on WCC recommendations for continuity of care. At that time, the surveyor notified the DON of Resident #502's WCC nutrition recommendations that were not addressed on 10/18/23 and 10/25/23. During a follow-up interview with the surveyor on 01/23/24 at 12:45 PM, the DON stated she reviewed Resident #502's WCC reports and stated that when the nutrition recommendation was made on 10/18/23, the UM should have followed up with the physician to address the recommendations. Review of the facility's Nutrition Assessment policy, dated October 2017, included, The dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission . and as indicated by a change in condition that places the resident at risk for impaired nutrition, and, Increased need for calories and/or protein - onset or exacerbation of diseases or conditions that result in a hypermetabolic state and an increased demand for calories and protein (e.g . wounds). NJAC 8:39-27.1(a)

Complaint #160989 Based on observation, interview and review of the medical record and other facility documentation, it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practices for one (1) of 36 residents reviewed (Residents #505). This deficient practice was evidenced by the following: On 1/10/24, the surveyor team entered the facility for the annual recertification survey. Resident #505 was not a resident in the facility and was discharged on [DATE]. The Admission Record (AR) indicated that Resident #505 was admitted to the facility with the diagnoses which included but was not limited to retention of urine, altered mental status and seizure disorder. The admission Minimum Data Set (MDS), an assessment tool dated 12/15/22, indicated that the resident was cognitively intact and required limited assistance with activities of daily living (ADL's). The MDS also indicated that the resident had an indwelling urinary catheter. The surveyor reviewed the Treatment Administration Record (TAR) dated 01/06/23, which reflected a physician's order for: Urinary Catheter #18Fr/10 ml balloon inflation to urinary Drainage Bag, Change as needed for signs and symptoms of infection or obstruction. every day shift every 28 day(s) change monthly for maintenance [sic]. The nursing signature spot on the TAR dated 01/06/23, reflected a nurse's signature with the code of 2 (two). The Chart Code graph located on the TAR, indicated that the code 2 meant that the resident refused to have the indwelling urinary catheter inserted. The surveyor reviewed the Progress Notes (PN) dated 01/06/23, and observed that there was no documentation as to why the indwelling urinary catheter was to be changed that day, nor was there documentation that Resident #505 refused to have the indwelling catheter inserted. There was also no documentation that the primary care physician (PCP) was notified, or that the family was notified that the resident refused to have the indwelling urinary catheter reinserted. On 01/11/24 at 09:28 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she was not familiar with Resident #505 as it had been a while since the resident was in the facility. The DON also indicated that the nurse that cared for the resident was not employed by the facility any longer. She explained that the nurse who documented that the resident refused to have the indwelling urinary catheter changed on 01/06/23 should have written a nurses note explaining why the resident refused. The DON reviewed the PN and confirmed that there was no documentation regarding why the resident refused the catheter replacement and why the catheter needed to be replaced. The DON also explained that the nurse should have also documented if he/she notified the physician and the family of the refusal for treatment. On 01/11/24 at 10:28 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) who stated that she had been employed in the facility for [AGE] years and primarily worked on the [NAME] Unit (Dementia Unit). The LPN stated that if a resident refused a medication or treatment that it should have been documented on the Medication Administration Record (MAR) or TAR and then also documented in the progress notes. The LPN explained that the nurse would be responsible to notify the PCP and family regarding the refusal. She continued to explain that if a resident was on a daily skilled noted then the nursing staff would be responsible to document daily, however if the resident was long term care the staff only documented by exception, meaning that the nurse was only responsible to document if a resident had any change in condition or something was out of the ordinary with the resident. On 01/11/24 at 10:33 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) for the [NAME] Unit who stated that 24-report sheets had information regarding resident change in condition, behaviors, incidents, and accidents. When a resident was on the 24-hour report sheet the nurses were responsible to document on those residents and include pertinent information on the progress notes. The RN/UM explained that the nurses were responsible to document treatment or medication refusals on the MAR and TAR and in the progress notes. She explained the nurse should have included in the progress note the refusal, why the resident refused, education to resident on risk vs benefit, how many attempts were made to administer the med or treatment that the resident refused. She stated that the nurse would also have been responsible to document in the PN who was contacted regarding the resident's refusal, such as the family and the PCP. She continued to add that it would have been important to notify the MD so that the MD could have adjusted medication or treatment if needed. The RN/UM stated that any resident change in condition should have been documented in the medical record. The surveyor continued to review the PNs which revealed the following: On 1/19/2023 at 13:44 (01:44 PM), the Nurse Practitioner (NP) documented: Seen for discharge from penis. Patient is seen and examined in bed. There is a Foley in place with cloudy, yellow urine with sediment. denies any pain or itching. There is brownish discharge from urethra and creamy, white discharge surrounding penis. ua, uc+s culture ordered (Urinalysis and urine culture and Sensitivity) [sic] . On 1/20/2023 13:40 (01:40 PM) the NP documented: Patient is seen and examined in bed. He is unresponsive - staring straight ahead. smelling discharge from urethra where Foley is inserted. Unable to change Foley until urology apt on 2/3 d/t difficulty inserting/requiring specialty catheter. Patient being sent out 911 [sic]. On 01/20/23 at 13:48 (01:48 PM) a Registered Nurse (RN) documented that Resident #505 was sent to the hospital for unresponsiveness. The PN also indicated that the resident was not responding to sternal rubs, was breathing and had a strong radial pulse. The PN indicated that the resident's NP was made aware, and spouse was made aware. The PN had no other details regarding the resident's condition or if vital signs (VS) were taken for Resident #505. The surveyor also questioned the DON regarding documentation for residents. The DON explained the RN should have documented the residents VS when the nurse found the resident unresponsive. The surveyor reviewed the Universal Transfer Form (UTF) dated 01/20/23 at 13:30 (01:30 PM) which indicated that the resident was sent to the hospital. The documentation on the UTF indicated the last VS that were taken on Resident # 505 were: -Blood Pressure (BP) 142/47 taken 01/20/23 at 08:36 AM. -Pulse 72 taken 01/20/23 at 08:36 AM. -Respirations 16 taken 01/20/23 at 08:36 AM. -Temperature 98.4 taken 01/19/23 at 08:13 AM. -Oxygen saturation 97.0 taken 01/20/23 at 08:36 AM. -Pain level 0 taken 01/20/23 at 08:33 AM. On 01/16/24 at 12:33 PM, the surveyor interviewed the Registered Nurse Assistant Director of Nursing (ADON) who stated that she used to work the [NAME] Dementia Unit in January 2023 as a Unit Manager when Resident #505 was a resident. The ADON stated that she was the nurse that documented that the resident was sent to the hospital for unresponsiveness on 01/20/23 at 13:48 (01:48 PM). The ADON reviewed the progress note dated 1/20/23 at 13:48 (01:48 PM) and reviewed the UTF that she completed prior to the resident being sent to the hospital, however, could not recall any details of the event that had occurred. The ADON stated that the notes that she documented were all the information that she had regarding Resident #505's change in condition. The ADON did not have a response or explanation as to why the VS on the UTF were not documented at the actual time that the resident was found unresponsive. The ADON also could not explain why the resident's VS were not documented in the PN. The ADON stated that she was the nurse that documented in Resident #505's TAR, that the resident had refused an indwelling urinary catheter change on 01/06/23. She admitted to not documenting in the resident's medical record regarding why the indwelling urinary catheter had to be changed. She also confirmed that she did not document the resident's refusal in the medical record. She stated that she should have documented that she notified the MD and the resident's family. The ADON stated that she did not recall the situation or why she did not document what had occurred on 1/6/23 and that why the resident refused to have the indwelling catheter changed. On 01/16/24 at 01:02 PM, the surveyor telephone interviewed the NP regarding Resident #505. The NP stated that she was informed by an agency nurse on 01/20/23 that the resident was unresponsive. The NP stated that she did not know the name of the nurse that notified her about the resident's change in condition. The NP stated that the nurse should have documented the change in condition in the progress notes. The NP stated that it would have been important to document a resident's medical condition in the PN to keep an accurate account of what was going on with the resident. She stated that the progress notes were also a good communication tool between disciplines. On 01/23/24 at 12:02 PM, the DON confirmed that the last documented VS on Resident #505's UTF, dated 1/20/23 at 1:38 PM, were not documented at being taken at the time the resident was found unresponsive. The DON could not explain why the VS were not documented at the time the resident was found unresponsive, however moving forward that the only thing that she could do was to educate the staff on accurate documentation. She also added that the staff were also educated on proper documentation if a resident refused treatment or services. The facility policy titled, Requesting, Refusing and/or Discontinuing Care of Treatment, with a revised date of 2021, indicated that residents and resident representatives have the right to request, refuse and or discontinue treatment. The policy also indicated that detailed information relating to the request, refusal and or discontinuation of treatment are documented in the resident's medical record. The policy specified that the documentation of the refusal should include the following: -The date and time the care or treatment was attempted. -The type of care and treatment. -The resident's response and reason of the refusal. -The name of the person who attempted of administer the care and treatment. -The resident was informed (to the extent that they understand) the purpose of the treatment of the potential outcome on not receiving the medication or treatment. -The resident's condition and any adverse effects. -The date and time the practitioner was notified was well as the practitioner's response. -All other pertinent observations. -The signature and title of the person recording the data. The policy also specified that the healthcare practitioner must be notified of the refusal of treatment. The facility policy titled, Indwelling Catheter Insertion, Male Resident, with a revised date of August 2022, indicated that if the resident refused the procedure documentation must include the reasons why and the intervention taken. The policy also indicated that the supervisor and the physician must be notified. The facilities policy titled, Guidelines for Charting and Documentation, dated 2012, indicated that the purpose of charting and documentation is to assure a complete account of the resident's care, treatment, response to care, signs, symptoms etc , and progress of the resident's care, a tool for measuring the quality of care provided to the resident, a legal record that protects residents, care providers and facility. The facility policy titled, Charting and Documentation, with a revised date of 2017, indicated that all services to the resident, progress toward the care plan goals, any changes in the resident medical, function, or psychological condition, shall be documented in the resident's medical record. It policy indicated that the medical record should facilitate communication between the interdisciplinary team regarding the resident condition and response to care. The policy also indicated that the documentation in the medical record will be accurate and will include care specific details. The following information is to be documented in the resident's medical record: -Changes in resident's condition. -Treatments or services performed. -The assessment date and any unusual findings obtained during the procedure/treatment -Whether the resident refused the treatment or procedures. -Objective observations. NJAC 8:39-35.2 (d)6, 16(e)

Complaint #: NJ165363, NJ165497, NJ168316 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/17/2023 and 10/19/2023, it was determined that the facility failed to provide a safe environment and supervision of a ambulatory cognitively impaired resident on a secured unit. The facility failed to identify that a staff member didn't follow the policy for storage of personal items. It was determined on 9/7/2023 that an Activity Assistant (AA) left her Cambridge fanny pack (a facility issued fanny pack with zipper provided to staff during orientation to carry around items securely.) unsupervised on the second shelve of a three-tier activity cart and the resident ( Resident #2) took it. Resident #2 was found by a Certified Nursing Assistant (CNA) with an opened bottle of Hydroxyzine 50 miligram (mg) (a medication used to treat anxiety) that belonged to the AA. The AA and Licensed Practical Nurse (LPN) counted the pills in the bottle and confirmed there were three tablets of Hydroxyzine 50mg missing from the pill bottle. The Physician was made aware, and Resident #2 was sent to the emergency room for evaluation. This deficient practice placed all residents with cognitive impairment with wandering behaviors at risks to encounter hazardous items that could cause injury, harm or death. The Immediate Jeopardy Past Non -Compliance began on 9/7/2023 and ended on 9/8/2023 after the facility educated the unit staff about storage policy and procedure of Employee Personal Items. The facility- initiated monitoring of the storage of personal items on the secured unit to ensure that this does not reoccur. The facility submitted the following document at the time of the survey that indicated the following: 1. On 9/7/2023 a full search of the unit was conducted by staff to ensure that there were no personal and hazardous items. 2. On 9/8/2023 , the facility conducted education of nursing and enrichment staff , which included the AA on storage of personal belongings and using lockers and/or locked spaces on the secured memory care unit. 3. After the re-education on 9/8/2023, Employee AA could returned to work on this secured unit. The facility continues making rounds by nursing management and Ambassadors utilizing their ambassador application tool. The environment has been safely maintained. There is sufficient evidence that the facility corrected the non-compliance and is in substantial compliance at the time of this Complaint Survey for the specific F689 regulatory requirements. This deficient practice was identified for 1 of 4 residents (Resident #2) reviewed for incidents and accidents. During a tour of the secure unit on 10/17/2023 at 9:00 A.M., the Surveyor did not observe any personl items visible on the unit or within the residents reach. On 10/17/2023 and 10/18/2023, a review of Resident #2's Electronic Medical Record (EMR) was as follows: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Major Depressive Disorder, Cognitive Communication Deficit, Unspecified Dementia, Severe with Anxiety. According to the Minimum Data Set (MDS), an assessment tool dated 9/27/2023, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 2/15, which indicated the Resident was severely cognitively impaired. Review of the facility's transfer form titled New Jersey Universal Transfer Form dated 09/07/2023 and timed 4:00 P.M., under reason for transfer reveal: Ingested medications that did not belong to him/her. During an interview on 10/17/2023 at 10:00 A.M., the AA informed the Surveyor that on 9/7/2023 she placed her fanny pack on the second shelve of a three-tier activity cart while conducting activities with the residents in the dining room on the memory care unit. While conducting activity, she was approached by the LPN with her medication bottle and asked how many pills were in the bottle? I told the LPN I had about 15 pills in the bottle that morning. I always count my pills, I don't take them every day, so I knew it was 15 pills at the beginning of the day. After the LPN and I counted the pills in the bottle, it was 12 pills left in the bottle. When asked by the Surveyor what were the pills in the bottle, the AA stated, it was my Hydroxyzine 50mg and I don't take them every day. She further stated that she was made aware by the LPN that her pill bottle was found opened with a resident. When asked by the Surveyor where was her pill bottle kept, the AA stated, I had it in my Cambridge fanny pack. Yes, the fanny pack was zipped up that day. I did not know my fanny pack was missing until the LPN came to me with my pill bottle. The AA continued to state she did not see anyone take her fanny pack from the three-tier activity cart while conducting activity that day. During the same interview when asked by the Surveyor if she should have her personal items unsupervised while doing activities on a unit with ambulatory cognitively impaired residents, the AA said No, I should have placed my fanny pack in a locker or kept in the activities office where it is always secured and away from all residents. When asked if she followed the facility policy for securing personal items, she said No. During an interview on 10/17/2023 at 11:10 A.M., the LPN said she was presented an opened bottle of pills by the CNA who told her Resident #2 had the opened pill bottle in their hand. I went down the hallway with the CNA to access Resident #2 and ensured the resident was doing okay. The cap of the pill bottle was retrieved from Resident #2's hand and then I went over to the AA in the dining room. I asked her if the bottle belong to her since it had her name on it. She said Yes, who has my bag? The AA further stated, I had my bag on the activity cart shelf while doing activities and I did not see anyone take it. I asked the AA how many pills were in her bottle, and she responded 15 pills. We both counted 12 pills that were left in the bottle. When asked by the surveyor if all cognitively impaired residents on the unit were at risk for taking the pill bottle left unsupervised, she said Yes. During an interview on 10/17/2023 at 12:08 P.M., the Memory Care Unit Director said she was informed of the incident on the unit via a text message while in a meeting. She further stated the expectation is for all activities staff on the unit to have their personal belongings stored in their locker or a locked and secure room which requires a code for entry. She further stated, the activity cart should only have supplies needed to conduct activities for the residents, nothing that could be harmful to the residents. When asked by the Surveyor if the facility policy for storing personal items was followed, she said, No. During an interview on 10/17/2023 at 1:51 P.M., the Director of Nursing (DON) in the presence of the Administrator, Regional Director of Operations and Regional Director of Clinical Services, said It was brought to our attention that Resident #2 had ingested some medications. When asked by the Surveyor what the medications were? The DON said, Hydroxyzine 50mg (3 tablets). She continued to say, Resident #2, was assessed, poison control was notified, and the Physician ordered for Resident #2 to be sent out to the emergency room for evaluation. The DON said the AA informed her that she left her fanny bag unsupervised and got distracted when she noticed her bag was missing. The fanny bag is a bag with a zipper provided by the facility for staff to carry around items securely. The DON stated, the AA informed me she proceeded to look for her bag and later retrieved it from Resident #2 along with her pill bottle in Resident #2's hand. The AA said she counted the pills in the bottle along with the LPN and had 12 pills left in the bottle from the initial 15 pills that were in the bottle earlier. When asked by the Surveyor who had found the pill bottle, the DON stated, the AA told me that she found Resident #2 with her pill bottle opened in their hand, she was talking to another staff member and when she turned around noticed that her bag was missing. I don't recall the name of the staff member the AA said she was talking to at the time her bag got missing. During the same interview, the DON said the expectations is for all staff to store their personal belongings in their locker or secure area away from the residents. When asked by the Surveyor if the facility's policy was followed for storing personal items, she said No. The DON further stated, Other residents could be at risk for ingesting the pills. Review of the facility policy title Employee Lockers under Policy Statement reveals: Our facility provides a locker for each employee for his /her personal use. Under Policy Interpretation and Implementation reveals: 1. Our facility provides a locker for each employee, at no cost to the employee, for safekeeping his/her personal effect. 5. Lockers must be kept locked when not in use and may not be used to store facility property or other items in violation of facility policies. Employees may not store personal items in residents' rooms or areas. Storing personal items in resident room is grounds for disciplinary action up to and including termination. N.J.A.C.: 8.39- 27.1 (a)

C#: NJ159688 Based on observation, interviews, medical record review, and other pertinent facility documentation on 11/28/2022 and 11/29/2022, it was determined that the facility failed to provide adequate supervision and maintain a safe environment for a resident (Resident #1) who was an elopement risk. On 11/22/2022, the Long-Term Care Complaint (LTCC) program received an anonymous phone call regarding a resident who escaped from the facility, and the police department was notified. During the on-site investigation conducted on 11/28/22 and 11/29/2022, it was noted that on 11/10/2022, the Maintenance staff removed the Air Conditioning (AC) unit from the room of Resident #1 that was located in the Dementia /locked Unit on the ground level. The Maintenance Staff failed to install security screws that would have prevented the window from opening more than 6 inches from the sill. On 11/11/2022, between the 11:00 p.m. to 7:00 a.m. and 7:00 a.m. to 3:00 p.m. shifts, Resident #1 was able to leave the facility unknowingly to staff by opening the window. The facility notified the police at 9:20 a.m., and an active missing person alert was initiated. On the same day in the evening, Resident #1 was found in another town 6.7 miles away. The Resident did not return to the facility. The facility failed to ensure that the staff noted Resident #1's daily function and the placement of the wander guard on the 11:00 p.m. to 7:00 a.m. shift. as ordered by the Physician. and in accordance with their policies titled Wandering and Elopement, Wander Management and Elopement Prevention and the Maintenance Worker job description. These deficient practices placed Resident #1 and other residents identified with cognitive impairment and wandering behaviors who could possibly exit from windows without the safety stops and adequate supervision of staff at risk for an Immediate Jeopardy situation. On 11/29/2022, Day 2 of the survey, an Immediate Jeopardy ( IJ) Federal citation was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), the Director of Nursing (DON), Assistant Director of Nursing (ADON), and The Regional Director of Field Operations on 11/29/2022 at 5:40 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ ran from 11/10/2022, when the AC unit was removed from the window, through 11/14/2022, after the completion of in-services and education of facility staff on residents at risk for Elopement, Prevention of Elopement, and the securing Residents' windows. On 12/5/2022, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan. All facility staff were re-educated on Resident rounding. All maintenance assistants were educated on the process/policy for securing the residents' room windows and an audit to determine all residents at risk for Elopement. So, the noncompliance remained on 11/14/2022 as a level D for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the following: The Resident is no longer at the facility, staff has been educated on Resident rounding, the process/policy on securing residents room windows, an audit to determine residents at risk for elopement and care plan was updated to meet the Resident's individual needs, educating and re-educating all nursing and non-nursing staff on residents at risk for Elopement, prevention of Elopement and care and management of residents that have eloped, training to check wander guards placement and function with sign off for accountability and notification to NJDOH, the Ombudsman, and the NJ State Board of Nursing. This deficient practice was identified for 1 of 3 residents (Resident #1) and evidenced by the following: According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. According to the Minimum Data Set (MDS), an assessment tool dated 10/25/2022, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 5/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #1 needed extensive assistance with one-person physical assistance with bed mobility and transfers and limited assistance with most Activities of Daily Living (ADLs). A review of Resident #1's MQS: Elopement/Wandering Risk Evaluation (EWRE) form dated 10/25/2022 revealed a score: NA (not applicable). Under A. Potential Risk Factors/Resident Status indicated .14. Has the family/responsible party/resident representative voiced concerns that would indicate the Resident may have wandering tendencies or try to leave? b. Yes, 15. Is Resident at risk for wander/elopement? a. Yes, 16. Are parties aware of [the] Risk for Wander/Elopement? a. Yes. 17. Initiate Elopement/Wander Care Plan Focus: I am at actual/potential risk for Elopement r/t Goal: I will not leave the facility without notifying staff before [the] next review date. Intervention: Engage me in group activities to decrease wandering, Photograph in Elopement Book, provide appropriate diversions for residents, and encourage Residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the Resident's health and/or safety, Psych consult and treat as indicated, Redirect during wandering episodes, Wander Bracelet placed. The DON continued to say [the] CP focus comes up with admission evaluation and add interventions to CP to personalize it. A review of the Resident's Care Plan (CP) initiated on 10/25/2022 revealed under Focus: I am at actual/potential risk for elopement r/t (related/to) cognitive impairment, non-acceptance of long-term placement. The CP also included under Goal: I will accept and adjust to Long Term Care placement. Also, under Interventions: included, Engage me in group activities to decrease wandering, evaluate resident's desire to leave the facility, monitor behaviors, Photograph in Elopement book, Psych (Psychiatrist) consult (consultation) and treat as indicated, Wander Bracelet placed to left ankle Exp (Expiration) 02/05/24. A review of Resident #1's Order Summary Report (OSR) Order Date Range from 10/01/2022 through 11/30/2022 revealed the following Physician Orders (POs): Wander Bracelet: Check[the] Function of[the] Wander Bracelet every day, one time a day order dated 10/25/2022 Wander Bracelet: Check [the] Placement of [the] Wander Bracelet on every shift. Left ankle every shift for elopement risk order dated 10/25/2022 A review of Resident #1's Treatment Administration Record (TAR) dated 10/01/2022 through 11/30/2022 revealed the above POs to check the function, and the placement of the wander guard was documented as being completed on 11/10/2022 on the night shift by the RN. A review of Resident #1's Progress Notes (PNs) written by the Registered Nurse (RN) dated 11/11/2022 at 5:58 p.m. revealed the following: Resident #1] left AMA (Against Medical Advice). Paperwork signed by spouse/POA (Power of Attorney) . The Surveyor reviewed the Assignment Sheet (AS) dated 11/10/2022 on the 11:00 p.m. -7:00 a.m. shift, which revealed there were two nurses: (2) Licensed Practice Nurses (LPNs) and (4) Certified Nursing Assistants (CNAs) on the [NAME] (Dementia/Locked) unit. At the time of the survey, there was no camera footage of the incident. During an interview on 11/28/2022 at 1:30 p.m., CNA #1 stated she was informed by another CNA (CNA #2) that Resident #1 was not in his/her room. She joined the staff in the search for Resident #1. The CNA stated she entered the bedroom of Resident #1 and observed that Resident #1's bedroom window was a little opened, the screen on the window was pushed up, and the window was all the way up. CNA #1 further stated, both the screen and window were up, and I was able to go through. Everyone was there, including Administration, or the owner. She further stated it was not difficult to get through Resident #1's bedroom window, it was easy to get through the bedroom window, and that she and Resident #1 was about the same size. During an interview on 11/28/2022 at 1:53 p.m., CNA #2, assigned to Resident #1, stated that at approximately 7:30 a.m., the CNA got her assignment and did her routine rounds. She entered Resident #1's room, saw the privacy curtain pulled halfway in the middle, the blanket was on the bed and assumed the Resident was in bed. At approximately 9:05 a.m., the CNA entered Resident #1's room to deliver the breakfast tray and realized the Resident was not in his/her room. She then alerted CNA #1, and they both proceeded to look for the Resident. CNA #1 stated they looked in Resident #1's room, bathroom, and other rooms and bathrooms on the unit. They did not see Resident #1 and alerted the Licensed Practical Nurse (LPN) assigned to Resident #1. The CNA stated she was unfamiliar with how Resident #1 looked, but the LPN and CNA #1 described Resident #1. On her way to work, she recalled seeing an older adult fitting the description of Resident #1 sitting on the bench at the bus stop on the main road but did not report this to other facility staff. CNA #1 indicated someone paged (called the code), and they all started looking for Resident #1. She continued to explain that some CNAs looked in the building while others went outside in their car and to the bus stop, where she had recalled seeing an adult sitting on her way to work. The adult was no longer at the bus stop. CNA #1 further stated, I think one of the CNAs said the Resident got out through his/her window. In the same interview, CNA #2 stated CNA #1 said if it was easy for her to get through the window, then Resident #1 must have gotten out the window since they were both the same size (petite). During an interview on 11/28/2022 at 3:25 p.m., the Assistant Director of Nursing (ADON), who was the interim DON at the time of the incident, stated on the morning of the incident, while in the morning meeting, the Administration was notified by the Unit Manager (UM) of the missing Resident (Resident #1). The ADON stated Code yellow was activated, and the entire Administration was involved in the search for Resident #1. She further stated the entire building (rooms, bathrooms, and common areas) was searched as other staff went outside the building, driving around the building and surrounding areas in search of Resident #1. The ADON also stated when the search was initiated. The local Police Department was notified of the missing Resident (Resident #1). During the same interview, the ADON also stated once she realized Resident #1 was not found in the area, the spouse (POA) was notified. The ADON stated during the call with Resident #1's spouse, he/she didn't verbalize concern for the missing Resident (Resident #1). She continued the spouse that if Resident #1 returned to their house, to call and inform the facility. According to the ADON, Resident #1 was later recovered by the Palmyra Police while attempting to enter the bar, stating Resident #1 was fine and did not want to return to the facility. The ADON further stated Resident #1's spouse was informed, and he/she was fine with Resident #1's decision not to return to the facility. The ADON continues to reveal that the spouse (POA) signed Resident #1 out of the facility AMA (Against Medical Advice). The ADON stated, no one knows how Resident #1 got out of the building, but his/her window was not locked. The screen was on the window and intact. I believed the AC Unit was removed the day prior to the incident. When asked by the Surveyor if the window should have been secured properly, the ADON replied, Yes, Resident #1's window should have been locked with screws where the window can only be raised not more than 4 inches. During an interview on 11/28/2022 at 4:25 p.m. with another LPN working on the [NAME] unit, he revealed that he did not have Resident #1 on his assignment but was made aware of the Elopement that morning on 11/11/2022 and assisted in the search. The LPN further stated, I personally do not check the function of the wander guard; I just check for placement. The alarm usually goes off if the residents with wander guard are close to the exit doors. That is how we know the wander guards works. During an interview on 11/28/2022 at 4:47 p.m., the LPN assigned to Resident #1 on 11/10/2022 during the 11:00 p.m. to 7:00 a.m. shift stated it was a regular night; I came in and did my rounds at 11:00 p.m. I saw the Resident's (Resident #1) legs in bed. He/she did not have scheduled medication at 6:00 a.m., so I did not go into the room that morning. The LPN stated, That night like I told my supervisor, I did not do rounds every two hours. The LPN continued, I honestly did not know. After the Elopement, I found out that [Resident #1] wore a wander guard. The alarm did not sound that night. The LPN revealed that she received a call on 11/11/2022 around 10:45 a.m. from her Supervisor alerting her about Resident #1's Elopement and stated the Supervisor told her that the Resident had eloped through his/her bedroom window and was seen on camera footage at the rear of the building around 6:30 a.m. that morning. The LPN acknowledged she did not follow protocol for rounding every 2 hours or the Physician's order to check the placement and function of Resident #1's wander guard. During a telephone interview on 11/28/2022 at 5:12 p.m., the Maintenance Technician (MT#1) informed the Surveyor that there was a work order to remove all the AC Units on the [NAME] Unit where Resident #1 resided. He revealed that he assisted another MT (MT#2) in the removal process. He further stated that MT #2 was the one who installed the screws in the window so that the window would not go up more than 4 inches. MT #1 stated that after installing the screws, they both looked at the window, and MT #2 went on to another job. During the same interview, MT #1 revealed that he was called and made aware of the Elopement and stated he got a write-up from his supervisor for not properly installing the screws in the window. During an interview on 11/29/2022 at 11:20 a.m., the Licensed Practical Nurse (LPN) assigned to Resident #1 during the 7:00 a.m. to 3:00 p.m. shift stated she did her initial rounds at approximately 6:50 a.m. She continued during her rounds that morning; she entered Resident #1's room and saw the privacy curtain pulled halfway in the middle with the blankets folded at the end of the bed and assumed that Resident #1 was in bed. The LPN further stated she did not physically see Resident #1 in his/her bed on the morning of 11/11/2022 during her shift. The LPN proceeded with her normal routine and medication pass. At approximately 9:00 a.m., the CNA stated that she could not find Resident #1, and the Unit Manager (UM) was notified from the management meeting. I told the UM I think he/she (Resident #1) is missing. The LPN stated a Code Yellow might have been called. I am not sure. Everyone in the building started to look for Resident #1. During the interview, the LPN revealed that the AC Unit was removed from Resident #1' bedroom window on 11/10/2022 and that the Resident watched as the AC Unit was removed. The window was pulled down with the screen down and easily went up that morning. The LPN said the ground is low on that side, so you would not fall. When asked by the Surveyor who checks the window, the LPN said, I guess or assume maintenance checks the window. During an interview on 11/29/2022 at 12:04 p.m., the Maintenance Technician (MT #2) informed the Surveyor that there was a work order to remove the AC Unit in room [ROOM NUMBER] (Resident #1's room). He revealed another MT (MT #1 was a new guy) was to secure the window with the screws so that the window only opens not more than 4-8 inches. He further stated that he assisted in the removal of the AC unit to the cart that went out of room [ROOM NUMBER] and proceeded to another room to continue the removal of the other AC units while MT #1 stayed to finish the assignment. He stated, MT#1 stuck screws in the window frame grove so the window could not open. When asked by the Surveyor if he physically saw MT #1 install the screws, he stated, I saw him with screwdriver and screws, but I did not see him install them. In the interview, he stated, I didn't examine the window; I am pretty sure he (MT #1) installed the screws. I did not see him put them in. He had an electric screwdriver and screws. MT #2 confirmed that the windows are to be properly secure, not more than 4-8 inches, immediately following the removal of the AC unit. During an interview on 11/29/2022 at 3:33 p.m., the DON revealed that Elopement is a patient who leaves the facility without acknowledging or notifying us (Center) where they are going. During the interview, the Administrator said, I agree with her. The DON also stated, we follow the standard of care protocol of two hours for rounding for residents, depending on the type of Resident and acuity. She continued for Elopement, and there was no increased rounding. We identify Elopement and use a wander guard system/wander guard bracelet. The DON stated wander guard placement is checked every shift (every 8 hours) and functions daily by the nurses and is documented as done on the treatment administration record. The Administrator also stated during the interview, No, we did not know. Resident #1 was leaving the facility. He/she did not voice this to anyone. We can only speculate that he/she removed the wander guard and went through the door. The day prior to the incident, the AC Unit was removed from the bedroom window, which could have been another form. The Administrator also stated, I believe the assessment, even though a BIMS of 5 was not a true reflection of cognitive ability, Resident #1 could make his/her own decision and move freely in the community. We determined his/her actions after Resident #1 left. We confirmed with their spouse, and the spouse was not concerned. Resident #1 was familiar with his/her surroundings and buildings. During the same interview, the DON and Administrator were made aware that the nurses interviewed stated that the wander guard for Resident #1 was not checked for placement and or function. The DON stated her expectation is that the nurses follow the Physician's order by checking the placement of wander guard every shift (every 8 hours), check the wander guard's function daily, and document it on the treatment administration record. During the survey, a signed statement was presented to the Surveyor by the facility from the CNA (CNA #3) assigned to Resident #1 on 11/10/2022, on the 11:00 p.m. to 7:00 a.m. shift. According to the document, the following statement was made by CNA #3: At 12:30 a.m., call light on, awake and talking, kicking me out of his/her room. When seen last? Time 11:10 p.m., 6:45 a.m. to 6:50 a.m., checked him/her 5-6 times during the night shift. However, the Surveyor conducted an off cite telephone interview with CNA #3 on 12/2/2022 at 10:23 a.m. The CNA stated, I don't recall the Resident (Resident #1). No one called me from the facility regarding the Elopement. I do not recall the incident that occurred on 11/11/2022. When asked about the written statement, the CNA responded, No, I did not give a statement regarding this incident. Review of the facility's policy updated March 2022 titled Wander Management and Elopement Prevention Under Policy: The facility will maintain the safety of residents who wanders and/or are at risk for Elopement. Under Interpretation: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including Elopement). 5a. Wander management system devices will be checked for placement each shift by nursing staff. 5b. Wander management system devices will be checked for functionality daily by nursing staff. 7. Doors with wander management system alarms will be checked for functionality daily by maintenance staff/designee. 9. Elopement drills will be conducted on a quarterly basis and will cover each shift. Review of the facility's policy dated March 2022 titled Wandering and Elopement Under Interpretation: 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the Resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary, and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. Review of the facility's Maintenance Worker job description under Purpose revealed: The primary purpose of your job is to maintain the grounds, Center equipment in a safe and efficient manner in accordance with current applicable federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by your supervisor, to assure that successful maintenance program is maintained at all times.

C#: NJ159688 Based on observation, interviews, medical record review, and review of other pertinent facility documentation during the on-site investigation on 11/28/2022 and 11/29/2022, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to follow the facility's Administrator job description and failed to ensure that the policies and procedures under the Accidents and Incidents-Investigation and reporting were implemented when Resident #1 eloped from the facility on 11/11/2022. The Administrator failed to report this incident along with an investigation to the New Jersey Department of Health. The Administrator also failed to ensure that a safe environment was maintained when the Maintenance staff removed the Air Conditioning (AC) unit on 11/10/2022 and failed to install security screws after removing it so that the windows could not open more than 6 inches. These deficient practices placed Resident #1 and other residents identified with cognitive impairment and wandering behaviors who could possibly exit from windows without the safety stops and adequate supervision of staff at risk for an Immediate Jeopardy situation. On 11/29/2022, Day 2 of the survey, two Immediate Jeopardy (IJ) Federal citations were identified and reported to the facility's Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), the Director of Nursing (DON), Assistant Director of Nursing (ADON), and The Regional Director of Field Operations on 11/29/2022 at 5:40 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ ran from 11/10/2022, when the AC unit was removed from the window, through 11/14/2022, after the completion of in-services and education of facility staff on residents at risk for Elopement, Prevention of Elopement, and the securing Residents' windows. On 12/5/2022, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan. All facility staff were re-educated on Resident rounding. All maintenance assistants were educated on the process/policy for securing the residents' room windows and an audit to determine all residents at risk for Elopement. So, the noncompliance remained on 11/14/2022 as a level D for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the following: The Resident is no longer at the facility, staff has been educated on Resident rounding, the process/policy on securing residents room windows, an audit to determine residents at risk for elopement and care plan was updated to meet the Resident's individual needs, educating and re-educating all nursing and non-nursing staff on residents at risk for Elopement, prevention of Elopement and care and management of residents that have eloped, training to check wander guards placement and function with sign off for accountability and notification to NJDOH, the Ombudsman, and the NJ State Board of Nursing. This deficient practice was identified for 1 of 3 residents (Resident #1) and evidenced by the following: According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. According to the Minimum Data Set (MDS), an assessment tool dated 10/25/2022, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 5/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #1 needed extensive assistance with one-person physical assistance with bed mobility and transfers and limited assistance with most Activities of Daily Living (ADLs). A review of Resident #1's MQS: Elopement/Wandering Risk Evaluation (EWRE) form dated 10/25/2022 revealed a score: NA (not applicable). Under A. Potential Risk Factors/Resident Status indicated .14. Has the family/responsible party/resident representative voiced concerns that would indicate the Resident may have wandering tendencies or try to leave? b. Yes, 15. Is Resident at risk for wander/elopement? a. Yes, 16. Are parties aware of [the] Risk for Wander/Elopement? a.Yes. 17. Initiate Elopement/Wander Care Plan Focus: I am at actual/potential risk for Elopement r/t Goal: I will not leave the facility without notifying staff before [the] next review date. Intervention: Engage me in group activities to decrease wandering, Photograph in Elopement Book, Provide appropriate diversions for residents, and encourage Residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the Resident's health and/or safety, Psych consult and treat as indicated, Redirect during wandering episodes, Wander Bracelet placed. The DON continued to say [the] CP focus comes up with admission evaluation and add interventions to CP to personalize it. A review of the Resident's Care Plan (CP) initiated on 10/25/2022 revealed under Focus: I am at actual/potential risk for elopement r/t (related/to) cognitive impairment, non-acceptance of long-term placement. The CP also included under Goal: I will accept and adjust to Long Term Care placement. Also, under Interventions: included, Engage me in group activities to decrease wandering, evaluate resident's desire to leave the facility, monitor behaviors, Photograph in Elopement book, Psych (Psychiatrist) consult (consultation) and treat as indicated, Wander Bracelet placed to left ankle Exp (Expiration) 02/05/24. A review of Resident #1's Order Summary Report (OSR) Order Date Range from 10/01/2022 through 11/30/2022 revealed the following Physician Orders (POs): Wander Bracelet: Check[the] Function of [the]Wander Bracelet every day, one time a day order dated 10/25/2022 Wander Bracelet: Check [the] Placement of [the] Wander Bracelet on every shift. Left ankle every shift for elopement risk order dated 10/25/2022 A review of Resident #1's Treatment Administration Record (TAR) dated 10/01/2022 through 11/30/2022 revealed the above POs to check the function, and the placement of the wander guard was documented as being completed on 11/10/2022 on the night shift by the RN. A review of Resident #1's Progress Notes (PNs) written by the Registered Nurse (RN) dated 11/11/2022 at 5:58 p.m. revealed the following: Resident #1] left AMA (Against Medical Advice). Paperwork signed by spouse/POA (Power of Attorney) . The Surveyor reviewed the Assignment Sheet (AS) dated 11/10/2022 on the 11:00 p.m. -7:00 a.m. shift, which revealed there were two nurses: (2) Licensed Practice Nurses (LPNs) and (4) Certified Nursing Assistants (CNAs) on the [NAME] (Dementia/Locked) unit. At the time of the survey, there was no camera footage of the incident. During an interview on 11/29/2022 at 11:20 a.m., the Licensed Practical Nurse (LPN) assigned to Resident #1 during the 7:00 a.m. to 3:00 p.m. shift stated she did her initial rounds at approximately 6:50 a.m. She continued during her rounds that morning; she entered Resident #1's room and saw the privacy curtain pulled halfway in the middle with the blankets folded at the end of the bed and assumed that Resident #1 was in bed. The LPN further stated she did not physically see Resident #1 in his/her bed on the morning of 11/11/2022 during her shift. The LPN proceeded with her normal routine and medication pass. At approximately 9:00 a.m., the CNA stated that she could not find Resident #1, and the Unit Manager (UM) was notified from the management meeting. I told the UM I think he/she (Resident #1) is missing. The LPN stated a Code Yellow might have been called. I am not sure. Everyone in the building started to look for Resident #1. During the interview, the LPN revealed that the AC Unit was removed from Resident #1' bedroom window on 11/10/2022 and that the Resident watched as the AC Unit was removed. The window was pulled down with the screen down and easily went up that morning. The LPN said the ground is low on that side, so you would not fall. When asked by the Surveyor who checks the window, the LPN said, I guess or assume maintenance checks the window. During an interview on 11/28/2022 at 3:25 p.m., the Assistant Director of Nursing (ADON), who was the interim DON at the time of the incident, stated on the morning of the incident, while in the morning meeting, the Administration was notified by the Unit Manager (UM) of the missing Resident (Resident #1). The ADON stated Code yellow was activated, and the entire Administration was involved in the search for Resident #1. She further stated the entire building (rooms, bathrooms, and common areas) was searched as other staff went outside the building, driving around the building and surrounding areas in search of Resident #1. The ADON also stated when the search was initiated. The local Police Department was notified of the missing Resident (Resident #1). During the same interview, the ADON also stated once she realized Resident #1 was not found in the area, the spouse (POA) was notified. The ADON stated during the call with Resident #1's spouse, he/she didn't verbalize concern for the missing Resident (Resident #1). She continued the spouse that if Resident #1 returned to their house, to call and inform the facility. According to the ADON, Resident #1 was later recovered by the Palmyra Police while attempting to enter the bar, stating Resident #1 was fine and did not want to return to the facility. The ADON further stated Resident #1's spouse was informed, and he/she was fine with Resident #1's decision not to return to the facility. The ADON continues to reveal that the spouse (POA) signed Resident #1 out of the facility AMA (Against Medical Advice). The ADON stated, no one knows how Resident #1 got out of the building, but his/her window was not locked. The screen was on the window and intact. I believed the AC Unit was removed the day prior to the incident. When asked by the Surveyor if the window should have been secured properly, the ADON replied, Yes, Resident #1's window should have been locked with screws where the window can only be raised not more than 4 inches. During an interview on 12/29/2022 at 3:33 p.m., the Licensed Nursing Home Administrator (LNHA) stated the Elopement was not reported to the NJ Department of Health or the Ombudsman. He further stated, If we had determined it to be an elopement, it would have been reported, it was AMA, and we do not report AMA to the NJ Department of Health. During the same interview, the Director of Nursing (DON) stated, No, it was not reported to the Ombudsman or the NJ Department of Health. She further stated all planned and unplanned discharges are usually sent to the Ombudsman at the end of each month. Review of the facility's undated policy titled Accidents and Incidents-Investigation and reporting Under Policy: All incidents and accidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Under Interpretation: 3. This facility is in compliance with current rules and regulations governing accidents and /or incidents involving a medical device. 6. The director of nursing services shall ensure that the Administrator receives a copy of the report of incident/Accident form for each occurrence. Review of the facility's job description titled Administrator Under Purpose: The primary purpose of your job position is to direct the day-to-day functions of the Center in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing Centers to assure that the highest degree of quality care can be provided to our residents at all times. N.J.A.C.: 8:39-13.1(a) REF: F689