Every finding on record at Christian Health Care Center

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a manner intended to prevent the spread of food borne illness and in accordance with professional standards for food service safety. This deficient practice was evidenced by the following:On 2/17/26 at 9:54 AM, during the initial tour of the kitchen, in the presence of the Senior Director of Dining Nutrition Services (SDoDNS) and the Manager of DNS (MoDNS), the surveyor observed the following in refrigerator 3: a container of cottage cheese that was labeled with an open date of 2/9/26 and a use by date of 2/12/26. The MoDNS stated that the facility policy was to discard opened items seven days after they were opened. He added that someone probably put the wrong use by date on the label and that today was the last date. The surveyor asked the MoDNS if the open date was 2/9/26 then would the discard date seven days later be 2/16/26. The MoDNS confirmed and threw the item in the garbage. On 2/17/26 at 9:59 AM, in the presence of the SDoDNS and MoDNS, the surveyor observed the following in freezer 2: 1. 8 cups with lids that were labeled sb which had a sticker with exp (expiration) 2/2/26. 2. 5 cups with lids that were labeled clams that had a sticker with use by 2/16/26. 3. 1 cup with lid that was labeled clam sauce that had a sticker with use by 1/18/26. On 2/17/26 at 10:00 AM, in the presence of the SDoDNS and MoDNS, the surveyor observed the Chef who brought a tray of prepared food from the preparation area to the refrigerator area that had facial hair longer than a quarter inch. The Chef was not wearing a beard guard. The surveyor asked the SDoDNS if the Chef should be wearing a beard guard. The SDoDNS stated that the Chef should of had a beard guard on. On 2/24/26 at 12:45 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the concern that the chef was not wearing a beard guard and four different items located in the refrigerator and freezer were past their use by date.On 2/25/26 at 11:21 AM, in the presence of the DON, the LNHA stated that they updated the policy on attire for the DNS staff and in-serviced the staff on wearing beard guards. The LNHA stated that the items were immediately discarded after surveyor inquiry and that they updated the policy to have both the prepared date and use by date. She added that the staff were in-serviced. A review of the facility's Dining and Nutrition Services Dress Code Policy with an effective date of 1/26, did not include any information on beard guards. A review of the facility's Food Storage Standards in DNS Policy with an effective date of 1/25, included the following:[name redacted] stored in refrigerators and freezers are to be covered, labeled and dated.NJAC 8:39-17.2(g)

Based on observation, interview, review of the medical records and other facility documentation, it was determined that the facility failed to, a.) provide adequate monitoring for the use of psychoactive medications (meds) for 1 of 6 residents reviewed for psychotropic meds (Resident #371) and b.) ensure that the resident did not receive an unnecessary medication (med) by duplicate and incomplete med orders, for 1 out 3 residents, (Resident #374), observed during the med pass observation.The deficient practice was evidenced by: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.On 2/17/26 at 10:51 AM, Surveyor #1 (S #1) observed Resident #371's door with posted sign for EBP (Enhanced Barrier Precautions). Inside the room, the Resident Representative (RR) was seated in a regular chair and Resident #371 was on bed, awake and non-verbal. The RR informed S #1 that the resident fell from home, hospitalized , and sustained a brain bleed. S #1 reviewed the medical records for Resident #371. A review of the Resident Face Sheet (RFS, an admission summary) reflected that Resident #371 was admitted to the facility with the diagnoses which included but not limited to; traumatic subdural hemorrhage (a type of traumatic brain injury that causes dangerous pressure on the brain) with loss of consciousness status unknown, subsequent encounter, history of falling, unspecified protein-calorie malnutrition, malignant neoplasm (cancerous) of unspecified part of bronchus or lung, and secondary malignant neoplasm of cerebral meninges (three layers of protective membranes that surround and protect the brain and spinal cord). A review of the Minimum Data Set (MDS), an assessment tool, revealed that it was in progress and to be completed. A review of the Physician's Orders (PO), dated 2/14/26, order for olanzapine (also known by the brand name Zyprexa, is an atypical antipsychotic med. It treats schizophrenia, bipolar I disorder, and treatment-resistant depression) 5 mg (milligram) tablet (tab), give 1 tab (5 mg) by g-tube (gastrostomy tube; a medical procedure that creates an opening through the abdominal wall directly into the stomach to insert a feeding tube) route once daily at bedtime for anorexia nervosa. The order was discontinued on 2/16/26. A review of the PO dated 2/16/26, order for olanzapine 5 mg tab, give 1 tab (5 mg) by g-tube route once daily at bedtime for depression. Schedule: every day at 9:00 PM (9 PM). A review of the PO dated 2/15/26, monitor target behavior (TB) as per care plan (CP) for psychotropic meds. The above order to monitor TB was transcribed to the Resident Medication Administration Record (RMAR), plotted for 7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM, and signed by nurses as monitored. There was no documented TB in the RMAR. The RMAR was initialed by nurses. A review of Resident #371's Care Plan Activity Report (CPAR) revealed a focus on Psychopharm with an effective date of 10/31/25, etiology: resident receives mirtazapine for depression and at risk for side effects (s/e). Additional detail: TBs: poor appetite, sadness, and fatigue. Further review of Resident #371's CPAR revealed there was no documented evidence that a TB for med olanzapine to adequately monitor the use of this psychoactive med (are substances that affect the brain). On 2/24/26 at 12:31 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the surveyor notified them of the above findings and concerns with regard to no adequate monitoring for the use of psychoactive med olanzapine and there was no CP for the TB of the med according to the PO. A review of the facility's Policy: Psychotropic Drug Use that was provided by the DON, with an effective date of 11/25, revealed under purpose, to ensure that all resident's receiving antipsychotic, anti-anxiety agents.antidepressants.for the treatment of specific behavioral disturbances will be monitored for effectiveness of therapy and occurrence of potential s/e and will be documented appropriately. On 2/25/26 at 11:21 AM, the survey team met with the LNHA and the DON stated that she acknowledged the lack of documentation for olanzapine and there was no CP for olanzapine. She further stated that whoever completed the baseline CP, it was missing the TB to adequately monitor the behavior for the use of olanzapine. 2. On 2/19/26 at 9:41 AM, Surveyor #2 (S #2) observed the Licensed Practical Nurse assigned to administer medications (meds) to Resident #374, prepare and administer due meds to Resident #374. During the observation, S #2 observed an order on the resident's RMAR that the LPN was preparing to administer. The order reflected: polyethylene glycol 3350 17 gram/dose oral powder Dispensed: polyethylene glycol 3350 17 gram/dose oral powder, 1 CAPFUL (17 G) once daily as needed (PRN) Protocol: Mix with 4-8 oz (ounces) of water, juice, soda, coffee, or tea. Start Date: 2/16/26 at 5:16 PM. S #2 asked the LPN why they were giving the med and what it was for, and the LPN stated that it was for constipation and the resident needs it. S #2 asked the LPN if med order that were PRN should have a reason to be given. The LPN stated yes, they should and that the order in question should be a routine regularly scheduled order for the resident since they need it. S #2 observed the LPN administered the resident's due meds and concluded the observation. S #2 reviewed the electronic medical record (EMR) for resident #374. The EMR revealed: A review of the RFS reflected the resident was admitted to the facility with diagnoses which included but were not limited to chronic kidney disease (the long-term, gradual loss of kidney function) and anemia (shortage of healthy red blood cells to transport oxygen). A review of Resident #374's comprehensive MDS with an assessment reference date (ARD) of 2/16/26, reflected, in Section C, that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #65 was cognitively intact. A review of the resident's RMAR revealed the following: An order scheduled for the 9:00 AM med pass that was discontinued after the observation of administration to the resident and not documented as given.polyethylene glycol 3350 17 gram/dose oral powder Dispensed: polyethylene glycol 3350 17 gram/dose oral powder, 1 CAPFUL (17 G) once daily PRN Protocol: Mix with 4-8 oz. of water, juice, soda, coffee, or tea. Start Date: 2/16/26 at 5:16 PM. An order for the same timeframe with a start date of 2/19/26 9:59 AM (after the observation and surveyor inquiry) and documented as given.polyethylene glycol 3350 17 gram/dose oral powder, give 17 grams by oral route once daily as PRN For: Constipation Protocol: Mix with 4-8 oz. of water, juice, soda, coffee, or tea. Start Date: 2/19/26 at 9:59 AM. An order that reflected to be used PRN: polyethylene glycol 3350 17 gram oral powder packet, give 1 packet by oral route once daily PRN for constipation Protocol: Mix with 4-8 oz. of water, juice, soda, coffee, or tea. Start Date: 2/12/26 at 8:06 PM. A review of the resident's order summary, order details revealed that the order in question was discontinued by the LPN after the observation and S #2's inquiry and the new order was added. As reflected by: First Entered By: (name redacted) on 2/19/26 at 9:59 AM; First Completed By: (name redacted) on 2/19/26 at 9:59 AM; Med Discontinued polyethylene glycol 3350 17 gram/dose oral powder, give 1 CAPFUL (17 G) once daily PRN. On 2/24/26 at 12:31 PM, the survey team met with the LNHA and DON for concerns. S #2 notified the DON of the results of the med pass observation and the concern with Resident #374's med orders being incomplete and duplicate. S #2 notified the DON that the original PRN order had no indication for use and an additional PRN for the same med with an indication for use existed. S #2 notified the DON that the LPN changed the order after the observation and S #2's inquiry and documented that the new order was given. On 2/25/26 at 11:22 AM, the survey team met with the LNHA and the DON stated that the order for Resident #374 was changed as S #2's had previously stated. The LNHA did not provide any further pertinent information. A review of the facility's Policy: Medication Orders, date effective 11/25, the Policy reflected under 3.k. PRN orders should also specify the condition, for which they are being administered . The policy did not reflect anything relating to duplicate med orders. NJAC 8:39- 27.1(a); 29.2(d); 33.2(a)

Repeat Deficiency Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen, according to the standard of clinical practice and the facility's policy and procedure, specifically, ensuring the appropriate rate of oxygen delivery was set for 1 of 3 residents, Resident #172 and by documenting the date and time the oxygen tubing was changed for 1 of 3 residents, Resident #102.This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.On 2/17/26 at 10:25 AM, during the initial tour of the facility, the surveyor observed Resident #102 in bed, sleeping, with an oxygen (O2) nasal cannula (n/c) (tubing that supplies O2 to the body through small tubes in the nostrils), applied and connected to an O2 concentrator (a machine that takes room air and delivers concentrated O2 to a person through tubing). The surveyor observed that the concentrator was set to deliver 2 liters per minute (lpm) and the tubing was connected to a humidification bottle (a container of water that the O2 bubbles through to add moisture to the O2). The surveyor observed that the tubing and humidifier had the date of 2/6/26 written in marker.The surveyor reviewed the electronic medical record (eMR) for Resident #102.A review of the Resident Face Sheet (RFS; an admission record) that reflected that the resident was admitted to the facility with diagnoses which included but not limited to hypoxemia (a condition characterized by abnormally low levels of O2 in the blood) and chronic kidney disease (a condition where the kidneys do not function fully).A review of the resident's Quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 12/18/25, Section C, revealed a Brief Interview of Mental Status (BIMS) score of 5 of 15, indicating that the resident had severe cognitive impairment.A review of the resident's Physician Order Sheets (POS) (a list of the resident's active medication and other orders) revealed the following orders: 1) an order that reflected Monitoring: Check for use of O2 concentrator weekly - clean filter, change tubing and humidifier. Schedule: Every week on Thursday. 2) Respiratory Therapy: O2 n/c 2 lpm.A review of the Resident Medication Administration Record (RMAR) revealed an order for the 11:00 PM-7:00 AM shift that reflected: Check for use of O2 concentrator weekly - clean filter, change tubing and humidifier. The RMAR also reflected that the order was documented as completed on 2/5/26 and 2/12/26.A review of the resident's Comprehensive Care Plan (CCP) revealed an intervention that reflected: Check for use of O2 concentrator weekly - clean filter, change tubing and humidifier. 2. On 2/17/26 at 10:27 AM, the surveyor observed Resident #172, in their room, seated in a wheelchair (w/c) with an O2 n/c applied, connected to a concentrator. The surveyor asked the resident how they use their O2. The resident stated that they use it all the time and need it day and night. The surveyor observed the concentrator setting reflected 2.5 lpm.The surveyor reviewed the eMR for Resident #172.A review of the RFS reflected that the resident was admitted to the facility with diagnoses which included but not limited to chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes obstructed airflow) and chronic respiratory failure (a long-term condition where the lungs cannot properly exchange O2 and carbon dioxide, resulting in chronically low O2).A review of the resident's cMDS, with an ARD of 1/6/26, Section C, revealed a BIMS score of 15 of 15, indicating that the resident had no cognitive impairment. Section O revealed that the resident was receiving O2 therapy.A review of the resident's POS revealed the following orders: 1) an order that reflected: Respiratory Therapy O2: n/c, Continuous 2 lpm.A review of the RMAR revealed an order for O2: n/c, Continuous 2 lpm.A review of the resident's CCP revealed an intervention that reflected: O2: n/c, continuous 2 lpm.On 2/20/26 at 10:23 AM, the surveyor interviewed the facility nurse educator (NE) about the policy for O2 tubing dating and concentrator settings. The NE stated that both the respiratory therapist and nurses are responsible for changing tubing and appropriate settings.On 2/24/26 at 12:31 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), and the surveyor notified them of the observations for Resident #102 and #172. The surveyor asked the DON who was responsible for changing tubing and O2 settings. The DON stated that both the respiratory therapist and nurses were responsible for changing tubing and appropriate settings. On 2/25/26 at 11:22 AM, the survey team met with the LNHA and the DON stated that education was conducted for staff relating to O2 tubing and humidifier dating and correct settings.The LNHA did not provide any further pertinent information.A review of the facility's Policy: Respiratory Therapy, date effective 2/26, the policy reflected, under Subject: Oxygen Therapy, Procedure: 14: Change all disposable equipment weekly or per Institution's infection control guidelines . NJAC 8:39-11.2(b); 27.1(a)

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a.) the blood pressure medications were administered for Resident #11, in accordance with the physician's orders (PO) and b.) the insulin was administered and documented in accordance with the PO for Residents #4 and #369. The deficient practices were identified on 3 of the 38 residents medications reviewed.This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 2/24/26 at 12:53, Surveyor #1 (S #1) reviewed the closed medical records of Resident #11 and revealed: A review of the Resident Face Sheet (RFS; an admission summary) revealed that Resident #11 was admitted to the facility with diagnoses that included but were not limited to; unspecified severe protein-calorie malnutrition, dysphagia unspecified (swallowing problem), encounter to gastrostomy (a medical procedure that creates an opening through the abdominal wall directly into the stomach to insert a feeding tube) and heart failure unspecified. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 1/19/26, with a brief interview for mental status (BIMS) score of 12 out 15, indicated that resident's cognitive status was moderately impaired. A review of the PO dated 1/16/26, reflected an order for midodrine 5 mg (milligram) tablet (tab), give 1 tab (5 mg) by peg tube (Percutaneous Endoscopic Gastrostomy (PEG) tube is a flexible feeding tube surgically inserted through the abdominal wall directly into the stomach to provide long-term nutrition, hydration, and medication) route every 8 hours as needed (PRN) for orthostatic hypotension (give for SBP (systolic blood pressure) below 100). Schedule: every 8 hours PRN. Protocol: hold if SBP greater than 130; do not administer midodrine 4 hours prior to bedtime. Monitor: blood pressure (BP). A review of the PO dated 1/18/26, reflected an order for C-metoprolol suspension 12.5 mg/5 ml (milligram/milliliters), give 10 ml by g-tube (gastrostomy tube; also known as peg tube) route once daily with food (10 ml=25 mg) for heart failure. Schedule: every day at 8:00 AM (8 AM). Protocol: hold for SBP less than 100 and/or HR (heart rate) less than 60. Monitor: BP and pulse. The above order for midodrine was transcribed to the Resident Medication Administration Record (RMAR), plotted as PRN, and signed by nurses as administered on 1/18/26, 1/26/26, and 1/29/26 with following BP: 1/18/26 at 4:44 PM, BP 78/42 1/26/26 at 10:00 AM, BP 99/54 1/29/26 at 7:05 PM, BP 99/45 Further review of the PRN PO for midodrine revealed that the medication (med) was administered on 1/29/26 at 7:05 PM, which was four hours prior to bedtime, and the PO was not followed. The above order for C-metoprolol was transcribed to the RMAR, plotted at 8 AM, and signed by nurses as administered, and there were no documented evidence that the BP was obtained when the med was administered from 1/19/26 to 1/27/26 according to PO. On 2/25/26 at 8:59 AM, S #1 interviewed the Director of Nursing (DON) and asked what the facility's process and expectation for the nurses with regard to PO in the RMAR and medications (meds) with parameters were. The DON responded, to follow the orders and clarify if needed. The DON further stated that the parameters for BP should be monitored and documented in the RMAR. On that same date and time, S #1 notified the above findings and concerns with PO with regard to meds midodrine and C-metoprolol and the order with regard to parameters were not followed. The DON also reviewed and printed the BP of the resident for January 2026 from the Monitoring tab of the electronic medical records, and she acknowledged that the BP did not include information that the BP was checked at 8 AM, or at least an hour before and an hour after as required in the PO for C-metoprolol. The DON also provided a copy of the midodrine administration audit report that showed that the resident received the midodrine med on 1/29/26 at 7:05 PM. The DON further stated that the bedtime hour was at 9:00 PM, and the 7:05 PM time when the midodrine was administered did not follow the PO. A review of the facility's Policy: Medication Administration that was provided by the DON, with an effective date of 1/26, revealed under policy, meds are administered by licensed nurses as ordered by physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per PO. When applicable, hold med for those vital signs outside the physician's prescribed parameters. On 2/25/26 at 11:21 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON for responses for the above concerns. The LNHA and DON did not provide additional information. 2. On 2/17/26 at 11:00 AM, Surveyor #2 (S #2) observed Resident #4 lying in bed. On 2/18/26 at 10:25 PM, S #2 reviewed the electronic medical record of Resident #4. A review of Resident #4's RFS reflected that the resident was admitted to the facility with diagnoses which included but were not limited to pulmonary fibrosis and type 2 diabetes mellitus (chronic metabolic condition where the body develops insulin resistance and cannot use insulin efficiently, leading to high blood sugar levels). A review of Resident #4's most recent comprehensive MDS reflected that the resident had a BIMS score of 15 out of 15, which indicated that Resident #4's cognition was intact. A review of Resident #4's February 2026 RMAR included the following order: insulin lispro (U-100) 100 unit/mL subcutaneous (SQ) pen Dispensed: insulin lispro (U-100) 100 unit/mL SQ pen, inject by SQ route per prescriber's instructions. Insulin dosing requires individualization. Protocol: Sliding Scale 201 - 250 = 4 Units 251 - 300 = 6 Units 301 - 350 = 8 Units 351 - 400 = 10 Units If < 70 or > 400 Call MD (Medical Doctor) Monitoring: Blood Sugar (BS) with a start date of 1/2/26 Further review reflected that the nurse did not indicate how many units of insulin were given at the 4:30 PM time on 2/1/26, 2/4/26, 2/5/26, 2/6/26, 2/10/26, 2/11/26, 2/12/26, 2/13/26 and 2/14/26 and at the 9:00 PM time on 2/2/26, 2/4/26, 2/5/26 and 2/9/26. On 2/19/26 at 10:10 AM, S #2 interviewed the Licensed Practical Nurse (LPN) who stated that the BS result, how many units of insulin, site where administered and the nurses initials were documented in the RMAR. S #2 asked the LPN to view Resident #4's RMAR. The LPN stated that the nurse should have written the dose given. On 2/19/26 at 10:17 AM, S #2 interviewed the Assistant Director of Nursing (ADON) who stated that she would expect the units given would be documented since the dose depended on the BS result. 3. On 2/18/26 at 12:51 PM, S #2 reviewed the hybrid (electronic and paper) medical records of Resident #369. A review of Resident #369's RFS reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; metabolic encephalopathy (a broad term for acute or subacute brain dysfunction caused by chemical imbalances, systemic illness, or organ failure), Type 1 diabetes mellitus (chronic autoimmune condition where the immune system destroys insulin-producing beta cells in the pancreas, resulting in little to no insulin production which leads to high blood sugar (hyperglycemia), requiring lifelong insulin therapy, blood sugar monitoring, and careful management to prevent complications)and congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues). A review of Resident #369's most recent Discharge Assessment Return Anticipated MDS (DRAMDS) reflected that the resident had a BIMS score of 14 out of 15, which indicated that Resident #369's cognition was intact. A review of Resident #369's January 2026 RMAR included the following order: insulin lispro (U-100) 100 unit/mL SQ solution Dispensed: insulin lispro (U-100) 100 unit/mL SQ solution, inject by SQ route before meals and at bedtime per sliding scale for dm Protocol: Sliding Scale 150-200=1 Unit 201 - 250 = 2 Units 251 - 300 = 3 Units 301 - 350 = 4 Units 351 - 400 = 5 Units for glucose greater than 400 give 6 units If < 70 or > 400 Call MD Monitoring: BS with a start date: 1/18/26 Further review reflected that the nurse did not indicate how many units of insulin were given at the 4:30 PM time on 1/18/26, 1/19/26, and 1/21/26 and at the 9:00 PM time on 1/18/26, 1/19/26, 1/20/26 and 1/21/26. On 2/20/26 at 12:22 PM, S #2 interviewed the DON who stated that for insulin sliding scale order the expectation was for the nurse to document the units given, the site, the BS result and the nurses initials. The surveyor asked the DON to view Resident #369's RMAR. The DON confirmed that the units given was not documented on some shifts and that she was going to look into it. On 2/24/26 at 12:45 PM, S #2 notified the LNHA and DON the concern that Resident #4 did not have the dosage of insulin units documented for multiple days and shifts on the February RMAR and Resident #369 did not have the dosage of insulin units documented for multiple days and shifts on the January RMAR. On 2/25/26 at 11:27 AM, in the presence of the LNHA, the DON stated that she educated the nurse that had missed documenting the dose and that she also in-serviced all staff. A review of the facility's Timely Administration of Insulin Policy with an effective date of 11/25, included the following, Policy: It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. Policy Explanation and Compliance Guidelines: 4. Procedure: f. Document on the medication administration record the time and location of the insulin injection. The policy did not contain any information on sliding scale dosage or documenting the amount of insulin given per sliding scale. NJAC 27.1(a)

REPEAT DEFICIENCYBased on interview and record review, it was determined that the facility failed to follow the physician's orders with regard to enteral tube feeding administration to assure the total volume was administered. This deficient practice was identified for 1 of 2 residents, (Residents #11), reviewed for enteral tube feeding.This deficient practice was evidenced by the following:On 2/24/26 at 12:53, the surveyor reviewed the closed medical records of Resident #11 and revealed:A review of the Resident Face Sheet (an admission summary) revealed that Resident #11 was admitted to the facility with diagnoses that included but were not limited to; unspecified severe protein-calorie malnutrition, dysphagia unspecified (swallowing problem), encounter to gastrostomy (a medical procedure that creates an opening through the abdominal wall directly into the stomach to insert a feeding tube) and heart failure unspecified.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 1/19/26, with a brief interview for mental status (BIMS) score of 12 out 15, indicated that resident's cognitive status was moderately impaired. In Section K (Swallowing/Nutritional Status), Resident #11 was coded as receiving nutrition through a feeding tube while a resident.A review of the physician's order (PO) dated 1/16/26, indicated the resident was NPO [nothing by mouth].A review of the PO dated 1/16/26, reflected an order for tube feeding (TF) method via pump Jevity 1.5 continuous at 55 ml/hr (milliliters/hour) for 18 hours or until 990 ml has been delivered. Stop time: 1 PM (1:00 PM).The above order for TF was transcribed to the Resident Medication Administration Record (RMAR), plotted at 1:00 PM, and signed by nurses as administered from 1/17/26 to 1/27/26. The following dates were signed by nurses with no total volume (TV) indicated or TV documented was not according to the PO of 990 ml:2/19/26, TV documented was 703 ml2/20/26, TV documented was 8 ml2/25/26, TV was blank2/26/26, TV documented was 112 ml2/27/26, TV was blankOn 2/25/26 at 8:59 AM, the surveyor interviewed the Director of Nursing (DON) and asked what the facility's process and expectation for the nurses with regard to PO in the RMAR was. The DON responded, to follow the orders and clarify if needed. The surveyor notified the DON of the above findings and concerns with PO with regard to TV of 990 ml was not followed.A review of the facility's Policy: Enteral Feeding and Accidental Tube Displacement that was provided by the DON, with an effective date of 11/25, reflected under enteral feedings, preparation, 1. Verify physician's order.III. Additional Nursing Care/Responsibilities/Documentation.2. Document amount of residual, type and amount of feedings as administered.On 2/25/26 at 11:21 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON for responses for the above concerns. The LNHA and DON did not provide additional information.NJAC 8:39-25.2(c)2; 27.1 (a)

Complaint #2708006Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to, a.) administer a medication (med) to a resident (Resident # 239) without a valid physician's order (PO) and b.) document the administration of med and reason as to why med was not administered according to PO (Resident #371), in accordance with professional standards and facility's policies and procedures. The deficient practices were identified on 2 of the 38 residents medications reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.On 2/19/26, Surveyor #1 (S #1) reviewed the electronic and paper medical record (MR) for Resident #239. A review of the MR revealed a Resident Face Sheet (RFS, an admission summary) that reflected that the resident was previously admitted with diagnoses that included but were not limited to hypertension (high blood pressure) and hyperlipidemia (excessive amounts of fats specifically cholesterol and triglyceride in the blood). A review of Resident #239's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 12/24/25, reflected, in Section C-Cognitive Status, that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated that Resident #239 had moderate cognitive impairment. On 2/24/26 at 11:39 AM, S #1 interviewed the Unit Manager (UM) for the unit where Resident #239 had resided and asked if they remembered the resident and if there were any concerns the resident voiced. The UM stated that they did recall the resident somewhat but wanted to check their notes and get back to S #1. On 2/24/26 at 11:49 AM, S #1 interviewed the Social Worker (SW) assigned to the unit where Resident #239 had resided and asked if they remembered the resident and if there were any concerns the resident voiced. The SW stated that they did remember the resident but wanted to check their notes for anything specific and get back to S #1. On 2/24/26 at 1:08 PM, S #1 asked the Director of Nursing (DON) about the information requested from the UM and SW. The DON stated that they would check. On 2/25/26 at 9:51 AM, the DON provided the requested information that S #1 requested for Resident #239. The provided documents revealed incident reports and timelines, progress notes (PN), individual statements, and records of remedial education. A review of the document titled Statement Form dated 12/22/25, reflected a statement from a nurse that they had given the resident a med intended for another resident. The statement reflected that the med was Omeprazole (a med used for excessive stomach acid, reflux or ulcers). A second Statement Form dated 12/21/25, reflected a statement from a different nurse that the resident had reported to them that another nurse had given them an antacid pill and they refused a thyroid pill that was offered because they were not on that med. A document titled Record of Additional/Remedial Education dated 12/22/25, reflected that the nurse who stated that they gave med to the wrong resident received additional education on safe med administration. The facility did not provide any further pertinent information. A review of the facility's Policy: Medication Administration, dated effective 1/26, the policy reflected under, 3. Identify resident/patient using 2 identifiers: photo in the MAR (Medication Administration Record) and or patient/resident identification wrist band, and/or ask and confirm the resident/patient's name if cognitive intact .10. Ensure that the six rights of med administration are followed. a. Right resident b. right drug . 2.On 2/17/26 at 10:51 AM, Surveyor #2 (S #2) observed Resident #371's door with posted sign for EBP (Enhanced Barrier Precautions). Inside the room, the Resident Representative (RR) was seated in a regular chair and Resident #371 was on bed, awake and non-verbal. The RR informed S #2 that the resident fell from home, hospitalized , and sustained a brain bleed. S #2 reviewed the MR for Resident #371. A review of the RFS, reflected that Resident #371 was admitted to the facility with the diagnoses which included but not limited to; traumatic subdural hemorrhage (a type of traumatic brain injury that causes dangerous pressure on the brain) with loss of consciousness status unknown, subsequent encounter, history of falling, unspecified protein-calorie malnutrition, malignant neoplasm (cancerous) of unspecified part of bronchus or lung, and secondary malignant neoplasm of cerebral meninges (three layers of protective membranes that surround and protect the brain and spinal cord). A review of the MDS) revealed that it was in progress and to be completed. A review of the PO, dated 2/14/26, order for ondansetron HCL 8 mg (milligram) tablet (tab), give 1 tab (8 mg) by g-tube (gastrostomy tube; a medical procedure that creates an opening through the abdominal wall directly into the stomach to insert a feeding tube) route every 8 hours as needed (PRN) for nausea/vomiting. The above order for ondansetron was transcribed to the Resident Medication Administration Record (RMAR) as PRN med. The RMAR was signed for PRN on 2/18/26. A review of the PN, dated 2/15/26 at 11:58 AM, electronically signed by Registered Nurse #1 (RN #1), under action, keeping in mind that patient (also known as resident) vomited 11-7 shift after previous bolus (as reported by Registered Nurse #2 (RN #2). Further review of the PN revealed the following documentations: -On 2/16/26 at 7:09 AM, electronically signed by RN #2, Resident had 1 x vomit episode at 6:20 AM. -On 2/16/26 at 11:50 PM, electronically signed by Licensed Practical Nurse (LPN), Patient c/o (complaint of) nausea: ondansetron HCL 8 mg tab PRN given with positive results. -On 2/19/26 at 2:54 PM, electronically signed by RN #3, under response: PRN Zofran (also known as ondansetron) given for nausea with relief. Further review of the MR revealed that there was no documented evidence that the PRN ondansetron was administered on 2/15/26, 2/16/26 at 7:09 AM or as to why the med was not administered when the resident had c/o nausea or vomiting. In addition, there was no documented evidence that the RMAR was signed by nurses when the PRN ondansetron was administered on 2/16/26 at 11:50 PM and 2/19/26 at 2:54 PM according to the PN. On 2/24/26 at 12:31 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and S #2 notified them of the above findings and concerns with regard to PRN ondansetron. A review of the facility's Policy: Medication Administration that was provided by the DON, with an effective date of 1/26, revealed under policy, medications (meds) are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice.Policy Explanation and Compliance Guidelines: 11. Review MAR to identify med to be administered.17. Sign MAR after administered. On 2/25/26 at 11:21 AM, the survey team met with the LNHA and DON in responses to the above concerns. The DON stated that the ondansetron administered should have been signed by the nurse in the RMAR and should have followed the PO. She also acknowledged that there should have been documentation as to why the PRN ondansetron was not administered and the non-pharmacological interventions were tried first prior to giving med. NJAC 8:39-11.2(b); 29.2 (b)(d)

Based on interview and record review, it was determined that the facility failed to accurately complete a portion of the Minimum Data Set (MDS), an assessment tool that facilitates the plan of care, to accurately reflect the resident's status for 2 of 38 residents reviewed (Residents #304 and #367).This deficient practice was evidenced by the following: 1.On 2/17/26 at 10:32 AM, Surveyor #1 (S #1) observed Resident #304 lying in bed asleep. Resident #304's private aid stated that sometimes the resident went outside with staff to smoke. On 2/18/26 at 11:02 AM, S #1 interviewed the Registered Nurse (RN) who stated that Resident #304 was allowed to smoke one cigar a day but that the resident did not go out every day. A review of Resident #304's Resident Face Sheet (RFS, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dementia (a general term for a group of brain disorders that cause a decline in cognitive function, including memory, thinking, reasoning, language, and judgment), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), and nicotine dependence. A review of Resident #304's individualized comprehensive care plan (CP) reflected a focus area for smoking. A review of Resident #304's most recent comprehensive Minimum Data Set (cMDS) reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that Resident #304's cognition was moderately impaired. Further review of the MDS indicated under Section J that the resident's current tobacco use was coded as no. The MDS was coded incorrectly. On 2/24/26 at 11:15 AM, S #1 interviewed the MDS Manager/Registered Nurse (MDSM/RN) regarding the process for MDS assessment for a resident that smoked. The MDSM/RN stated that on the comprehensive there was a question for tobacco use. S #1 asked if Resident #304 smoked. The MDSM/RN stated that Resident #304 smoked. S #1 asked the MDSM/RN to view Resident #304's last cMDS. The MDSM/RN stated that she was not the one that did Resident #304's cMDS and that she would have to talk to the person who did. On 2/24/26 at 11:58 AM, S #1 interviewed the Director of Nursing (DON) who stated that Resident #304 had smoked since she had been at the facility. S #1 asked the DON if Resident #304's MDS should indicate that the resident smoked, and the DON stated that she would expect it to be on the MDS. On 2/24/26 at 12:45 PM, S #1 notified the Licensed Nursing Home Administrator (LNHA) and DON the concern that Resident #304's MDS was not coded accurately for the resident's tobacco use. On 2/25/26 at 11:26 AM, in the presence of the LNHA, the DON stated that the MDS was modified and that education was provided to staff on MDS accuracy. The LNHA did not provide any additional information. The facility did not provide a policy regarding MDS accuracy. 2. On 2/25/26 at 10:30 AM, Surveyor #2 (S #2) reviewed the MDS Section A revealed under Section A0310G, Type of Discharge, was coded as 2 - Unplanned. Further review of the MDS Section A0310F reflected that the assessment was coded as 10 - Discharge assessment - return not anticipated, and Section A2105, Discharge Status, was coded as 01 - Home/Community. Section Q0400 indicated that active discharge (d/c) planning was already occurring for the resident to return to the community. A review of the Nursing Progress Note (PN) dated 12/8/25 at 4:04 PM, revealed that the resident was discharged to home at 3:00 PM. The PN further indicated that the Resident's Representative (RR) and resident were informed of all d/c instructions, physician follow-up appointments, and medication reconciliation was completed. The resident left the building alert and verbally responsive with all belongings. A review of the Medical Discharge Summary, electronically signed on 1/2/26, reflected a d/c date of 12/8/25, with a condition noted as stable, and follow-up with the primary care physician was scheduled within 35 days. A review of the CP dated 12/2/25 revealed d/c goals including: the resident would be discharged within 30 days, would attain and be discharged at optimal level of functioning, and would be discharged to the appropriate level of care. All goals were documented as discharged with an effective date of 12/2/25. A review of the therapy d/c summaries (Physical Therapy, Occupational Therapy, and Speech Therapy), all signed on 12/8/25 and 12/9/25, consistently documented the d/c reason as discharged to Home and reflected that the patient made progress throughout the plan of treatment and was discharged with family support. None of the therapy documentation indicated an unplanned or emergent d/c. On 2/25/26 at 10:55 AM, S #2 interviewed the MDS Coordinator/RN (MDSC/RN) regarding the inaccuracy identified in Resident #367's MDS. The MDSC/RN stated, It is planned because he is going home. When asked if she saw the section checked off as unplanned, she responded, Yes I see it, and further stated, It should have been planned. She further stated that it was not a d/c against medical advice. She also stated that if the resident went home or to another facility it was usually a planned d/c. She added that a Per Diem MDS Coordinator completed the MDS assessment and the cause of the inaccuracy was human error. A review of the facility's MDS 3.0 Assessment Process Policy, reviewed on 10/2025, by the DON, revealed under Policy that the current version of the RAI Manual will be utilized when conducting a comprehensive assessment. The MDS 3.0, according to federal regulations, requires the facility to conduct accurate and standardized assessments of each resident's functional capacity using the RAI, including for d/c planning . NJAC 8:39-33.2(d)

Based on interviews and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 2 of 38 residents, (Resident #132 and Resident #347), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following:According to the Resident Assessment (RAI) Manual, dated October 2025, RAI-required Assessment Summary:-The admission (Comprehensive) assessment, the MDS completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The CAA(s) (Care Area Assessment) Completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The Care Plan Completion date is no later than CAA(s) Completion date + 7 calendar days. The Transmission date is no later than Care Plan Completion date + 14 calendar days.-The Discharge MDS assessment return not anticipated, the MDS completion date is the discharge date + 14 calendar Days. The Transmission date is MDS Completion date + 14 calendar days.On 2/19/26 at 11:17 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) and MDS Manager/RN (MDSM/RN) regarding MDS. Both the MDSC/RN and the MDSM/RN informed the surveyor that the facility followed the RAI Manual when completing an MDS assessment. They further stated that an Entry MDS to be completed and submitted or transmitted within seven days, for Discharge MDS to be completed within 14 days and plus another 14 days for transmission, and for Quarterly and comprehensive MDS to be completed within 14 days and plus 14 more days for transmission.On that same date and time, the surveyor asked if they had issues of not completing and transmitting the MDS within RAI manual timelines or requirements, or did they have late completion and transmission of MDSs. The MDSM/RN responded that there were one or two that were late but for the most part they were able to complete and transmit MDSs in a timely manner. The surveyor then asked the MDSM/RN for transmission reports for Resident #132 and Resident #347, and she stated that she would get back to the surveyor.On 2/19/26 at 12:40 PM, the MDSM/RN met with the surveyor and provided copies of MDS transmission reports for Residents #132 and #347. The MDSM/RN stated while showing the documents that Resident #347's Discharge MDS with an assessment reference date (ARD) of 10/17/25, was completed and submitted but did not show in the transmission report that it was transmitted or accepted by CMS. The MDSM/RN stated that she thought it was a glitched with the electronic records that they were using.On that same date and time, she also stated that for Resident #132's MDS, the comprehensive MDS with an ARD of 4/17/25, was submitted but it did not show in the transmission report that it was transmitted or accepted by CMS, and it was probably a glitch also.On 2/19/26 at 12:53 PM, the surveyor reviewed the MDS provided by the MDSM/RN and MDS in the electronic medical records, and revealed:1.Resident #132's comprehensive MDS assessment with an ARD of 4/17/25, admission date of 4/10/25, Care Plan Completion date was 4/23/2025, completion date was on 4/23/25 and was submitted (or transmitted) on 2/19/26. The comprehensive MDS was transmitted late, after 300 days, which should have been transmitted no later than Care Plan Completion date + 14 calendar days.2.Resident #347's Discharge MDS assessment return not anticipated (DRNA) with an ARD of 10/17/25, was completed on 10/30/25 and was transmitted on 2/19/26. The discharge MDS was transmitted late, after 112 days, which should have been transmitted MDS Completion date + 14 calendar days.On 2/20/26 at 9:43 AM, the MDSM/RN confirmed that Resident #132's MDS was submitted on 2/19/26 for an ARD of 4/17/25, which was the admission MDS because it was not transmitted and they did not know it was not transmitted until surveyor's inquiry. The DRNA MDS of Resident #347 was submitted 2/19/26 for an ARD of 10/17/25, which was transmitted after surveyor's inquiry. On 2/24/26 at 12:31 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the surveyor notified them of the above findings and concerns with regard to late transmissions of MDSs of Residents #132 and #347.A review of the facility's MDS.0 Completion Policy that was provided by the DON, with an effective and original date of 10/25, revealed under Policy Explanation and Compliance Guidelines .2. Types of OBRA (Omnibus Budget Reconciliation Act of 1987, in MDS refers to federal nursing home regulations establishing mandatory, standardized assessment schedules for all residents in certified facilities, regardless of payer type) Assessments: a. Entry Tracking 1. Complete and submit with every entry into the facility no later than entry date + 7 calendar days .b. admission Assessment-completed within 14 days of admission counting the day of admission as day #1 when: .f. Discharge Assessment-completed using the discharge date as the ARD, must be completed within 14 days of the discharge date /ARD On 2/25/26 at 11:21 AM, the survey team met with the LNHA and DON for responses for the above concerns, the LNHA did not provide additional information.NJAC 8:39 - 11.1

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure that the completion of the Minimum Data Set (MDS), a Significant Change in Status Assessment (SCSA), was done in a timely manner. This deficient practice was identified for 1 of 35 residents reviewed for resident assessments (Resident # 85), and was evidenced by the following:On 2/17/26 at 11:42 AM, the surveyor observed Resident #85 sitting up on a bed and a Certified Nursing Assistant (CNA) assisting the resident with the lunch tray. On 2/18/26 at 10:56 AM, the surveyor observed the resident lying in bed. The surveyor asked Resident #85 if they were okay, the resident nodded their head, and then closed their eyes.On 2/18/26 at 11:03 AM, the surveyor interviewed the License Practical Nurse (LPN) who stated that she was on duty when the resident fell on 9/30/25 in the hallway. The LPN also stated the resident was trying to grab something from their cart, the resident was with a CNA, and the resident lost their balance and fell. The LPN further stated that an X-ray was done which revealed a fracture of the right hip, was sent out to the hospital, and had surgery. The LPN stated that the resident used to walk, received therapy when the resident was re-admitted but did not follow directions, was not able to stand up, had poor balance, and a mechanical lift was now being used for transfers (Hoyer). On 2/18/26 at 4:15 PM, the surveyor reviewed the medical record for resident #85. A review of the Resident face sheet (an admission summary) reflected that the resident had diagnoses which included but not limited to;displaced intertrochanteric fracture right femur, subsequent for closed fracture with routine healing, history of falling; Alzheimer's disease, Parkinson's, age related osteoporosis without current pathological fracture, muscle weakness, and unsteadiness on feet.A review of the Care Plan (CP) revealed for Activities of Daily Living (ADL) dated 12/20/24, transfers independent, walking 10 feet independent, lower body dressing supervision or touching assistant. A CP for falls dated 10/13/25, additional detail- RLE (right lower extremity) ORIF (Open Reduction and Internal Fixation, a surgical procedure used to treat severe, displaced, or complex bone fractures. It involves opening the skin (open reduction) to realign fractured bones and using hardware like metal plates, screws, or rods to stabilize them for proper healing) 10/2025, Hoyer lift as needed for transfers, Weight Bearing as Tolerated (WBAT) RLE.A review of the Order Summary revealed the following: Monitor incision sites to right hip and thigh every shift dated 10/9/25; Notify Medical Doctor/Nurse Practitioner (MD/NP) to evaluate for staple removal today as per ortho (orthopedic) surgeon dated 10/13/25; Hoyer lift as needed dated 10/13/25; WBAT RLE dated 10/13/25.A review of the quarterly MDS (MDS) with an assessment reference date (ARD) of 9/19/25, revealed a Brief Interview of Mental Status (BIMS) with impaired cognition; lower body dressing with supervision or touching assistance; walked 10 feet independently; walked 50 feet independently; and transferred independently.A review of the comprehensive MDS dated [DATE], revealed, the resident with lower body dressing partial/moderate assistance; walking 10 feet-not attempted due to medical condition or safety concerns; walking 50 feet-blank. There was no SCSA MDS done when the resident was re-admitted on 10/2025. The resident was re-admitted with Right Hip ORIF, a surgical wound to right upper leg and a Hoyer transfer.On 2/20/26 at 11:32 AM, the surveyor interviewed the Rehabilitation Director, Physical Therapist (PT), who stated that the resident was on therapy program from 10/10/25- 2/4/26. She further stated that the resident came from the hospital with post fall and right femur fracture, was walking before that, had a complete change of function, and decline: maximal/total assist; Hoyer transfer; no progress in therapy, and reached maximum potential. The PT stated, I would say, a Significant Change, based on decline of physical function status, the resident was walking 25 feet contact guard on 6/30/25, now non-ambulatory, transfers were now dependent, lower body dressing prior level was maximal assistance and now total assistance. She further stated that she did not think we discussed Significant Change at that time.A review of the PT evaluation on 10/10/25, revealed transfers prior level of function (PLOF) was minimal assistance and on 10/10/25, total dependent; ambulation PLOF 25 feet with contact guard assistance and on 10/10/25, non-ambulatory. A review of the OT (Occupational Therapy) evaluation on 10/10/25 revealed lower body dressing PLOF was maximum assistance and on 10/10/25 totally dependent.On 2/20/26 at 11:51 AM, the surveyor interviewed the MDS Manager/Registered Nurse (MDSM/RN), who stated, My Coordinator for the Long-Term Care was responsible for scheduling assessment for Significant Change MDS, with two or more decline. She further stated that if there were two areas of a decline, we do a Significant Change, as per the Resident Assessment Instrument (RAI) Manual (guidance to assess residents' clinical and functional needs). On 2/20/26 at 11:59 AM, interviewed the MDS Coordinator/RN (MDSC/RN) who stated, I did not complete this particular MDS, but multiple areas were triggered a Significant Change to be done. She also stated that the Assistant Director of Nursing (ADON) would let us know a decline, sometimes Social Worker would let us know of BIMS and if there were decline, the Dietician for weight changes. She further stated, we communicate as a team and send a notification. She added that If they did not have their baseline, then we triggered the Significant Change. MDSC/RN stated that she categorized all the ADLs as one area and would require another area of decline. On 2/20/26 at 1:11 PM, both the MDSM/RN and MDSC/RN provided the surveyor with an e-mail dated 10/17/25 from MDSC/RN addressed to ADON regarding a possible Significant Change. There was no evidence of a SCSA MDS being completed at this time.On that same date and time, the surveyor asked, according to the RAI manual, what was the timeframe to do a Significant Change assessment from the resident's physical status change. The MDSC/RN responded, I was not involved in resident's care, we did a team meeting 12/23/25, and rehab proceeded, the team did not designate a Significant Change. MDSC/RN further stated, if I was doing that MDS I would trigger a Significant Change.Furthermore, the MDSM/RN confirmed, it was 14 days to complete a SCSA from the day of the determination of a decline. The surveyor asked, this e-mail was dated 10/17/25, and the resident was re-admitted on [DATE], should a SCSA been completed before the 12/18/25, and the MDSM/RN responded Yes. On 2/24/26 at 12:32 PM, the survey team met with the License Nursing Home Administrator (LNHA) and the Director of Nursing (DON) regarding the concern with SCSA not being completed within two weeks of resident not returning to their baseline.On 2/25/26 at 11:22 AM, the survey team met with the LNHA and DON stated with regard to the missed SCSA, we did an in-service, everybody was educated on the real time to do a SCSA.A review of the facility's Policy: MDS 3.0 Completion revealed under Policy Explanation and Compliance Guidelines .#2 (d) SCSA-a comprehensive assessment completed within 14 days of the identification of a status change that meets the requirements .a major decline or improvement in a resident's status that will not normally resolve itself without intervention by staff .impacts more than one area of the resident's health status .NJAC 8:39-11.1; 11.2(i)

Based on interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to include in the written notification of transfer that was provided to the Resident or Resident Representative (RR), the facility's bed hold reserve payment and the Long-Term Care Ombudsman (LTCO) information and appeals rights for 2 of 2 residents, (Resident #365 and Residents #369), reviewed for hospitalizations. This deficient practice was evidenced by the following: 1.On 2/25/26, Surveyor #1 (S #1) reviewed the hybrid (electronic and paper) medical records (MR) of Resident #365. A review of Resident #369's Resident Face Sheet (RFS, an admission summary), reflected that the resident was admitted to the facility with diagnoses which included but were not limited to, essential hypertension (high blood pressure) and type 2 diabetes mellitus (a chronic condition where the body resists the effects of insulin or fails to produce enough). The MR revealed a New Jersey Universal Transfer Form (UTF) that the resident was transferred to a hospital emergency room for generalized weakness and to rule out sepsis. A review of Resident #365's discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #365's cognition was intact. Further review of the MDS indicated that the resident was transferred to a short-term general hospital. A review of Resident #365's electronic MR included a letter to the RR dated 1/4/26, which included that the resident was transferred to the hospital and admitted with a fever and that attached was a copy of the Notice of Bed-Hold Policy-Secondary Notification. The letter did not include the bed hold reserve payment amount. The letter did not include the LTCO information or the resident's appeal rights. 2.On 2/18/26 at 12:51 PM, Surveyor #2 (S #2) reviewed the hybrid MR of Resident #369. A review of Resident #369's RFS reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; metabolic encephalopathy (a broad term for acute or subacute brain dysfunction caused by chemical imbalances, systemic illness, or organ failure), type 1 diabetes mellitus (chronic autoimmune condition where the immune system destroys insulin-producing beta cells in the pancreas, resulting in little to no insulin production which leads to high blood sugar (hyperglycemia), requiring lifelong insulin therapy, blood sugar monitoring, and careful management to prevent complications), and congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues). A review of Resident #369's most recent discharge MDS reflected that the resident had a BIMS score of 14 out of 15, which indicated that Resident #369's cognition was intact. Further review of the MDS indicated that the resident was transferred to a short term general hospital. A review of Resident #369's electronic MR included a letter to the RR dated 1/30/26, which included that the resident was transferred to the hospital and admitted with DKA (diabetic ketoacidosis) and that attached was a copy of the Notice of Bed-Hold Policy-Secondary Notification. The letter did not include the bed hold reserve payment amount. The letter did not include the LTCO information or the resident's appeal rights. On 2/20/26 at 9:31 AM, S #2 interviewed the Director of Admissions and Case Management (DoAaCM) regarding the written notification required when a resident was transferred to the hospital. The DoAaCM stated that after the confirmation that the resident was admitted to the hospital, the next morning the letter with the bedhold information was sent to the RR. S #2 asked if the bed reserve payment information was on the letter. The DoAaCM stated that the price was not on the letter and that it may be in the admission agreement. She added that this was a secondary notice and that the first notice was in the admission agreement which had the usual per diem rate and fee schedule. On 2/24/26 at 12:45 PM, S #2 notified the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the concern that Resident #369's written emergency transfer notification did not include the bed hold reserve payment and the LTCO and appeal information. On 2/25/26 at 11:27 AM, in the presence of the DON, the LNHA stated that they changed the notice to include the appeal process and reserve payment. The LNHA stated that the admission staff were in-serviced on the new process. A review of the facility's Transfer and Discharge (including AMA) Policy with an effective date of 11/25, included the following: Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source.10. Emergency Transfers to Acute Care.g. Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated. The LNHA revealed in the letter that was signed by the DSS that the letter was to inform of the bed hold policies of the facility. In accordance with NJ (New Jersey) Medicaid guidelines, the facility will reserve your bed for a period of 10 days if you are a Medicaid recipient.For short term resident whose payment is Medicare or private insurance, the bed hold provisions noted above for private pay residents will apply. The policy did not provide any information regarding the contents for the notice of transfer and bed hold notice. A review of the facility's admission Process Policy with an effective date of 4/2025, included the following: I. Bedhold: Pursuant to the terms outlined in the admission Contract, Resident's bed will be held in the following manner: a. Private Pay Residents: Preference regarding bed-hold is indicated at the time of admission. If bed-hold is elected, resident's bed will be held until return or until facility is otherwise notified to release bed-hold by resident or responsible party. b. Medicaid Residents: Resident's bed will be held for a period of 10 days as per current regulation. If resident has not returned to the facility before the end of the 10-day hold period expires, the resident may be readmitted to a different room (if previous room is no longer available) or placed on a waiting list and offered the next available bed. c. Beds will not be held for Short-Term Rehab patients. Primary Notice of Bedhold Policy is provided upon Admission. Secondary Notice of Bedhold Policy is provided the morning following confirmed discharge by contacting Resident Representative via mail with copy of notification to review the policy; email confirmation is provided if email is available. NJAC 8:39-4.1(a)31; 5.1

Based on observation and interview, it was determined that the facility failed to, a.) post the State of New Jersey (State) inspection results in an area that was readily accessible to residents, families, and the public and b.) ensure reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction available for review. This deficient practice was observed in 2 of 2 common areas in the facility (reception desk and west lounge area).The deficient practice was evidenced by the following:On 2/20/26 at 11:35 AM, the surveyor asked Receptionist #1 (R #1) where the facility's survey results was and she responded that she was a Volunteer and she did not know, and she had to ask Receptionist #2 (R #2) who was the regular receptionist. At that time, R #2 was unable, and the surveyor was unable to locate the survey results.On 2/20/26 at 11:40 AM, the surveyor went to the Heritage Manor (HM) [NAME] unit and asked the Registered Nurse (RN) who were at the nursing station, where the survey result was, and she stated that she would have to ask someone.Afterward, the RN came back and stated that the survey results were on the other side of the HM [NAME] unit. The Concierge Manager (CM) came and accompanied the surveyor to the Hearth Area also known as the lounge area of the HM [NAME] unit, at the other end of the unit. The CM showed the white binder Annual Long Term Care Survey which was in the book shelf, next to the books. The CM confirmed that the survey result binder had the most recent recertification survey results dated 10/8/24, and that there was no other survey results printed and filed in the binder. The CM stated that she was unsure what the policy and requirements for posting survey results were.At that same time, the surveyor notified the CM that the survey binder result was not readily accessible, and unable to locate unless someone from the facility knew where it was. The CM did not respond.On 2/20/26 at 11:45 AM, the surveyor returned to the reception desk, the main entrance to the facility, and asked R #2 where the facility's survey results were, and she stated that it was inside a cabinet near the entry door, and it should be in the bottom of the cabinet. The surveyor located the cabinet and saw the white binder on the bottom of the cabinet. The survey binder results were not easily accessible.At that same time, the surveyor observed a white binder Annual Long Term Care Survey with survey results dated 10/8/24 and a Focus Infection Control (FIC) Survey dated 1/17/24. There were no other survey results in the binder except for the two survey dates.On 2/20/26 at 11:47 AM, the surveyor interviewed the Director of Nursing (DON) regarding the survey results in the white binder. The DON confirmed that the survey results inside the binder were from 10/8/24 recertification survey and the 1/17/24 FIC Survey. The surveyor asked the DON if she was aware of the regulation regarding survey results and she responded that they were required to put the most recent survey results which was the 10/8/24. The surveyor then asked for the facility's policy about survey results, and she stated that she would get back to the surveyor.On 2/20/26 at 1:50 PM, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that the facility had no policy with regard to the posting of survey results. She further stated that as far as she knew the facility was required to have the last recertification survey which was the October 2024 results in the survey binder for residents and visitors. She further stated that she was not aware that it should be at least the 3 years surveys which could include recertification surveys and other surveys like complaint surveys.At that same time, the surveyor notified the LNHA of the concern that the survey results were not easily accessible for those two common areas, the reception desk and HM [NAME] nursing unit. The surveyor also notified the LNHA that the RN and R #1 were not aware where the survey results were located.On 2/24/26 at 11:12 AM, the LNHA provided a copy of Policy: Survey Binder Availability with an original date and effective date of 2/26, revealed under Policy: all surveys, certifications, and complaint investigations made of or about Christian Health during the 3 preceding years and any plan of correction in effect will be available for individuals to review. Definitions: place readily accessible is an area (such as HM [NAME] (Hearth Bookcase) or other area frequented by most residents, visitors or other individuals where individuals wishing to examine survey results do not have to ask to see them. Results of the most recent survey means the Statement of Deficiencies (Form CMS-2567) generated by the most recent standard survey and any deficiencies resulting from any subsequent complaint investigation(s) The LNHA confirmed that the policy was formulated after surveyor's inquiry. On 2/24/26 at 12:31 PM, the survey team met with the LNHA, DON, and the surveyor notified them of the above findings and concerns with the posting of survey results. The LNHA stated, We corrected the survey binder and put the last three years survey results. The LNHA further stated that the survey results were out of the cabinet in the reception desk to be more accessible, after surveyor's inquiry. A review of the facility's survey history revealed that the facility had recertification survey on 6/14/23, FIC survey on 1/15/24, and complaint surveys on 7/2/24 and 12/16/25 which were not filed in the survey binders. NJAC 8:39-9.4(b)(c)

Based on the interview and review of facility documentation, it was determined that the facility failed to ensure that facility wide assessment included the resources required to establish policies and procedures a.) to ensure water management was included and b.) for the management of emergency food and water supply in order to meet the requirements and needs of all residents in the facility. This failure had the potential to affect all 277 residents who currently live in the facility. This deficient practice was evidenced by the following: During the entrance conference on 9/30/24 at 10:16 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) a copy of the facility's assessment. Both the LNHA and DON stated that the facility's census (the number of residents currently under the care of a specific facility) was 277. A review of the facility's Facility Wide Assessment (FWA) with a date of July 2024 that was provided by the DON on 9/30/24 at 01:31 PM did not include information about the facility's emergency food and water supply for the residents and employees. In addition, there was no documented evidence that the FWA included about the facility's water management, or measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building. On 10/07/24 at 8:19 AM, the surveyor met with the LNHA and the DON. The LNHA stated that the FWA process was that all IDT (Interdisciplinary Team) were involved in the input. The LNHA informed the surveyor that the IDT meets once a year and as needed for modifications, completes a thorough assessment, and presents to QAPI (Quality Assurance Performance Improvement) meeting. She further stated that the FWA was all about the residents' care. The LNHA also stated that they received the CMS (Centers for Medicare and Medicaid Services) Memo about the changes in the regulation for facility assessment and they were aware of it. On that same date and time, the surveyor notified the facility management of the above findings and concerns. The surveyor also asked where in the facility's FWA discussed emergency food and water supply and water management. Both the LNHA and DON stated that they would get back to the surveyor. On 10/07/24 at 10:27 AM, the DON presented an updated FWA in the presence of another surveyor. The DON informed the surveyor that the date was updated because it was confusing. The DON stated that the date of assessment was May 2024 and reviewed at the 2nd Quarter QAPI meeting in June 2024, and then the assessment was again reviewed and updated in July 2024. The DON further stated that page 17 was updated to reflect the water management and three (3) days of emergency food and water supply that should be included in the FWA. The DON acknowledged that the emergency water and food supply and water management should have been included in the FWA. On 10/07/24 at 01:09 PM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the concerns with the FWA that it did not include water management and emergency food and water supply. On 10/08/24 at 9:03 AM, the DON provided a copy of the facility's QAPI Policy with a review date of 01/22. The DON informed the surveyor in the presence of another surveyor that the QAPI policy included information about the Facility Assessment and there was no separate policy for Facility Assessment. The DON acknowledged that the concern of the surveyor that the water management and emergency food and water supply were not included in the Facility Assessment was an oversight. A review of the QAPI Policy provided by the DON revealed: Purpose: The facility will also identify in conjunction with the Facility Assessment high-risk, problem-prone, and high-volume areas to evaluate for improvement by identifying, collecting, and using data relevant to the unique characteristics and needs of those we serve. Procedure: 6. Issues identified as part of the QAPI Program, such as new equipment, service, or facility resources, are addressed in the Annual Facility Assessment . On 10/08/24 at 12:25 PM, the survey team met with the LNHA, DON, Medical Director, and the VP (Vice President) of Senior Services for an Exit Conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-5.1(a)

REPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) the resident's oxygen (O2) tubing was dated for two (2) of five (5) residents, Residents #9 and #38, b.) a physician's order for O2 and SPO2 (saturation of peripheral oxygen) monitoring was administered as ordered for two (2) of five (5) residents, Resident #9 and #124, and c.) proper storage of O2 cannula and tubing for one (1) of five (5) residents, Resident #157, reviewed for respiratory care, according to standards of clinical practice and facility policy and procedure. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 9/30/24 at 11:09 AM, Surveyor #1 (S#1) observed Resident#9 lying in bed with their eyes closed. Resident #9 was receiving O2 therapy at 2 LPM (liters per minute) via nasal cannula (n/c; a device that delivers extra O2 through a tube and into the nose) from an O2 concentrator (a medical device that provides supplemental oxygen). The surveyor observed that the O2 tubing was not dated to indicate when the tubing was last changed. On 10/01/24 at 10:36 AM, S#1 observed Resident#9 lying in bed with their eyes closed. Resident#9 was receiving O2 therapy at 2 LPM via n/c from an O2 concentrator. The surveyors observed that the O2 tubing was not dated. A review of Resident#9's Resident Face Sheet (FS; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to atherosclerotic heart disease (a condition where plaque builds up in the arteries of the heart, narrowing them and reducing blood flow), hypertension (high blood pressure) and tachycardia (a heart condition where the heart rate is faster than 100 beats per minute (bpm) while at rest). Resident #9's most recent annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the resident's cognitive skills for daily decision making were severely impaired. Further review of the MDS indicated that the resident had not received O2 therapy. On 10/01/24 at 10:41 AM, S#1 interviewed the Licensed Practical Nurse (LPN) regarding O2 therapy. The LPN stated that the O2 tubing was changed every 3 days and that it was dated with a piece of tape. She added that it was not documented when changed. As needed (PRN) use based pulse ox (oximeter), not documented when changed. On 10/01/24 at 11:02 AM, S#1 interviewed Team Leader/Registered Nurse #1 (TL/RN#1) from Heritage Manor [NAME] (HMW) regarding O2 therapy. TL/RN#1 stated that the O2 tubing was changed weekly and was dated. She added that there was an order in the Medication Administration Record (MAR) to change the tubing. The surveyor then asked TL/RN#1 to view Resident #9's O2 tubing. TL/RN#1 confirmed that the O2 tubing was not dated and that it should have been. On 10/01/24 at 11:32 AM, S#1 reviewed Resident #9's September 2024 electronic MAR/TAR (Treatment Administration Record) which included the following order: O2 n/c PRN 2 LPM for sob (shortness of breath) or to maintain SPO2 (a measurement of the amount of O2 in the blood) above 92%; check SPO2 q (every) shift with a start date of 10/03/2023. Further review of the MAR/TAR reflected that the order was not signed by the nurse as administered on 9/30/24 when the surveyor observed that Resident #9 was receiving O2. There was no indication that the O2 had been administered for the month of September. Further review of the order reflected that the residents SPO2 should be check q shift. Review of Resident #9's medical record reflected that the SPO2 was documented as being checked on 9/20/24 and 9/27/24. There was no documented evidence in the resident's medical chart that the SPO2 was being checked q shift. On 10/01/24 at 11:57 AM, S#1 interviewed the LPN regarding O2 order. She stated that if there was an order for PRN O2 then it would be documented in the TAR and the SPO2 would also be documented. The surveyor asked the LPN about Resident #9. The LPN stated that the resident was on hospice and the staff would check the SPO2 if it came up in the TAR. She added that it was not coming up in the TAR but that it was listed in the order section. On 10/01/24 at 12:10 PM, S#1 interviewed TL/RN#1 regarding O2 order. TL/RN#1 stated that if it was a PRN it would be in the TAR. She added that if the O2 was administered to the resident then it should be documented in the TAR. She then stated that if it was needed for a lower SPO2 then the SPO2 would be documented also. S#1 then asked TL/RN#1 about Resident #9's O2 order. She stated that she would have to look at the order and then get back to the surveyor. On 10/02/24 at 12:26 PM, S#1 interviewed the Director of Nursing (DON) regarding O2. The DON stated that O2 tubing was changed weekly and dated with tape. She added that it was a collaboration with the respiratory therapist and that nurses were also responsible. The surveyor then asked the DON about Resident #9's O2 order. The DON stated that she knew an issue was identified by the surveyor and that she gave the staff an inservice. She added that they had to click monitoring for the SPO2 part of the order. The DON stated that the order should have been followed, the nurse should have signed that the PRN order for O2 was administered and there should be an additional order for SPO2. On 10/02/24 at 01:29 PM, in the presence of the survey team, S#1 notified the Licensed Nursing Home Administrator (LNHA) and DON, the concerns that Resident #9 O2 tubing was not dated and that there was no documented evidence that the O2 had been administered and the SPO2 was being monitored q shift. On 10/03/24 at 12:35 PM, in the presence of the survey team and the LNHA, the DON stated that education was provided to staff on O2 and transcribing the order. She added that the SPO2 was ordered but that monitoring was not clicked. A review of the undated facility provided policy titled, Oxygen Therapy included the following: 14. Change all disposable equipment weekly or per institution's infection control guidelines. The facility did not provide any additional information. 49078 2. On 9/30/24 at 10:52 AM, Surveyor #2 (S#2) observed Resident #38 sitting in a wheelchair, awake and willing to converse. Resident #38 was receiving O2 therapy at 2 LPM continuously via n/c from an O2 concentrator. The surveyor observed that the O2 tubing was not dated to indicate when the tubing was last changed and the humidifier bottle (a bottle of sterile water to add moisture to the O2) attached to the concentrator had a date written on the label of 9/25. A review of Resident FS reflected that the resident was admitted to the facility with diagnoses which included but were not limited to acute and chronic respiratory failure (a condition where the lungs cannot properly supply O2 to the blood), and chronic obstructive pulmonary disease (COPD; a condition where damage to the lungs limits inflow and outflow of air). A review of Resident #38's most recent Quarterly MDS (QMDS) dated [DATE], reflected that the resident's cognitive skills for daily decision making were intact. A review of the EMR reflected a physician's order (PO) for O2, via n/c, continuous. The EMR also reflected an order to clean O2 concentrator filter, change tubing and humidifier weekly and PRN. On 10/01/24 at 10:41 AM, S#2 observed Resident #38 sitting in a wheelchair (w/c) receiving O2 therapy at 2 LPM from an O2 concentrator. The resident stated to S#2, my tank is empty, it needs to be replaced. The surveyor observed that the gauge on the O2 tank hanging on the back of the resident's wheelchair reflected the needle in the red zone, indicating empty. S#2 observed that the tubing was not dated, and the humidifier bottle had the same date of 9/25 as previously observed. On 10/01/24 at 11:05 AM, S#2 interviewed the Assistant Director of Nursing (ADON) assigned to the Heritage Manor East (HME). S#2 asked the ADON who was responsible for changing residents' O2 tubing, moving the tubing from a concentrator to an O2 tank and what was the procedure. The ADON stated that the nurse on duty, for that room, should change the humidifier bottle and tubing at least once a week if the concentrator or tank is in use and the tubing and bottle should be dated. Tubing should be stored in a bag. The ADON also stated that a nurse must do any switch between a concentrator and a tank. On 10/02/24 at 12:57 PM, S#2 observed Resident #38 sitting in a w/c in their room. The surveyor interviewed the resident who stated they got a new O2 tank this morning. S#2 observed the tank and tubing, and the tank was full. S#2 did not observe a date on the tubing. On 10/03/24 at 10:16 AM, S#2 observed Resident #38 in a w/c, with an O2 with a n/c attached to an O2 tank. The surveyor did not observe a date on the tubing and observed a date of 9/25 on the humidifier bottle attached to the concentrator. This was the same date as observed 9/30/24 by this surveyor. On 10/03/24 at 12:39 PM, S#2 notified the DON and LNHA in the presence of the survey team of the concern regarding the dating of Resident #38's tubing and humidifier bottle. S#2 asked the DON who was responsible for changing and dating the tubing and humidifier bottles. The DON stated it was responsibility of nursing or respiratory therapist to date those items when they were changed or cleaned. A review of the facility provided policy titled, O2 Therapy dated 4/24, included the following: 14. Change all disposable equipment weekly or per institution's infection control guidelines. The facility did not provide any further pertinent documentation. 38327 3. On 9/30/24 at 11:34 AM, Surveyor #3 (S#3) observed Resident #124 lying on the air mattress. The resident had an O2 via n/c attached to a concentrator at 2 LPM. The O2 humidified water bottle was dated 9/26. The resident stated that they always use O2. On 10/02/24 at 8:30 AM, S#3 observed the resident lying on the bed with an O2 via n/c at 2 LPM. The surveyor reviewed the medical records of Resident #124 and revealed: According to the Resident FS, the resident was admitted to the facility with a diagnosis that included but was not limited to hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, anemia (low blood count), anxiety disorder, and dependence on supplemental O2. The resident's most recent QMDS, with an assessment reference date (ARD) of 8/13/24 revealed in Section C Cognitive Status Brief Interview for Mental Status (BIMS) score of 14 out of 15 which reflected that resident was cognitively intact. The personalized care plan (CP) with a focus on respiratory dysfunction, at risk for breakthrough SOB with the goals of SPO2 with an effective date of 6/04/24. The active CP interventions included but were not limited to monitor for s/s (signs and symptoms) SOB-obtain SPO2 q shift and PRN for s/s SOB-see PRN O2 with an effective date of 6/04/24. A review of the September and October 2024 PO revealed: -order date 6/04/24 O2 n/c PRN for SOB 2 LPM to maintain SPO2 greater than 90% monitoring: O2 SPO2. -order date 6/04/24 Obtain SPO2 q shift and PRN for s/s of SOB The above orders for PRN O2 at 2 LPM and obtain SPO2 q shift and PRN were transcribed to the MAR for September and October 2024 and showed: -September 2024 Obtain SPO2 q shift and PRN: On 9/02/24 at 7 AM-3 PM shift the SPO2 was recorded at 90%. On 9/04/24 at 11 PM-7 AM shift the SPO2 was blank (no SPO2 obtained). On 9/05/24 at 11 PM-7 AM shift the SPO2 was blank. -September 2024 PRN O2: there was no signature of the nurse that the PRN O2 was administered on and 9/02/24 at 7 AM-3 PM shift and 9/30/24. Further review of the above PO and MAR revealed that there was no documented evidence that the resident received the PRN O2 on 9/02/24 at 7 AM-3 PM shift when the SPO2 was below 91%. There was no documented evidence that the nurse signed the MAR on 9/30/24 when the surveyor observed the resident with O2 at 11:34 AM of 9/30/24. In addition, the nurses did not follow the PO to obtain the SPO2 q shift on 9/04/24 and 9/05/24 of the 11 PM-7 AM shift. On 10/03/24 at 10:59 AM, S#3 interviewed TL/RN#2 who was at the medication (med) cart for Beach St (street) in HME. TL/RN#2 informed S#3 that the SPO2 should be documented in the MAR and signed when PRN O2 was administered according to the PO. S#3 then notified TL/RN#2 of the above concerns and findings. On 10/03/24 at 12:32 PM, the survey team met with the LNHA and DON. S#3 notified the facility management of the above concern and findings. On 10/07/24 at 01:09 PM, the survey team met with the LNHA and DON. The DON stated that I could only move forward with concerns with Resident#124. The facility did not provide additional information. On 10/08/24 at 12:04 PM, the survey team met with the LNHA and DON. The DON stated that we talked about the omission to the MAR which we continually educate staff and auditing acuities. 48423 4. During the initial tour on 9/30/24 at 11:48 AM, S#3 observed Resident #157 in bed with an O2 concentrator with humidifier at their bedside, which was on and set to 2 LPM. The humidifier was dated 9/27 with black marker. S#4 reviewed the medical record for Resident #157. The Resident FS reflected that Resident #157 was admitted to the facility with diagnoses which included but was not limited to: Acute respiratory failure (a condition where there's not enough O2) with hypercapnia (too much carbon dioxide in your body), history of pneumonia (an infection of the air sacs of one or both lungs), anemia (deficiency of red blood cells), gastrostomy (a surgical procedure to make a hole into the stomach through the abdomen to insert a feeding tube into the stomach), and dysphagia (difficulty in swallowing). A review of the QMDS dated [DATE], the resident had a BIMS score of 10, indicating that Resident #157 had a moderate impaired cognition. A review of Resident #157's PO reflected the following orders: Monitoring: Check for use of O2 concentrator weekly- clean, filter, change tubing and humidifier dated 5/28/24. Monitoring: Obtain SPO2 q shift and PRN for s/s SOB *see PRN O2 order for SPO2 less than 93% schedule dated 5/28/24 Respiratory Therapy- O2: [X]n/c; [X] PRN for SOB - 2 LPM to maintain SPO2 > 92% dated 5/28/4. On 10/02/24 at 11:48 AM, Surveyor #4 (S#4) observed Resident #157 sitting in chair and was not using O2 at the time. S#4 observed the O2 tubing was connected to the concentrator and the other end was hanging on the tube feeding pole which was behind the resident's chair. The tubing was not placed in a plastic bag or stored properly. During an interview with S#4 on 10/02/24 at 12:09 PM, the LPN stated that when O2 was not in use, the O2 tubing would be placed in a plastic bag and the bag would be placed in nightstand drawer. The LPN further stated it was important to do that so that the tubing does not get contaminated if it was touched by staff and you can give micro-organisms to the resident and complicate their health. It was important to prevent the infection to the residents. At 12:25 PM, S#4 and the LPN visited Resident #157's room and both observed the resident's O2 tubing hanging on the feeding pump pole. LPN #1 stated that she would have to dispose off the O2 tubing and get a new one because she could not tell how long the O2 tubing had been there for. The LPN acknowledged that it was not acceptable practice to place the O2 tubing on the tube feeding pole. During an interview with S#4 on 10/02/24 at 12:29 PM, TL/RN#2 stated that when O2 was not in use, the O2 tubing would be placed in a special plastic bag with white strings. To store the O2 tubing in the plastic bag was important for infection control. S#4 notified TL/RN#2 of what was observed in Resident #157's room and TL/RN#2 acknowledged that it was not acceptable practice for infection control. On 10/02/24 at 01:13 PM, the survey team met with the LNHA and DON. S#4 notified the facility management of the above findings. The DON who acknowledged the O2 tubing should not be hanging on the tube feeding pole and further stated that the tubing should be bagged for infection control. A review of the facility's policy, Respiratory Therapy with effective date 4/24 did not address the protocol for the nurses regarding how to store O2 equipment properly when not in use. On 10/08/24 at 12:25 PM, the survey team met with LNHA, DON, [NAME] President (VP) of Senior Services and VP of Medical Affairs for an Exit Conference. The facility did not refute the findings. NJAC 8:39-11.2(a)(b); 19.4(a); 27.1(a)

Based on interviews and a review of facility provided documents, it was determined that the facility failed to provide Saturday mail and package delivery services to residents. This deficient practice was identified for seven (7) of seven (7) residents interviewed during the resident council group meeting (Residents #10, #48, #167, #173, #212, #218, and 232) and was evidenced by the following: During the resident council meeting conducted by the surveyor on 10/02/24 at 10:29 AM with Residents #10, #48, #167, #173, #212, #218, and #232, the surveyor asked the residents if they received mail on Saturdays. All residents stated that there was no mail or packages on Saturdays because the mail room was closed. On that same date and time, Resident #212 informed the surveyor that a couple of weeks ago the resident had a delivery from an outside vendor [name of company] that was returned which the resident had known because the resident's representative told them. Resident #212 stated that they notified the Social Worker about it and the reason it was returned was because the packages were too many. The resident further stated that there was no mail and packages delivered to the residents on weekends because they (mail room) were closed. At that same time, Resident #167 informed the surveyor that they do not accept packages on a weekend, which was written on some paper, and I have a problem getting things. The resident further stated since then the resident knew that there were no mail/packages delivered to the resident on weekends. The resident further stated that in order for the resident to get packages, they were sent to the resident's representative (RR) to make sure delivery was received and will be given to the resident once the RR visited the resident. On 10/03/24 at 10:50 AM, the surveyor interviewed the Unit Clerk (UC) from Heritage Manor East (HME) unit regarding the facility's process and practice for receiving residents' mail and packages. The UC informed the surveyor that the mails and packages come from the Mail Room (MR) and usually the assigned person from the MR delivers them to the unit and the UC will deliver them to the residents. The UC stated that she signed the log when she received the mail and packages from the MR. The UC stated that the MR was open Monday through Friday and closed on weekends. At that same time, the UC stated that sometimes delivery personnel from the community left packages in the loading dock. She further stated that like two weeks ago Resident # 228 had a package that was left in the loading dock, and she had to pick it up and give it directly to the resident. On 10/03/24 at 11:14 AM, the surveyor interviewed the Shipping, Receiving & Inventory Manager (SRIM) who informed the surveyor that there was an assigned person also in the department that delivered mail and packages to the unit. The SRIM stated that the assigned person will hand over the mail and packages to the UC and the UC will sign the log that the mail and packages were received, and the UC will distribute them to the respective residents. He further stated that the MR and his department were open Monday through Friday and closed on weekends. The SRIM confirmed that was the facility's practice that the MR opened on weekdays and closed on weekends. On 10/03/24 at 12:32 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The surveyor notified the facility management of the above concerns. A review of the facility's POLICY: Requisition Ordering Process for Stock, Non-Stock Items, and Inventory Control Procedure with an effective date of 5/24 which the DON stated was the facility's policy for mail/packages and mail room, revealed: Procedure: The purpose of this policy is to identify the procedures used to properly acquire necessary supplies and place them into use in a timely manner . 4. For non-stock items, this includes receiving non-stock requests, placing orders, receiving order items, verifying they are what was ordered and are in proper condition, and either delivering them to their intended recipient/department or returning them to the supplier if unsatisfactory . Definitions: d. Non-stock=items/goods or services that are non-inventory items for departments, patients/residents . D. Non-stock purchase requisition process: 10. Materials management personnel will deliver the items to the intended recipient/department by the end of the day during normal business hours . On 10/08/24 at 12:25 PM, the survey team met with the LNHA, DON, Medical Director, and the VP (Vice President) of Senior Services for an Exit Conference. The facility management did not provide additional information and did not refute the findings. N.J.A.C. 8:39-4.1 (a)(19)

Based on interviews and a review of facility provided documents, it was determined that the facility failed to consistently respond to issues and concerns presented during resident council meetings and resident questionnaires obtained from residents in lieu of a formalized resident council meeting for two (2) of three (3) resident council minutes reviewed. This deficient practice was evidenced by the following: According to the Heritage Manor East (HME) Resident Council Meeting Minutes that was provided by the Director of Nursing (DON) revealed: 1. July 18, 2024 at 02:30 PM -Staff in attendance: Director of Activities (DoA), Director of Food and Nutrition Services (DFNS), Assistant Director of Nursing (ADON), Social Worker (SW), Activities Assistant #1 (AA#1), and Activities Director (AD). -Residents in attendance: 18 -Dietary Committee Meeting: residents would like to know could the supper be served at 5:45 PM instead of arriving at 6:00 PM? Residents would prefer it earlier, if possible. The DFNS will discuss with his team. 2. August 15, 2024 at 02:30 PM -Staff in attendance: DoA, DFNS, Chief of Clinical Dietician (CoCD), Executive Director-Administrator ([NAME]), ADON, AA#2 and AA#3, and Director of Environmental Services (DES). -Residents in attendance: 27 -Dietary Committee Meeting: [did not address the concern on 7/18/24 about supper to be delivered earlier] 3. September 19, 2024 at 02:30 PM -Staff in attendance: DoA, Director of Dining & Nutrition Services (DoDNS, also known as the DFNS), Registered Dietician (RD), ADON, Volunteer Ombudsman (VO), SW, Resident Relations Associate (RLA), and Activities Specialist (AS). -Residents in attendance: 25 -Dietary Committee Meeting: The unsampled resident mentioned that the supper truck was arriving around 6:00-6:15 PM. The DoDNS will look into the time of arrival. During the resident council meeting conducted by the surveyor on 10/02/24 at 10:29 AM four (4) out of seven (7) residents stated that there was only one staff from the Activity Department assisted during supper time at the HME dining area. Four of seven residents also stated that supper was served late at HME. Furthermore, the four residents stated that the late delivery of meals for supper and one staff assisting during that time affected 15 to 20 residents who were in the dining room. On that same date and time, Resident #167 informed the surveyor that the above concerns with late delivery of meals for supper had been discussed as concerns to the facility management during Resident Council Meetings and there was no resolution. Resident #167 further stated that there was no consistency with meal deliveries. The resident also stated that the residents requested supper to be served before 6:00 PM. On 10/02/24 at 12:12 PM, the surveyor interviewed the Activity Person (AP) who was present on 10/01/24 dinner time at HME. The AP informed the surveyor that she worked the 9-5 shift yesterday and had to work overtime until 7 PM last night. The AP stated that most of the time she was by herself serving the HME dining room for residents of 15 to 20. She further stated that at times a Certified Nursing Aide (CNA) will help her. The AP acknowledged that it took time to serve the 15-20 residents and would be helpful to have extra hands. On 10/02/24 at 12:21 PM, the surveyor interviewed the Clinical Nutrition Manager (CNM) and DFNS in the presence of another surveyor. The surveyor asked both CNM and DFNS if they remembered that facility management or residents reported concerns that residents requested an earlier food truck delivery for dinner before 6:00 PM. Facility management responded that they did not recall that was discussed with them. The DFNS further stated that if it was discussed in the resident council meeting, the activity person should have documented that, and he would addressed it. At that same time, the DFNS provided a copy of the Dining Room Schedule and he indicated from the paper, the supper at HME Great Room/Media Room delivery time was at 5:45 PM-6:45 PM. The surveyor asked the DFNS if that was considered late for the 6:45 PM dinner delivery and there was no response from the DFNS. On 10/02/24 at 01:13 PM, the survey team met with the [NAME] (also known as the Licensed Nursing Home Administrator [LNHA]) and DON. The surveyor notified the facility management of the above concerns. On 10/03/24 at 12:32 PM, the survey team met with LNHA and DON. The DON stated that the concerns regarding the Resident Council Meeting, we will move it to 5:30 PM and we spoke to the staff, it was an oversight. At that same time, the surveyor asked the reason why it was not acted upon the July and September 2024 resident council meeting the residents' concerns with late meal delivery for supper and requested an earlier time to be delivered. The surveyor also asked what was the timeline that the facility should act upon on those requests and concerns and should the DFNS and Dietitian received those concerns. The LNHA stated that it was an expectation, same as grievances, concerns, and requests in the Resident Council Meeting of the residents should have a resolution. The LNHA further stated that we have a summary from resident council meetings that come out and distributed to those who attended, and he (DFNS) should receive a copy. A review of the facility's Diet Ordering Policy with an effective date of 01/24 that was provided by the DON revealed: Procedure: J. If a client is in need of an altered schedule for meals or snacks, staff nurses and RD will make arrangements for accommodating the schedule for optimal intake. A review of the facility's Resident Council Meeting Policy with an effective date of 10/24 that was provided by the DON showed: Policy: It is the policy of the facility to provide its' residents with the opportunity to meet in a group atmosphere, on a regular basis, to take an active role in discussing various community related topics/issues in a non-threatening environment and to present those topics to the appropriate administrative persons. Residents have the right to express concerns, have them heard & reviewed and when possible, resolved . Procedure: B. If a resident in attendance brings up an issues/concern to be addressed by another Department, the appropriate department will receive a copy of the meeting minutes, indicating that a response is requested of them to address the issue. A review of the Grievance (complaint) Resolution Policy with an effective date of 10/24 that was provided by the DON showed: Policy: The facility strives to provide quality care and satisfaction in the delivery of its services. We understand that there may be times when our customers may not be completely satisfied with the services provided. Under those circumstances, we encourage dissatisfied customers to notify our staff of their concerns and/or to contact appropriate public agent(s) in order to provide the opportunity to rectify the issue. Procedure: Responsibilities of: 1. Residents and/or their representatives can express their concerns in writing, by telephone, or in-person to members of the facility . 4. Appropriate department heads will follow through to seek resolution . 8. It is the responsibility of the department head where the concern occurred in collaboration with concierge to discuss final outcomes will all interested parties inclusive of the resident representative. On 10/08/24 at 12:25 PM, the survey team met with the LNHA, DON, Medical Director, and the VP (Vice President) of Senior Services for an Exit Conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-4.1(a)(29)

Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to provide appropriate interventions, implement interventions, and ensure that interventions to prevent further falls were documented and monitored for one (1) of three (3) residents, Resident #153, reviewed for incident and accident. This deficient practice was evidenced by the following: On 9/30/24 at 11:29 AM, the surveyor observed Resident #153 was not in their room. The room was observed with a bed alarm on top of the nightstand table and a low bed. The bed had a regular mattress [not specialized]. The surveyor reviewed the medical records of Resident #153 and revealed the following: The Resident Face Sheet (an admission summary) showed that the resident was admitted to the facility with a diagnosis that included but was not limited to Alzheimer's disease unspecified, dementia in other diseases classified elsewhere, muscle weakness (generalized), other sequelae of cerebral infarction (stroke), and repeated falls. A review of the provided Matrix for Providers by the Director of Nursing (DON) showed that the resident was triggered for Alzheimer's dementia and fall. A review of the provided fall investigations by the DON revealed: -3/25/24 at 8:10 AM unwitnessed fall. The Certified Nursing Aide (CNA) found resident in the bathroom sitting up on the floor with back in front of sink. The resident hit head, and complaint (c/o) pain on the left side of the head. -5/11/24 at 10:15 AM unwitnessed fall with no injury. The resident was found lying on the floor, outside the bathroom. -8/04/24 unwitnessed fall with no injury. The resident was found sitting upright by the foot side of the bed. The pad sensor alarm was sounding. Resolution Comment: New intervention: scoop mattress. The most recent Significant Change in status MDS, with an Assessment Reference Date of 6/29/2024, showed that the cognitive skills for daily decision-making were coded #2 which indicated that the resident had moderately impaired cognition. Section J Health Conditions indicated that the resident had a fall incident with no injury. A review of the personalized care plan (CP) revealed a focus on falls with interventions that included the following: -revised, effective date 3/25/24, offer toileting assistance prior to breakfast meal. -revised, effective date 5/11/24, offer toileting assist after breakfast. -active, effective date 8/03/24, scoop mattress as indicated for safety. -resolved, effective date 12/30/22, tab alarm to w/c (wheelchair). Further review of the above CP showed that there was no CP intervention for low bed, bed alarm, and pad sensor. On 10/01/24 at 12:03 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) from Heritage Manor East (HME). Afterward, both the surveyor and the ADON went to resident's room and the surveyor asked the ADON to check if the resident had scoop mattress. The ADON pulled the foot part bedsheet and touched the mattress. The ADON then performed hand hygiene with use of ABHR (alcohol base hand rub) that was inside the resident's room. On that same date and time, outside the resident's room the ADON confirmed that the resident had no scoop mattress, and it was a regular mattress. Furthermore, inside the ADON's office, the surveyor asked the ADON should the fall incidents be in the CP and why the scoop mattress intervention was not followed. The ADON confirmed that the scoop mattress was in the fall CP intervention. The ADON stated that she had to check why the scoop mattress was not in use at the time of observation. She further stated that they did not CP the actual fall but update the current CP for fall interventions. The surveyor notified the ADON of the initial observation on 9/30/24 that the resident had no scoop mattress. On 10/02/24 at 01:13 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The surveyor notified the facility management of the above findings and concerns. On 10/02/24 at 02:03 PM, the surveyor interviewed the DON. The surveyor asked the DON how the facility know and determine that the fall CP interventions were followed and if there were an accountability that the resident was offered toileting before and after breakfast. The DON acknowledged that there was no documented evidence that the resident was offered toileting according to fall interventions. The DON at that time checked the electronic medical records. At that same time, the DON stated that there was no option for the electronic records in the CP to add actual fall as the focus. The DON further stated that what facility can do was to update CP in each fall for new interventions and it was facility's process to update CP for new interventions for each fall. On 10/04/24 at 11:44 AM, the surveyor interviewed the assigned CNA of the resident. The CNA stated that Resident #153 was cognitively impaired had periods of incontinence. The CNA stated that she was unable remember if the resident had history of falls. The surveyor asked the CNA how she would know what kind of assistance and safety precautions the resident had. The CNA stated that it would be available in the kiosk (a small structure in public area used for providing information) where the CNA task and accountability can be found. She further stated that as for her a floater, she relied on the kiosk and nurse's verbal instructions. At that same time, the CNA stated that she was unable to remember if the resident should be with tab alarm. The surveyor and the CNA went to see the resident's mattress, the surveyor asked the CNA what kind of mattress the resident had. The CNA stated that it was not an air mattress, and it was a regular mattress. At that time, the CNA was not able to identify the scoop mattress which was in resident's bed. On 10/04/24 at 01:46 PM, the surveyor notified the DON the concern about tab alarm observed on the 1st day of tour on 9/30/24 on top of the nightstand and the 8/04/24 fall incident investigation that was mentioned about the pad alarm sounding off and that were not included in the active CP interventions. The DON stated that the facility discontinued (d/c) tab alarms before and not sure why it was in the fall incident investigation and why it was in the resident's room on the time the surveyor observed the resident's room. On 10/08/24 at 9:58 AM, the surveyor reviewed and printed out the CNA tab in the electronic medical records that included the aide's accountability and tasks and revealed: The electronic CNA Monitoring under Safety (searched data from December 2023 through October 2024) showed: -4/13/24 at 6:06 PM, changed by Admission Nurse/Registered Nurse, and the details were blank. -8/06/24 at 9:38 AM, changed by ADON. Details: Notes changed from non-slip footwear, remind to call for assist to non-slip footwear, remind to call for assist, scoop mattress. -10/03/24 9:41 AM, changed by ADON. Details: Alarms changed from j-wander/elopement alarm to blank. Notes changed from non-slip footwear, remind to call for assist, scoop mattress to offer toileting assist before and after breakfast, non-slip footwear, remind to call for assist, scoop mattress. Further review of the above CNA Monitoring under Safety for the CNAs tasks and accountability revealed that the fall interventions for offering toileting before and after breakfast were entered in the CNAs monitoring for safety not until 10/03/24, which was after surveyor's inquiry. On 10/08/24 at 10:30 AM, the surveyor showed to the DON the history when the CP interventions for fall incidents that happened on 3/25/24 and 5/11/24 for offer toileting before and after breakfast was entered to CNA task for monitoring for safety after surveyor's inquiry which was on 10/03/24. The DON acknowledged the surveyor's concerns about CP interventions entered in the CNAs task after surveyor's inquiry. A review of the facility's Resident Safety Program-Fall Prevention Policy with an effective date of 5/24 that was provided by the DON showed: Policy: All residents who are at risk for falls will be identified through a comprehensive assessment process. This risk will be addressed in the residents individualized treatment plan and be evaluated through the IDC (Interdisciplinary) Process. Procedure: 1. Interventions are implemented based on risk areas identified by the Falls Risk Assessment . 5. Safety devices (Physician Order is required) i.e. tab alarms to chair or bed or both, side rails up or down, self-release safety belt, wedge cushions, antitippers for wheelchairs. On 10/08/24 at 12:25 PM, the survey team met with the LNHA, DON, Medical Director, and the VP (Vice President) of Senior Services for an Exit Conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-33.1(d)

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure a.) complete documentation of supplemental intake, for residents identified as at risk for malnutrition according to the physician's order and care plan interventions for two (2) of four (4) residents, Residents #90 and #124, and b.) monitored weight according to the physician order for one (1) of four (4) residents, Resident #124, reviewed for nutrition. This deficient practice was evidenced by the following: 1. On 10/03/24 at 10:46 AM, the surveyor observed Resident #90 sitting up in bed, alert and verbally responsive. The resident stated that they would lose weight, gain weight back, and lose weight again. The resident stated recently they had a good appetite and did receive supplement drinks that they usually consumed. The resident had no concerns with their care. The surveyor reviewed the paper and electronic medical record (EMR) of Resident #90. The Resident Face Sheet (FS; a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, right lower leg fracture, anemia, thalassemia (a blood disorder that occurs when the body doesn't produce enough hemoglobin, a protein in red blood cells that carries oxygen), congestive heart failure, chronic kidney disease, and atrial fibrillation (a heart condition that causes an irregular, often very fast heartbeat). A comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/11/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #90 scored a 11 out of 15, which indicated the resident had moderate cognitive impairment. A physician's order (PO) dated 8/18/24 read, Ensure Plus, one can two times a day as supplement; every day at 10 AM and 7 PM; please record amount taken in monitoring section. A care plan (CP) with a focus that read, at risk for Nutrition/hydration deficits due to the following areas: recent surgery, bowel concerns; at risk for constipation; risk for skin breakdown; edema; characteristics of malnutrition; recent poor by mouth intake for food and fluids. The CP included goal, [Resident] will consume greater than 75% of fluids provided. Interventions included Encourage by mouth fluids and provide nutrient dense supplements Ensure BID [two times a day]. A review of the August 2024 Medication Administration Record (MAR) and the monitoring section for intake documentation in the EMR revealed there was no recorded amount of the ensure supplement consumed by the resident on the following entries: 8/01/24 at 10 AM and 7 PM 8/02/24 at 10 AM 8/03/24 at 10 AM and 7 PM 8/04/24 at 10 AM and 7 PM 8/05/24 at 10 AM 8/06/24 at 10 AM 8/08/24 at 10 AM and 7 PM 8/09/24 at 10 AM 8/10/24 at 10 AM 8/11/24 at 10 AM and 7 PM 8/12/24 at 10 AM 8/14/24 at 10 AM and 7 PM 8/15/24 at 10 AM A review of the September 2024 MAR and the monitoring section for intake documentation in the EMR revealed there was no recorded amount of the ensure supplement consumed by the resident on the following entries: 9/02/24 at 7 PM 9/03/24 at 7 PM 9/07/24 at 10 AM and 7 PM 9/08/24 at 10 AM and 7 PM 9/09/24 at 7 PM 9/11/24 at 7 PM 9/12/24 at 10 AM and 7 PM 9/13/24 at 7 PM 9/14/24 at 10 AM 9/16/24 at 10 AM and 7 PM 9/17/24 at 7 PM 9/18/24 at 10 AM and 7 PM 9/19/24 at 7 PM 9/20/24 at 7 PM 9/21/24 at 7 PM 9/25/24 at 10 AM and 7 PM 9/26/24 at 7 PM 9/27/24 at 7 PM 9/29/24 at 10 AM 9/30/24 at 10 AM and 7 PM A review of the Dietician progress note (PN), dated 8/19/24 indicated the resident had a fair to good appetite, and had significant weight loss during a recent hospitalization . The resident weighed 198 pounds (lbs) on 7/08/24 and 176.8 lbs on 8/17/24, 21 lbs down. The Dietician's recommendations included but were not limited to, provide ensure plus two times a day and to monitor weights, labs (laboratory), by mouth intake and bowel movements. A follow up Dietician PN, dated 9/04/24, revealed the resident had some weight fluctuations, wanted to reduce the Ensure to once a day, and had varying by mouth intake. On 10/03/24 at 10:56 AM, the surveyor interviewed the Registered Nurse (RN) assigned to care for Resident #90. The RN stated the resident's appetite and food intake varied. Additionally, the RN stated the resident's supplement intake varied and they would refuse the supplement sometimes. On that same date and time, the surveyor asked about the documentation of the consumed intake by the resident. The RN confirmed the supplement entry in the MAR would be signed and the amount consumed recorded. The RN further explained when signing the entry, it would prompt the nurse to record the amount consumed. The surveyor asked about the blank entries observed in the MAR. The RN acknowledged it was expected for the supplement amount consumed to be recorded in the EMR and that there were times the resident did not want to drink the supplement at the time administered. The surveyor asked if the resident's intake of the supplement was monitored and recorded later. The RN stated no. On 10/04/24 at 01:10 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) about supplement documentation. The ADON stated the nurse would review the PO in the MAR, administer as ordered and record the amount the resident had consumed. The surveyor discussed the concern for entries identified in the EMR of the supplement amount consumed not be recorded by the nurses. The ADON acknowledged it was expected for the amount consumed to be documented and if it could not be entered at the time of administration a PN could be written by the nurses. On 10/07/24 at 01:10 PM, the surveyor, in the presence of the survey team, notified the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the identified in the EMR of the supplement amount consumed not be recorded by the nurses for a resident at risk for malnutrition. On 10/08/24 at 12:04 PM, the LNHA and the DON met with the survey team. The DON stated nursing staff were in-serviced about the supplement omissions and would continue to monitor to optimize the documentation process. There was no additional information provided by the facility. 38327 2. On 9/30/24 at 11:34 AM, the surveyor observed Resident #124 lying on their air mattress. The resident stated he/she was a picky eater, and aware that had loss some weight. The resident further stated that they were on a supplement to gain weight. On 10/02/24 at 8:30 AM, the surveyor interviewed the resident inside their room. The resident stated that the facility food was okay and had no concerns. The surveyor reviewed the medical records of Resident #124 and revealed: According to the Resident FS, the resident was admitted to the facility with a diagnosis that included but was not limited to hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, anemia (low blood count), anxiety disorder, and dependence on supplemental oxygen. The resident's most recent quarterly MDS (qMDS) with an ARD of 8/13/24 revealed in Section C Cognitive Status with a BIMS score of 14 out of 15 which reflected that resident was cognitively intact. The qMDS Section K Swallowing/Nutritional Status revealed that the resident had a weight loss of 5% or more in the last month or a loss of 10% in the last six months. The personalized CP with a focus on Nutrition with an effective date of 02/10/24 showed the resident's admission weight was 190 lbs. The CP interventions included but were not limited to provide nutrient-dense supplements and provide a selective menu for residents with an effective date of 02/10/24. A review of the PN that was electronically signed by the Registered Dietician (RD) on 9/23/24 showed that Resident #124 had a significant weight loss in the past six months, 39.5 lbs, the appetite was inconsistent, and ensure plus (strawberry) was offered and accepted by the resident. The PN included will continue to monitor intake/weight and intervene as appropriate. Further review of the PN showed that on 9/25/24 the Physician documented on their monthly notes that there was no mention in the conversation of any associated symptoms such as pain, and weight loss. The PN included an assessment and plan: -Diastolic CHF (congestive heart failure): on diuretics torsemide 10 mg (milligrams) once daily, monitor weights and cardiology follow-up outpatient. A review of the September and October 2024 PO revealed: -order date 8/23/24 Ensure plus one can 1 x a day as supplement flavor strawberry at 02:00 PM. Please record the amount taken in monitoring. -02/07/24 Please take daily weight in AM, before breakfast. Protocol: Please record weight in the monitoring section. Monitoring Weight. The above PO for Ensure plus and daily weight were transcribed to the MAR and showed: -September 2024 Ensure: four (4) out of 30 days were administered with 237 ml (milliliters) amount, five (5) out of 30 days coded with an asterisk (not administered), and the rest of the days were blank. -September 2024 Daily weight: two (2) out of 30 days had documentation of the resident's weight, 27 out of 30 days coded as refused, and one (1) out of 30 days was blank. -October 2024 Ensure: 2 out of 2 were blanks. -October 2024 Daily weight: 2 out of 2 were coded refused. Further review of the medical records showed that there was no documented evidence that the Physician was notified of the resident's refusal for daily weight and supplements. There was no documented evidence as to why the supplement and weight were refused and if they were addressed by the clinical team. On 10/03/24 at 10:59 AM, the surveyor interviewed the Team Leader/Registered Nurse (TL/RN) who was at the medication (med) cart for Beach St (street) in Heritage Manor East (HME). The TL/RN informed the surveyor that the supplement Ensure should be in the MAR and the intake amount should be documented in the MAR. The surveyor then notified the TL/RN of the above concerns and findings. At that same time, the surveyor asked the TL/RN what the expectation for nurses was when the resident had multiple refusals to obtain daily weight and the resident's supplement. The TL/RN stated that the nurse should have called the Physician and notify that daily weight was not done or refused as well as the ensure. She also stated that the nurse should document it in the EMR communication with the Physician. On 10/03/24 at 12:32 PM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above concern and findings. On 10/04/24 at 11:56 AM, the surveyor interviewed the RD in the nursing station of HME. The RD informed the surveyor that she had been working in the facility for four years and that she covered all LTC (Long Term Care) units including HME. While the surveyor and RD reviewing the white binder for weights, the RD stated that the records for weights were the monthly weights that she prepared for each unit and there was no separate list for daily weights, and it was the nurses who entered the daily weights. She further stated that the process for monthly weights, I put a list collected by the 6th of the month, I review who needs to reweigh and complete the reweigh. The RD also stated that everything should be completed including the reweigh on the 10th of the month. On that same date and time, the RD informed the surveyor that the weight meeting was every 3rd of the week of the month. She stated that a significant weight loss of 5% in a month and 10% weight loss in 6 months weight loss of body weight then intervention provided. She further stated that she verbally follows up on how the resident takes supplements like Ensure or Glucerna. The RD also stated that I do not check the record or staff input of the intake, I don't know where to see and check them. At that same time, the surveyor asked how you know and follow up on the intervention if they were effective, and the RD stated, I don't know where to look. The surveyor also asked about the daily weight and how do you know it was being done. The RD stated, I don't order the daily weights, usually they order that daily weights in PACU (Post-acute care unit) specifically for CHF residents, and when the resident transitioned to LTC I usually recommend to discontinue (d/c) the order for daily weight. At that time, the surveyor notified the RD of the above concerns with Resident#124. The surveyor asked the RD if she recommended d/c the daily weight of the resident, and the RD stated, I can not answer that. On 10/07/24 at 01:09 PM, the survey team met with the LNHA and DON. The DON stated that I could only move forward with concerns with Resident#124. The facility did not provide additional information. On 10/08/24 at 12:04 PM, the survey team met with the LNHA and DON. The DON stated that from the clinical discussion, we had about the supplement, we did education and continually did tight audits. The DON stated that we talked about the omission to the MAR which we continually educate staff and auditing acuities. A review of the facility's High Calorie/High Protein Supplements Policy with an effective date of 01/24 that was provided by the DON revealed: Purpose: To provide supplemental caloric support to at risk residents. Procedure: A. Amount of supplement and frequency will be determined through nutrition assessment based on individual needs. B. All commercial medical food supplements will be ordered or approved by a physician or designee. C. Nursing staff will supervise the delivery and consumption of all supplements and record them appropriately in the MAR. D. Supplement acceptance will be documented in the progress notes, care plans, and assessments as appropriate A review of the facility's Weight Taking and Review Policy with an effective date of 01/24 that was provided by the DON showed: Policy: Residents will be weighed on a monthly basis unless more frequent monitoring is indicated. These weights will be reviewed for trending or significant changes with the IDC (Interdisciplinary) Team monthly. Procedure: D. The wing weight sheets will have specific dates for weighing residents J. Weighing intervals more often than monthly should be ordered for specified time periods and will be supervised by the wing nurse and recorded on the MAR for those specific time frames. These weights will be reviewed by the RD as per weighing interval and reported at the IDC meeting. K. All resident weights will be entered into the resident's medical record by the Nutrition Services or Nursing designee into the monitoring section of electronic medical records On 10/08/24 at 12:25 PM, the survey team met with the LNHA, DON, Medical Director, and the VP (Vice President) of Senior Services for an Exit Conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-17.1(c), 17.2(d), 27.1(a)

Based on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regards to ensuring completion of neuro (neurological) checks after a resident had a fall for one (1) of three (3) residents (Resident #415) reviewed for falls. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 10/01/24 at 11:57 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the fall investigation for Resident #415. On 10/03/24 at 9:10 AM, the surveyor reviewed a fall investigation, dated 9/27/24 for Resident #415. The resident had an unwitnessed fall incident at approximately 3:00 AM in which Resident #415 was found lying on the floor. The resident reported they fell and hit their right knee and head. The physician and the resident's representative were notified. The resident had an abrasion to the right side of their head and neuro-checks (brief neurological assessments performed repeatedly to monitor and evaluate a person's mental status and brain function) were initiated. The surveyor reviewed the paper and electronic medical record (EMR) of Resident #415. The Resident Face Sheet (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, colon cancer, chronic obstructive pulmonary (lung) disease, muscle weakness, and atrial fibrillation (a heart condition that causes an irregular, often very fast heartbeat). A Minimum Data Set (MDS) assessment, a tool to facilitate the management of care, with an assessment reference date of 10/01/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #415 scored a 12 out of 15, which indicated the resident had moderate cognitive impairment. A physician's order (PO) dated 9/27/24 read, Neuro-checks every 30 minutes for an hour then every hour for 2 hours, and then every 4 hours for 24 hours. A nurse progress note (PN) by the Licensed Practical Nurse (LPN) dated 9/27/24 at 7:41 AM documented that the resident had a fall incident at three in which the resident was found on the floor with a small abrasion to the right side of their head. A PN by the LPN dated 9/27/24 at 7:41 AM, had a start date/time 9/27/24 3:38 AM, documented a detailed neuro check assessment and vital signs for resident. The other sections of the note included mental status assessments, pupil assessment, pain assessment, and range of motion of extremities were completed. In the section that read time observed, the LPN checked 3 AM, 4 AM, 5 AM and 6 AM. The note did not detail a neuro check assessment for each time indicated that the resident was observed. A follow up PN by LPN dated 9/27/24 at 7:46 AM documented that neuro checks were initiated, and the physician was notified. A PN dated 9/27/24 at 11:48 AM, included a detailed neuro-check assessment and vital signs with an observed time of 11:15 AM. A PN dated 9/27/24 at 4:27 PM included a detailed neuro-check assessment and vital signs with an observed time of 3:15 PM and 11:15 PM. The note did not detail a neuro check assessment for each time the resident was observed. A PN dated 9/27/24 at 7:47 PM, included a detailed neuro-check assessment and vital signs with an observed time of 7:15 PM. A PN dated 9/28/24 at 4:58 PM, included a detailed neuro-check assessment and vital signs with an observed time of 7:15 AM. There were no other PN found that documented any other neuro-check assessment done after the resident's fall. On 10/03/24 at 10:56 AM, the surveyor interviewed the Registered Nurse (RN) about falls and neurochecks. The RN stated for unwitnessed falls neuro-checks would be initiated and the PO would be obtained. The RN further explained the PO for neuro-checks would outline the frequency it was to be done. On 10/03/24 at 11:24 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) about neurochecks. The ADON confirmed neuro-checks would be performed with unwitnessed falls. The ADON reviewed in the EMR, the protocol of neuro-check orders to inform the surveyor of its frequency. The ADON stated neurochecks were to be completed every 15 minutes for one hour, every 30 minutes for one hour, every one for 2 hours, every four hours for 20 hours. The PO would prompt in the EMR for when the nurses were to document their neuro-check assessments. On 10/03/24 at 02:14 PM, the surveyor placed a call to the LPN who was assigned to care for Resident #415 at the time of the fall with no answer and a message to return the call was left. The surveyor did not receive a return call. On 10/04/24 at 02:40 PM, the surveyor informed the Director of Nursing (DON) of the concern regarding the neuro-checks completed for Resident #415. The DON confirmed the PO for neuro-checks would specify the frequency for assessments and documentation to be completed. The DON stated would follow up and provide additional information. On 10/07/24 at 01:10 PM, the Licensed Nursing Home Administrator (LNHA) and the DON met with the survey team. The DON acknowledged the neuro check assessments were not complete and in-service education was being provided to the nurse about it. On 10/08/24 9:00 AM, the surveyor requested for any policy related to neuro-check assessments. On 10/08/24 at 10:37 AM, the DON stated there was no policy related to neuro-checks found. On 10/08/24 at 12:04 PM, the LNHA and DON met with survey team. The DON stated for education was being provided regarding neuro-checks protocols and they were working to optimize the documentation process. There was no additional information provided by the facility. The surveyor reviewed the facility provided policy titled, Resident Safety Program- Fall Prevention with a last reviewed date of 5/24. The policy did not address neuro-check assessments or protocols. NJAC 8:39-11.2 (b); 27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for four (4) of 38 residents, (Residents #15, #153, #194, and #253) reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual October 2024, for Use Effective October 1, 2024, revealed: Section C Cognitive Patterns: C0100: Should Brief Interview for Mental Status Be Conducted? Coding Instructions o Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Section J Health Conditions: J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment, whichever is more recent. Coding Instructions for J1900. Determine the number of falls that occurred since admission/entry or reentry or prior assessment and code the level of fall-related injury for each. Code each fall only once. If the resident has multiple injuries in a single fall, code the fall for the highest level of injury. Definitions: Injury (Except major) Includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. Section M-5, under M0210 (Unhealed Pressure Ulcers/Injuries) Coding Instructions read: .Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back period. Then skip to M1030, Number of Venous and Arterial Ulcers .Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage Chapter 3-page M-11, under M0300A (Number of Stage 1 Pressure Injuries) it read, Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . 1. On 9/30/24 at 11:21 AM, Surveyor #1 (S#1) observed Resident #15 lying in their bed with a visitor at the bedside. The resident was using oxygen via nasal cannula (a medical device that consists of a small, flexible tube with two prongs that sit inside a patient's nostrils) that was attached to the concentrator. On 10/02/24 at 12:47 PM, Surveyor #2 (S#2) observed Resident #15 awake while resting in their bed. The surveyor greeted the resident. The surveyor reviewed the medical records of Resident #15 and revealed the following: A review of the Face Sheet (FS; an admission summary) reflected that the resident was admitted to the facility with a diagnoses that included but was not limited to: Diabetes mellitus (abnormal level of sugars in blood), and HTN (high blood pressure). A review of significant change in status MDS (SCMDS) with an Assessment Reference Date (ARD) of 9/13/24, under Section B0700. Makes Self Understood- Ability to express ideas and wants, consider both verbal and non-verbal expression- reflected Code 2 which indicated: 2.) Sometimes understood- ability is limited to making concrete request. Review of Section C - Cognitive Pattern did not reflect Resident #15's Brief Interview for Mental Status (BIMS) score. Further review of MDS question C0100: Should BIMS (C0200-C0500) be conducted? Reflected Code 0 which indicated No (resident is rarely/never understood) 'Skip to and complete C0700-C1000, Staff Assessment for Mental Status. On SMDS, Surveyor #2 observed that BIMS interview was not conducted. On 10/08/24 at 9: 47 AM, the surveyor met with Director of Nursing (DON) and notified the above findings and concerns. 2. On 9/30/24 at 11:43 AM, during an initial tour, S#2 observed Resident #194 in Resident lounge/C lounge. The resident was resting, with eyes closed in their geri-chair. On 10/02/24 at 11:11 AM, S#2 observed resident asleep in their bed. There was an orange-colored round sticker [dot] next to their name on the name plate. The surveyor reviewed the medical records of Resident #194 and revealed the following: A review of the FS reflected that the resident was admitted to the facility with a diagnoses that included but was not limited to bipolar disorder, anxiety disorder and major depressive disorder. A review of SCMDS with an ARD of 8/09/24, under Section B0700. Makes Self Understood- Ability to express ideas and wants, consider both verbal and non-verbal expression- reflected Code 2 which indicated: 2.) Sometimes understood- ability is limited to making concrete request. Review of Section C - Cognitive Pattern did not reflect Resident #15's BIMS score. Further review of MDS question C0100: Should BIMS (C0200-C0500) be conducted? Reflected Code 0 which indicated No (resident is rarely/never understood) 'Skip to and complete C0700-C1000, Staff Assessment for Mental Status. On SCMDS, Surveyor #2 observed that BIMS interview was not conducted. During an interview with S#2 on 10/07/24 at 11:33 AM, Registered Nurse/MDS Coordinator #1 (RN/MDSC#1) stated that if a resident was coded as sometimes understood in Section B, BIMS would be attempted. On 10/07/24 at 01:09 PM, the survey team met with Licensed Nursing Home Administrator (LNHA) and DON and notified the above findings and concerns. 38327 3. On 9/30/24 at 11:29 AM, S#1 observed Resident #153 was not in their room. The room was observed with a bed alarm on top of the nightstand table and a low bed. The bed had a regular mattress [not specialized]. S#1 reviewed the medical records of Resident #153 and revealed the following: The FS showed that the resident was admitted to the facility with a diagnosis that included but was not limited to Alzheimer's disease unspecified, dementia in other diseases classified elsewhere, muscle weakness (generalized), other sequelae of cerebral infarction (stroke), and repeated falls. A review of the provided Matrix for Providers by the DON showed that the resident was triggered for Alzheimer's dementia and fall. A review of the provided fall investigations by the DON revealed: -3/25/24 at 8:10 AM unwitnessed fall, hit head, and complaint (c/o) pain on the left side of the head. -5/11/24 at 10:15 AM unwitnessed fall and no injury. -8/04/24 unwitnessed fall, no injury, and pad alarm was sounding off. The most recent SCMDS, with an ARD of 6/29/2024, showed that the cognitive skills for daily decision-making were coded #2 which indicated that the resident had moderately impaired cognition. Section J Health Conditions indicated that the resident had a fall incident with no injury. The quarterly MDS (qMDS) with an ARD of 3/29/24 revealed that on Section J, the resident had a fall incident with no injury. Further review of the above documents showed there were three unwitnessed fall incidents with two with no injuries and one with c/o pain on the left side of the head on 3/25/24. The 3/29/24 qMDS showed that Section J for fall was coded for no injury even though the resident c/o pain (minor injury). On 10/02/24 at 8:57 AM, S#1 in the presence of another surveyor interviewed the MDS Manager (MDSM). The MDSM stated we follow the RAI manual and that there was no separate policy for MDS. The MDSM further stated we gather the information from the interviews, charts which included notes and orders when doing MDS. She also stated that for falls we check the investigation. On that same date and time, the surveyor asked the MDSM if the resident c/o pain during fall incident, would that be considered an injury. The MDSM stated yes, minor injury and should be coded in the MDS. S#1 then notified the MDSM of the above findings and concerns regarding MDS accuracy for qMDS on 3/29/24. The MDSM stated that she will get back to the surveyor. On 10/02/24 at 01:13 PM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above findings and concerns. 46049 4. On 9/30/24 at 10:18 AM, Surveyor #3 (S#3) observed Resident #253 lying in their bed, alert and verbally responsive. The resident reported they had a wound on their backside. The resident stated the wound was being treated by the staff and a wound consultant who would visit. S#3 reviewed the electronic and paper medical record for Resident #253. The Resident FS documented that the resident had diagnoses that included but were not limited to, dementia, spondylosis (degeneration of the bones and disks in the neck), dorsalgia (pain in the back), anxiety, and type II diabetes mellitus. A comprehensive MDS assessment with an ARD of 9/04/24, indicated the facility assessed the resident's cognition using a BIMS test. Resident #253 scored a 09 out of 15, which indicated the resident had moderate cognitive impairment. In Section M of the MDS, the resident was coded as having no unhealed pressure ulcers or injuries. An assessment dated [DATE] which included a skin exam of the resident documented Resident #253 had non-blanchable redness (stage I pressure injury) to the sacrum. On 10/03/24 at 01:56 PM, S#3 interviewed Registered Nurse/MDS Coordinator #2 (RN/MDSC#2) who stated a resident's medical records including but not limited to, assessments, physician orders, treatments and preventative measures would be reviewed. RN/MDSC#2 stated if a resident had a wound within the look back period from the assessment reference date of the MDS, it should be coded in the assessment. S#3 reviewed the concern for Resident #253 who had non-blanchable redness (stage I) at time of MDS assessment, and it was not coded. RN/MDSC#2 would review the medical record and provide further information. On 10/04/24 at 9:11 AM, the DON informed the surveyor that she audited with RN/MDSC#2 the MDS of Resident #253. The DON stated the non-blanchable redness (stage I) should have been coded in the MDS assessment. On 10/07/24 at 01:10 PM, S#3, in the presence of the survey team, informed the LNHA and the DON of the concern for Resident #253's MDS accuracy. The DON stated RN/MDSC#2 modified the MDS assessment. On 10/08/24 at 12:25 PM, the survey team met with the LNHA, DON, Medical Director, and the VP (Vice President) of Senior Services for an Exit Conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-33.2 (d)

Based on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to ensure accurate documentation and review of a resident's advance directives for one (1) of five (5) residents (Resident #253) reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #253. The Resident Face Sheet (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, dementia, spondylosis (degeneration of the bones and disks in the neck), and type 2 diabetes mellitus. A comprehensive Minimum Data Set (MDS) assessment, a tool to facilitate the management of care, dated [DATE], indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #253 scored a 09 out of 15, which indicated the resident had moderate cognitive impairment. A physician's order (PO) dated [DATE] read, Do Not Intubate (DNI). A PO dated [DATE] read, Do Not Resuscitate (DNR). The resident's paper chart included a New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, dated [DATE], which documented the resident had advance directives (AD) that they desired attempt resuscitation/CPR[Cardiopulmonary Resuscitation] and Do not Intubate. The form was signed by the resident's representative (RR) and an advance practice nurse (APN). A review of progress notes revealed there was no documentation that indicated the resident desired to have a DNR status. On [DATE] at 10:44 AM, the surveyor interviewed a Registered Nurse (RN) about AD protocol. The RN stated nurses could find the resident's AD and code status in the electronic medical record (EMR). The RN further explained on the main screen for a resident in the EMR, the code status would be indicated at the top of the screen and could also be found under the PO. The RN stated the nurses, health care providers (physicians and APNs), and the social worker (SW) would follow up about AD. On [DATE] at 10:52 AM, the surveyor interviewed the Registered Nurse/Team Leader (RN/TL) about AD protocol. The RN/TL stated upon admission the resident/RR would be asked to provide AD, which would include living wills, and/or POLST. The RN/TL further explained if they had no AD, staff would provide education and offer to complete a POLST. The nurses and SW would follow up on a resident's AD. The physician would be notified, orders obtained for a resident's code status. Furthermore, a health care provider would review with the resident/RR the POLST, and it would be signed. The RN/TL stated the staff would make sure AD information in the EMR and provided AD documentation would match. The surveyor reviewed with the RN/TL Resident #253's POLST and documentation in the EMR. The RN/TL stated she would follow up and provide further information. On [DATE] at 11:57 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the facility's AD policy. On [DATE] at 01:14 PM, the Director of Nursing (DON) provided the AD Policy. On [DATE] at 01:26 PM, the RN/TL informed the surveyor that she had confirmed with the RR the desired AD. The RN/TL stated they wished resuscitation to be attempted and a DNI code status for the resident. The surveyor asked the RN/TL why a DNR order was entered in Resident #253's EMR. The RN/TL acknowledged the POLST was correct and the DNR order should not have been entered in the resident's EMR. On [DATE] at 01:15 PM, the survey team met with the DON and the LNHA. The surveyor notified the facility management of the above concerns for Resident #253's AD. There was no verbal response by the facility at this time. On [DATE] at 12:32 PM, the DON and the LNHA met with the survey team. The DON acknowledged the concern with Resident #253's AD. The DON stated an audit of other residents' medical records was conducted, and re-education was provided to the staff. A review of the facility provided policy titled, Advance Directives, POLST, Emergency Orders with an effective date of ,d+[DATE] read under Procedure, B. Choices and Orders for Emergency Care: a. A completed and executed POLST is a legal physician/LIP [Licensed Independent Practitioner] order and is transferrable and immediately actionable . N.J.A.C. 8:,d+[DATE].6

Complaint #NJ00163279 Based on observation, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide adequate supervision for a resident who was an elopement risk for 1 of 3 residents reviewed for elopement on a secured behavioral unit (Resident #229). The facility failed to provide adequate supervision and identify that a resident with a history of elopement and cognitive impairment was missing upon the activation of an exit door alarm on a secured unit. This posed a serious and immediate risk to the health, safety, and well-being of Resident #229. The Immediate Jeopardy (IJ) situation was determined to have existed on 4/7/2023 when Resident #229 exited the building without staff knowledge and was found by law enforcement 1.2 miles away from the facility, which is adjacent to a wide, double-lane roadway. The facility developed and implemented a corrective action plan, and the past-noncompliance IJ was determined to have been removed on 4/7/2023. The facility's noncompliance was corrected on 4/7/2023. The Licensed Nursing Home Administrator (LNHA) and other facility administration were notified of the Immediate Jeopardy on 6/12/23 at 3:13 PM. The LNHA stated it was human error by a Certified Nursing Aide in their lack of response to the sounding door alarm. The LNHA further stated the facility followed protocol after discovering that the resident could not be located by the staff on the unit and the facility implemented systemic corrective actions. On 6/12/2023 at 2:09 PM, the Administrator, Director of Nursing (DON), and Director of Quality (DQ) also acting as Assistant DON were informed of the past noncompliance IJ situation. This deficient practice was evidenced by the following: The surveyor reviewed the electronic medical record (eMAR) for Resident #229 which revealed the following: The facility's Resident Face Sheet (a one-page summary of important information about the patient) listed diagnoses that included, but were not limited to, Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/30/23, revealed the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS) score. The resident scored a 3 out of 15, which indicated that the resident had a severe cognitive impairment. The MDS assessment further revealed that the resident used a wander/elopement alarm daily and had diagnoses that included but were not limited to, Alzheimer's Disease, Anxiety Disorder, and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of the Physician's Order tab located in the eMAR documenting all current physician's orders for Resident #229, dated 3/23/23, read: ROAM TAG ALERT [a wander alarm] TO RIGHT ANKLE-ENSURE PLACEMENT Q [every] SHIFT FOR: ELOPEMENT PRECAUTION. Continued review of the physician's order tab with an entry for Resident #229, dated 3/23/23, read: ROAM TAG ALERT TO RIGHT ANKLE- ENSURE FUNCTION Q 11-7 SHIFT FOR: ELOPEMENT PRECAUTION. Review of an individualized care plan (CP) dated 4/3/2023 with a focus of elopement for Resident #229, listed interventions that included: ensuring placement and function of the roam tag alert on the resident's right ankle; redirecting and engaging the resident in another activity when the resident expressed the desire to go home or when seeking exits; and to notify the supervisor, ADON (Assistant Director of Nursing) immediately of any elopement attempts. A nursing progress note (PN) dated 3/23/23 revealed that the resident was exit seeking, pushing at unit exit doors. The PN further documented that the resident was redirected by staff. The PN indicated that the resident had a history of elopement prior to admission to the facility. Additional review of Resident #229 PNs revealed that on 3/25/23, 3/26/23, 4/2/23, and 4/4/23 the resident was exit seeking, pushing at exit doors on the unit, and had to be re-directed by the staff. The PNs on 4/2/23 and 4/4/23 further revealed that the resident was pushing at exit doors on the unit and setting off the alarms prior to re-direction by the staff. A review of an investigation report completed by the facility indicated that Resident #229 had an actual elopement on 4/7/23, and the investigation revealed the following: Resident #229 received care and medications by the night shift nurse on 4/7/23 at 5:55 AM. A review of security camera footage after the resident's elopement by the facility, revealed that the resident was last seen at 7:05 AM, in which the resident exited through a fire exit door on the unit, that led to the outside of the facility. At 9:09 AM, the Certified Nursing Aide/Certified Behavioral Technician (CNA/CBT) #2 assigned to the resident informed the Registered Nurse (RN) Team Leader that she could not locate Resident #229 and a search for the resident was initiated. At 9:11 AM, the ADON of the unit was notified, responded to the unit, and notified security to review the camera footage. At 9:15 AM -9:25 AM, the DON was notified, and an elopement code was activated. At 9:30 AM, the Administrator called 911. At 9:55 AM, the resident's family was notified. At 10:05 AM, Resident #229 was found by law enforcement at a park, 1.2 miles away from the facility and was returned to the unit. The resident was evaluated by the medical team and a body assessment was completed upon the resident's return to the facility. The resident had no physical injuries. On 6/8/23 at 11:26 AM, the surveyor interviewed the ADON with the Registered Nurse (RN) Team Leader of the secured behavioral unit about the elopement of Resident #229. The ADON stated that when the resident was found to be missing, the search began, and security looked at camera footage to identify where the resident went. The DON stated that she reviewed the security camera footage and the footage revealed that Resident #229 exited the behavior unit through doors located on the C-wing hall. The ADON who also reviewed the footage added that the resident exited through fire-egress doors- which could be opened when leaning on the doors for a certain amount of time as designed for emergency situations. The ADON informed the surveyor that after the resident was found, a medical workup was completed, staff were re-educated on elopement protocols and alarm systems, and the resident's CP was updated with a new intervention. The CP new intervention indicated that the resident was an early riser and should be directed to a supervised area to have breakfast and an early activity. On 6/8/23 at 11:45 AM, the surveyor observed Resident #229 by an activity day room on the unit. The resident was walking independently, alert, pleasant, able to verbalize their name and stated, My day is going ok when asked how they were doing. The resident was observed with a roam tag alert to their right ankle and supervised by staff. A review of post-elopement facility documents revealed that the facility provided formal remediation for staff directly involved. This included CNA/CBT #1, who shut the sounding alarm without notifying staff on the unit and CNA/CBT #2 who was the direct care for Resident #229, both received re-education and disciplinary action. All staff were re-educated on elopement protocols, the facility alert systems, door alarms and rounding on residents. At the time of the survey, security camera footage was no longer available for the time of the incident on 4/7/23. On 6/9/23 at 11:25 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1 who was assigned to Resident #229 at the time of the resident's elopement on 4/7/23. LPN #1 stated the resident eloped during shift change and at the time she was assisting another resident who was having bloodwork drawn. LPN #1 acknowledged she did not conduct rounds or see the resident that morning prior to becoming aware that the resident was missing. LPN #1 stated that she had assumed the CNA/CBT's conducted rounds on the residents. LPN#1 stated that she became aware the resident was missing when CNA/CBT#2, who was assigned to the resident, reported that she was unable to locate the resident. They began searching for the resident and elopement protocols were initiated. LPN #1 stated that after the elopement incident, she ensures that she conducts rounds on the residents. On 6/9/23 at 12:19 PM, the surveyor interviewed the ADON about elopement protocols and about the elopement of Resident #229. The ADON stated it was human error, CNA/CBT #1 checked surrounding area by the exit door when she heard the door alarm sound off. After checking the area, CNA/CBT #1 turned off the alarm and continued her assignment. The ADON explained that if an exit door alarm is triggered that a head count of residents should always be done by staff as there is the possibility of a door alarm being triggered by a resident. On 6/9/23 at 1:33 PM, the ADON provided the surveyor with a report for the alert system from the day of the elopement. The provided document was an activity log for Resident #229 for 4/7/23 from the roam tag alert system on the unit. The activity log indicated a log time of Friday 04/07/23, at 07:05:13 AM with a status that read Active Alarm Received. The last entry on the log was Friday 04/07/23 at 07:05:43 AM with a status that read Alarm Complete. On 6/9/23 at 1:45 PM, the surveyor along with the DON reviewed the report for the alert system from the day of the elopement. The DON stated that the alert system picked up Resident #229's roam tag alert when the resident opened the C-wing exit door and the last entry was indicated completed as the resident walked away from the exit door and the roam tag alert was no longer in range to be detected. On 6/12/23 at 11:35 AM, the surveyor interviewed CNA/CBT #2 who was assigned to care for Resident #229 on the day of the elopement. The surveyor asked CNA/CBT #2 if she saw Resident #229 or conducted rounds that morning. CNA/CBT #2 replied she arrived a few minutes late that day and stated, I don't know what happened that day, that she usually did rounds. The CNA/CBT #2 stated that she looked for the resident during breakfast time, around 9 AM, could not locate the resident, and notified the nurse. On 6/12/23 at 11:44 AM, the surveyor interviewed CNA/CBT #1 who worked on unit the day of Resident #229's elopement and responded to exit door alarm that was activated. CNA/CBT #1 stated at the start of the 7-3 day shift she went to the breakroom first then to the nurses' station, in which she heard an alarm from an exit door on the unit. CNA/CBT #1 stated that she looked for the exit door with the alarm and found it was the C-wing exit door. CNA/CBT #1 stated that she went through the exit doors, looked around the nearby area by the doors, and did not see anything. CNA/CBT #1 stated that she returned to the unit through the doors and cleared the door alarm. CNA/CBT #1 stated coworkers were aware she went to respond to the door alarm but could not recall what transpired then. CNA/CBT #1 informed the surveyor that she could not recall if she informed the nurse or supervisors about the door alarm she responded to. CNA/CBT #1 became visibly emotional during the interview with the surveyor, and stated the incident was all jumbled up in her mind. CNA/CBT #1 verified that she received formal re-education and disciplinary action after the elopement incident. The surveyor reviewed the facility's policy with an effective date of 8/22, titled Elopement Alert, which was provided by the Director of Quality. The policy included, under purpose, To provide a safe, organized, and effective response to a patient elopement. The policy did not address the procedure for response to the roam tag alert system and door alarm activation when a resident is found missing and an elopement code is activated. On 6/12/23 at 2:57 PM, the surveyor asked the DON for any other policies regarding the roam tag alert, staff response and protocols for activated door alarms and alert systems. The DON stated that once a door alarm was activated, it should be automatically assumed by the staff that a resident may have eloped and a head count should be initiated immediately to check that all residents are present on the unit. The DON revealed that there were no further related policies to be provided. On 6/12/23 at 3:13 PM, the survey team met with the Administrator, DON, and DQ about the elopement of Resident #229 and informed them of the IJ past non-compliance. The Administrator stated it was human error by CNA/CBT #1 in response to the door alarm, which she received formal remediation that included re-education and disciplinary action. The Administrator further stated the facility followed protocol after discovering that the resident could not be located by the staff on the unit. The Administrator could not comment on the expectation of the facility nursing staff for rounding on residents on the unit, but that all staff were re-educated, all processes and systems in place were checked. The survey team informed the facility that the failure to provide supervision to Resident #229 who had a history of elopement and exit-seeking behaviors leading up to the actual elopement on 4/7/23 when a CNA/CBT #1 did not appropriately respond to the alarming door to prevent elopement. This resulted in an IJ situation. On 6/13/2023 at 9:00 AM, the facility provided a copy of their corrective action plan that was developed and implemented beginning on 4/7/23 after Resident #229 eloped from the facility. Review of the plan revealed the following actions taken on 4/7/23: Mandatory re-education in-service on elopement precautions and policies was provided to all [NAME] [secured behavioral unit] staff. Roam alert technical re-training was provided to the staff Formal remediation for the one (1) staff person directly involved Security personnel was placed at the door for additional surveillance post-event evaluation [NAME] [alert] system was re-inspected and confirmed to be working properly The plan of care for the resident was updated Process review was initiated The plan further indicated ongoing education to staff regarding elopement precautions and policies, roam alert, and resident safety protocols; quarterly inspection and testing of the alert system; Monitoring resident behaviors for exit-seeking and implementing appropriate interventions for residents; The DON, Administrator, and/or designee will review any incidents and ensure necessary interventions are implemented; The facility will continue to self-report all incidents as required by NJ DOH regulations. After conducting observations, interviews, record review and review of pertinent documents, the survey team verified the facility implemented all components of the action plan and the deficient practice was corrected on 4/7/23 prior to the annual survey entrance. On 6/13/23 at 11:43 AM, the surveyor interviewed the DON, about rounds conducted by nursing staff and about the nursing staff not being aware the resident was missing until approximately 2 hours later. The DON acknowledged it was expected for nursing staff to conduct rounds during the shift, including at the start of the shift. The DON further stated CNA/CBT #1, responded to the door alarm, searched the immediate area, cleared the door alarm but did not notify the nurse or supervisor about it. NJAC 8:39-33.1(d)

Based on observations, interviews, and record review, it was determined that the administration failed to ensure staff implemented the facility's abuse policy for three instances of abuse that occurred. Resident #105 assaulted Resident #197, Resident #198, and Resident #234. The assault against Resident #197 resulted in a laceration that required sutures. This had the potential to affect all residents. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate jeopardy (IJ) was related to State Operations Manual, Appendix PP, S483.70 (Administration) at a scope and severity of L. The IJ began on 08/02/2021 when Resident #105 returned to the facility after the resident was sent to a psychiatric long-term care following a physical assault on Resident #197. Although the record indicated Resident #105 continued to exhibit aggressive behaviors which included grabbing, hitting, and using vulgar language on staff and residents upon the resident's return from the psychiatric setting, the facility failed to put measures in place to ensure residents were free from abuse perpetrated by Resident #105. The resident assaulted two additional residents respectively on 08/13/2021 and on 10/07/2021. On 10/09/2021 at 6:18 PM, an immediate jeopardy (IJ) was identified. At 9:55 PM, the facility administrator was provided with the completed IJ template and notified of the existence of an IJ for abuse. The Administrator signed the template and returned the original to the survey team. A Removal Plan was requested. On 10/10/2021, the survey team conducted an onsite verification to verify the Removal Plan had been implemented. Resident #105 had been removed from the facility on 10/10/2021. The facility continued to train staff on recognizing and preventing, reporting, and investigating abuse. The IJ continued until 10/10/2021 at 6:17 PM, when the survey team verified the elements of the Removal Plan had been implemented. The noncompliance remained on 10/10/2021 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the facility continuing in-servicing with facility staff. Findings included: The October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], indicated the resident's cognition was moderately impaired with a SAMS (Staff Assessment for Mental Status). The resident required physical assistance of two persons to dressing and toileting. The resident required physical assistance of one person for personal hygiene. The resident required assistance with setup for bed mobility and eating. The resident exhibited behavioral symptoms such as kicking, hitting, pushing, scratching, grabbing and sexual abuse directed towards others. The resident's identified symptoms put others at significant risk for physical injury. The resident significantly intrudes on the privacy or activity of others. The resident exhibited the behaviors four to six times daily. The resident currently resided in a locked behavior unit. Observations conducted during the survey from 10/06/2021 through 10/09/2021 revealed Resident #105 was not monitored and was by themself. The resident was always observed in the personal spaces of other residents with closed fist, threatening to punch them. Resident #105 continuously said derogative language, such as using the F-word and B-word towards staff and residents. The resident grabbed staff when they walked by the resident. The observations revealed staff sat at the nurses' station and at the lounges across the unit and were not able to protect other residents should Resident #105 decide to assault a resident. On 10/06/2021 at 3:29 PM, Resident #105 was heard saying the F word which was directed at staff and residents on the [NAME] Unit. Resident #105 approached the surveyor with a closed fist, threatening to punch the surveyor during this time. On 10/07/2021 at 11:05 AM, Resident #105 aggressively grabbed the Rehab Assistant (RA) by his left arm when the RA walked by the resident. Resident #105 had multiple incidents of abuse, and the facility failed to implement their abuse policies to prohibit abuse, protect the residents, and prevent further abuse. 1. Review of a facility incident report, dated on 06/02/2021, indicated it was reported by an unidentified eyewitness that Resident #197 was propelling themself in their wheelchair on the [NAME] Unit hallway trying to get past Resident #105. The incident report indicated Resident #197 told Resident #105 to excuse them, and Resident #105 responded by punching Resident #197 with a closed fist, which caused a laceration to Resident #197's upper lip. The incident report indicated Resident #197 required an emergency room visit to get their upper lip sutured. The incident report indicated that the facility sent Resident #105 to a psychiatric long-term care, where Resident #105 was admitted from 06/02/2021 through 08/02/2021. Although the 08/02/2021 hospital discharge record indicated that Resident #105 returned to the facility with an order of an antipsychotic ([MEDICATION(S)] 5 milligram [mg] tablet, give one tablet [5mg] by oral route three times per day) added to the resident's medication regimen, the nursing progress notes indicated that Resident #105 continued to exhibit aggressive behaviors. Upon Resident #105's return to the facility and the documented continued aggressive behaviors of the resident, the facility failed to address the unprovoked physical assault Resident #105 directed towards Resident #197 by failing to put a measure in place to prevent future physical assault directed by Resident #105 to other residents at the facility. There was no evidence in the record that the facility followed up with Resident #197 to know how the interaction with Resident #105 made the resident feel. Resident #105's care plan was not updated to reflect any new intervention. The October 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two persons for transfer. During an interview on 10/09/2021 at 1:50 PM, Resident #197 stated they frequently had a nightmare about the situation (referring to the assault incident perpetrated by Resident #105 against them). The resident stated they stayed in their room when Resident #105 was in the common area. Resident #197 stated that Resident #105 was a monster who tormented women. The resident stated that facility staff did not interview Resident #197 about the incident after Resident #197 returned from the hospital. 2. Review of a facility incident report, dated 08/13/2021, indicated it was reported by an unidentified eyewitness that Resident #105 was sexually inappropriate with Resident #198. Per the report, Resident #105 was observed to have touched Resident #198 on their buttocks while Resident #198 was walking in an unidentified hallway. It was noted in the report that when Resident #198 questioned why Resident #105 touched them inappropriately, Resident #105 pushed Resident #198 to the floor. A review of Resident #198's medical record indicated the facility assessed Resident #198 in this case to rule out any injury. There was no documentation of a follow-up communication with Resident #198 to know how the resident felt following the interaction with Resident #105. Review of Resident #105's medical record indicated a monthly psychology follow-up was done on 09/14/2021 at 10:45 AM, after the incident. The medical record did not indicate the facility made the psychiatrist aware of the inappropriate sexual behavior Resident #105 exhibited towards Resident #198. Resident #105 continued to be reported, per nursing progress notes, to exhibit aggressive behaviors. However, the facility did not devise an intervention to ensure other residents at the facility continued to be free of abuse from Resident #105. The record indicated Resident #105 continued to abuse vulnerable residents and staff and posed a safety risk verbally and physically. Resident #105's care plan was not updated to reflect any new intervention. The October 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was independent with activities of daily living 3. Review of a progress note, dated 10/07/2021, indicated Resident #105 pulled on Resident #234's hair. Registered Nurse (RN) #11, who documented the information in the medical record that Resident #105 pulled Resident #234's hair, failed to report the incident to the facility's abuse coordinator. The facility did not report the incident to the state until the survey team brought it to their attention. During an interview with the Activity Assistant (AA) on 10/10/2021 at 3:39 PM, the AA stated that he witnessed the encounter firsthand. Per the AA, Resident #105 pulled Resident #234's hair such that it caused Resident #234's head to tilt abruptly towards the side of the pull and the resident yelled out in pain. Per the AA, Resident #105 had a repeat encounter with Resident #234 within a space of few minutes. The AA stated that he reported his observation to the nurse on the shift. On 10/07/2021 at 2:25 PM, Licensed Practical Nurse (LPN) #7 stated that Resident #105 was aggressive, combative, and not easily redirectable. LPN #7 stated that Resident #7 liked to say racial slurs and derogatory speech. She stated that Resident #105 got into other residents' personal space. LPN #7 stated that the resident had grabbed, hit, and punched staff and residents. LPN #7 stated, You need to know how to speak, in order to not get the resident agitated. LPN #7 reviewed Resident #105's care plan and acknowledged Resident #105's care plan related to the resident's behavior had not been updated after it was formulated on 02/24/2020 through 02/27/2020. LPN #7 stated that she had no remarks about the intervention portion of Resident #105's care plan which read, Allow behaviors to continue in a safe manner if it assists with keeping Resident #105 calm. On 10/07/2021 at 3:15 PM, Certified Behavioral Therapist (CBT) #1 stated that Resident #105 was aggressive towards residents and staff. He stated that Resident #105 insulted staff and residents with profanity. CBT #1 stated that the resident had hit staff and residents and was a safety concern to self and other residents. On 10/07/2021 at 11:39 AM, the RA stated that Resident #105 had been aggressive towards staff and residents since the resident's admission. On 10/09/2021 at 9:00 AM, Assistant Director of Nursing (ADON) #2 stated that Resident #105 had been very challenging with the resident's care. ADON #2 stated that Resident #105's behaviors created a stressful environment for other residents. ADON #2 stated that the only way the facility had limited the encounters with the resident was their proactiveness. Per ADON #2, Resident #105 had had more than ten incidents with staff and residents during which the resident physically assaulted staff and residents. ADON #2 stated that Resident #105 attacked residents and staff unprovoked. ADON #2 stated the facility had attempted to transfer the resident to another facility deemed more appropriate for the resident's care but were met with resistance. He gave an instance of when the facility sent the resident to [facility name omitted] which operated a psychiatric long-term care program, and Resident #105 was sent back within seven days with four-point restraints. He stated that no facility wanted to take responsibility for Resident #105. Addressing Resident #105's assault on Resident #197, ADON #2 stated that, following the incident on 06/02/2021, Resident #105 was sent to [Facility name omitted], psychiatric hospital, where the resident was admitted and managed until the resident returned on 08/02/2021. ADON #2 stated that Resident #105 had their medication regimen adjusted at the psychiatric hospital prior to the resident's return to the facility. ADON #2 acknowledged that per the facility's record on Resident #105, the resident's aggressive behaviors continued upon the resident's return from the hospital. ADON #2 verified there was no adjustments in Resident #105's care plan which reflected the facility intervened in ensuring Resident #105 did not continue to abuse residents at the facility. Addressing the incident when Resident #105 was noted to have inappropriately touched Resident #198 on 08/13/2021, ADON #2 stated that the interaction was considered behavioral. Per the ADON, it was not uncommon for residents on the behavior unit to touch each other inappropriately. ADON #2 added Resident #105 was referred to the psychiatrist following the incident. The ADON, however, recanted his statement after reviewing the pertinent record and acknowledged there was nothing in the record that showed that the psychiatrist was made aware of Resident #105's inappropriate sexual behavior exhibited towards Resident #198. During an interview on 10/09/2021 at approximately 9:15 AM, Assistant Director of Nursing (ADON) #2 confirmed that no interventions were implemented after Resident #105 returned on 08/02/2021 from the psychiatric stay. ADON #2 verified that the facility failed to implement measures specified by the Abuse, Neglect, or Exploitation Policy after Resident #105's initial occurrence on 06/02/2021, which failed to protect residents from being abused. During an interview on 10/10/2021 at 10:06 AM, the Nursing Home Administrator (NHA) stated that it was important for the residents at the facility to be free of abuse, as it was their right. The NHA stated that a different set of eyes see the same situation differently. The NHA stated that he was not on the [NAME] Unit every day. Per the NHA, he had relied on ADON #2 to take care of the situations on the unit. The NHA stated that he had heard of incidences on abuse perpetrated by Resident #105 towards staff and residents. The NHA stated he had not seen Resident #105 being aggressive during his rounds. The NHA stated that he was majorly concerned about residents on the unit not eloping. The NHA stated that when an abuse incident was reported to be repeatedly perpetrated by the same resident, he relied on nursing staff to tell him what they (referring to nursing staff) had done and their input on what they thought the facility should do differently. The NHA stated that he expected an investigation into all abuse allegations. Per the NHA, investigation was key to identifying the trigger for the aggressor, and it helped direct the proper intervention which helped to ensure residents at the facility continued to be free from abuse. The NHA stated that he was not of the impression that the facility did not respond to the situation with Resident #105 accordingly. The facility's policy titled, Abuse, Neglect or Exploitation, with effective date of 10/2020, indicated, III. INVESTIGATION AND FOLLOW-UP .C. Responsibilities of [NAME] President, Administrator, and Risk Management .6. Analyze occurrences to determine whether changes are needed to prevent reoccurrence. 7. Institute corrective measures as needed. 8. Conduct follow up performance improvement activities, if appropriate Based on the plan that was provided to the surveyors, removal of IJ occurred on 10/09/2021 at 10:39 PM. Onsite Verification: Onsite verification was conducted on 10/10/2021 to verify that the facility had implemented the Removal Plan. The onsite verification revealed the facility had transferred Resident #105 to the hospital for psychiatric evaluation. The facility started retraining all staff who worked on the [NAME] Unit on abuse which included identifying, reporting, and role of each employee in investigating abuse. New Jersey Administrative Code S 8:39-5.1(a)

Based on observations, record reviews, interviews, and facility policy review, it was determined the facility failed to provide a safe environment to prevent resident-to-resident abuse for three (Residents #197, #198, and #234) of three residents reviewed for resident-to-resident abuse. All residents on the [NAME] Unit were at risk of abuse from Resident #105. Resident #105 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #105 punched Resident #197 on 06/02/2021, resulting in an emergency room visit and stitches to Resident #197's upper lip. Resident #105 had inappropriate sexual contact with Resident #198 on 08/13/2021. Resident #105 pulled Resident #234's hair on 10/07/2021. Staff reported that Resident #105 got agitated and aggressive unprovoked. The facility staff stated that Resident #105 grabbed residents inappropriately and hit residents and staff. Staff stated that residents and staff were fearful of Resident #105. The Assistant Director of Nursing stated that Resident #105's behaviors created a stressful environment for other residents and staff. Following each of these identified incidences, the facility failed to implement any measures which prevented and ensured there were no repeated situations that put other residents at risk of physical or sexual assault from Resident #105. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect and Exploitation) at a scope and severity of K. The IJ began on 08/02/2021 when Resident #105 returned to the facility after the resident was sent to a psychiatric long-term care following a physical assault on Resident #197. Although the record indicated Resident #105 continued to exhibit aggressive behaviors which included grabbing, hitting, and using vulgar language on staff and residents upon the resident's return from the psychiatric setting, the facility failed to put measures in place to ensure residents were free from abuse perpetrated by Resident #105. The resident assaulted two additional residents respectively on 08/13/2021 and on 10/07/2021. On 10/09/2021 at 6:18 PM, an immediate jeopardy (IJ) was identified. At 9:55 PM, the facility administrator was provided with the completed IJ template and notified of the existence of an IJ for abuse. The Administrator signed the template and returned the original to the survey team. A Removal Plan was requested. On 10/10/2021, the survey team conducted an onsite verification to verify the Removal Plan had been implemented. Resident #105 had been removed from the facility on 10/10/2021. The facility continued to train staff on recognizing and preventing, reporting, and investigating abuse. The IJ continued until 10/10/2021 at 6:17 PM, when the survey team verified the elements of the Removal Plan had been implemented. The noncompliance remained on 10/10/2021 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the facility continuing in-servicing with facility staff. Findings included: The October 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], indicated the resident's cognition was moderately impaired with a SAMS (Staff Assessment for Mental Status). The resident required physical assistance of two persons to dressing and toileting. The resident required physical assistance of one person for personal hygiene. The resident required assistance with setup for bed mobility and eating. The resident exhibited behavioral symptoms such as kicking, hitting, pushing, scratching, grabbing and sexual abuse directed towards others. The resident's identified symptoms put others at significant risk for physical injury. The resident significantly intruded on the privacy or activity of others. The resident exhibited the behaviors four to six times daily. The resident currently resided in a locked behavior unit. A review of Resident #105's medical record indicated a behavior care plan, dated 02/24/2020, indicated under the focus portion of the plan that Resident #105 resisted care and was combative (hitting/punching/slapping) with staff and at times requires additional certified behavioral technician (CBT) for provision of care. The focus portion also indicated Resident #105 wanders and the resident becomes very intrusive with peers, yells, curses, and threatens peers. Resident #105 takes food from peers' trays at times, becomes verbally and physically aggressive. The intervention portion of the care plan, last revised 02/27/2020, included the following: allow behaviors to continue in a safe manner if it assists with keeping Resident #105 calm, staff to monitor the effectiveness of techniques and report any changes to nurse, doctor, or interdisciplinary committee (IDC) team, offer appropriate seating areas to reduce agitation and over-stimulation, and offer distraction and remove from area when becoming agitated. The record revealed the facility did not re-evaluate the effectiveness of the care plan and ensured to integrate measures other than those already in place after Resident #105 physically assaulted Resident #197 on 06/02/2021, after Resident #105 physically assaulted and sexually assaulted Resident #198 on 08/13/2021, and after Resident #105 physically assaulted Resident #234 on 10/07/2021. Resident #105's care plan had not been updated past 02/27/2021. Observations conducted during the survey from 10/06/2021 through 10/09/2021 revealed Resident #105 was not monitored and was by themself. The resident was always observed in the personal spaces of other residents with closed fist, threatening to punch them. Resident #105 continuously said derogative language, such as using the F-word and B-word towards staff and residents. The resident grabbed staff when they walked by the resident. The observations revealed staff sat at the nurses' station and at the lounges across the unit and were not able to protect other residents should Resident #105 decide to assault a resident. On 10/06/2021 at 3:29 PM, Resident #105 was heard saying the F word which was directed at staff and residents on the [NAME] Unit. Resident #105 approached the surveyor with a closed fist, threatening to punch the surveyor during this time. On 10/07/2021 at 11:05 AM, Resident #105 aggressively grabbed the Rehab Assistant (RA) by his left arm when the RA walked by the resident. The following three resident-to-resident abuse incidents occurred involving Resident #105: 1. Review of a facility incident report, dated on 06/02/2021, indicated it was reported by an unidentified eyewitness that Resident #197 was propelling themself in their wheelchair on the [NAME] Unit hallway trying to get past Resident #105. The incident report indicated Resident #197 told Resident #105 to excuse them, and Resident #105 responded by punching Resident #197 with a closed fist, which caused a laceration to Resident #197's upper lip. The incident report indicated Resident #197 required an emergency room visit to get their upper lip sutured. The incident report indicated that the facility sent Resident #105 to a psychiatric long-term care, where Resident #105 was admitted from 06/02/2021 through 08/02/2021. Although the 08/02/2021 hospital discharge record indicated that Resident #105 returned to the facility with an order of an antipsychotic ([MEDICATION(S)] 5 milligram [mg] tablet, give one tablet [5mg] by oral route three times per day) added to the resident's medication regimen, the nursing progress notes indicated that Resident #105 continued to exhibit aggressive behaviors. Upon Resident #105's return to the facility and the documented continued aggressive behaviors of the resident, the facility failed to address the unprovoked physical assault Resident #105 directed towards Resident #197 by failing to put a measure in place to prevent future physical assault directed by Resident #105 to other residents at the facility. There was no evidence in the record that the facility followed up with Resident #197 to know how the interaction with Resident #105 made the resident feel. Resident #105's care plan was not updated to reflect any new intervention. The October 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two persons for transfer. During an interview on 10/09/2021 at 1:50 PM, Resident #197 stated they frequently had a nightmare about the situation (referring to the assault incident perpetrated by Resident #105 against them). The resident stated they stayed in their room when Resident #105 was in the common area. Resident #197 stated that Resident #105 was a monster who tormented women. The resident stated that facility staff did not interview Resident #197 about the incident after Resident #197 returned from the hospital. 2. Review of a facility incident report, dated 08/13/2021, indicated it was reported by an unidentified eyewitness that Resident #105 was sexually inappropriate with Resident #198. Per the report, Resident #105 was observed to have touched Resident #198 on their buttocks while Resident #198 was walking in an unidentified hallway. It was noted in the report that when Resident #198 questioned why Resident #105 touched them inappropriately, Resident #105 pushed Resident #198 to the floor. A review of Resident #198's medical record indicated the facility assessed Resident #198 in this case to rule out any injury. There was documentation of a follow-up communication with Resident #198 to know how the resident felt following the interaction with Resident #105. Review of Resident #105's medical record indicated a monthly psychology follow-up was done on 09/14/2021 at 10:45 AM, after the incident. The medical record did not indicate the facility made the psychiatrist aware of the inappropriate sexual behavior Resident #105 exhibited towards Resident #198. Resident #105 continued to be reported, per nursing progress notes, to exhibit aggressive behaviors. However, the facility did not devise an intervention to ensure other residents at the facility continued to be free of abuse from Resident #105. The record indicated Resident #105 continued to abuse vulnerable residents and staff and posed a safety risk verbally and physically. Resident #105's care plan was not updated to reflect any new intervention. The October 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was independent with activities of daily living. 3. A review of Resident #105's medical record indicated a nursing note written by Registered Nurse (RN) #11 on 10/07/2021 at 1:58 PM. Per the note, Resident #105 was reported to be pacing the unit, charging at staff and residents. The note indicated that Resident #105 pulled on Resident #234's hair while Resident #234 sat at the table in the lounge area of the unit. There was no documentation of a nursing assessment completed with Resident #234 to determine the resident's state of mind or whether the resident was in pain after the encounter. Resident #105's care plan was not updated to reflect any new intervention. On 10/10/2021 at 3:39 PM, the Activity Aide (AA) stated that he witnessed the encounter between Resident #105 and Resident #234 firsthand. Per the AA, he was sitting with a group of residents on A lounge (an enclosed common area on the [NAME] Unit) during a group activity when he saw Resident #105 come into the lounge, made eye contact with Resident #234, and yanked a bulk of Resident #234's hair such that Resident #234's head tilted abruptly towards the side of the pull. The AA stated that Resident #234 yelled out, ''Ouch, Ouch, in a manner that was consistent with discomfort/pain. The AA stated that the incident happened quickly, and he was unable to intervene before Resident #105 laid their hand on Resident #234's hair. Per the AA, Resident #105 punched the AA in the chest and arm a couple of times when the AA stood up to intervene. The AA stated that when he thought he had successfully redirected Resident #105 out of the lounge and was headed to the nurses station to report the situation to the nurse, Resident #105 made their way back into the lounge through another door which accessed the lounge from another side of the unit and physically assaulted Resident #234 again in the same manner as described above. The AA stated that nursing staff came to intervene and successfully removed Resident #105 into the resident's room. The AA stated he reported the incident to RN #11 exactly how it unfolded. He verified that RN #11 did not come into the lounge to assess Resident #234 following the incident. The October 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/07/2021 at 11:39 AM, the RA stated that Resident #105 had been aggressive towards staff and residents since the resident's admission. On 10/07/2021 at 2:25 PM, Licensed Practical Nurse (LPN) #7 stated that Resident #105 was aggressive, combative, and not easily redirectable. LPN #7 stated that Resident #7 liked to say racial slurs and derogatory speech. She stated that Resident #105 got into other residents' personal space. LPN #7 stated that the resident had grabbed, hit, and punched staff and residents. LPN #7 stated, You need to know how to speak, in order to not get the resident agitated. LPN #7 reviewed Resident #105's care plan and acknowledged Resident #105's care plan related to the resident's behavior had not been updated after it was formulated on 02/24/2020 through 02/27/2020. LPN #7 stated that she had no remarks about the intervention portion of Resident #105's care plan which read, Allow behaviors to continue in a safe manner if it assists with keeping Resident #105 calm. On 10/07/2021 at 3:15 PM, Certified Behavioral Therapist (CBT) #1 stated that Resident #105 was aggressive towards residents and staff. He stated that Resident #105 insulted staff and residents with profanity. CBT #1 stated that the resident had hit staff and residents and was a safety concern to self and other residents. On 10/09/2021 at 9:00 AM, Assistant Director of Nursing (ADON) #2 stated that Resident #105 had been very challenging with the resident's care. ADON #2 stated that Resident #105's behaviors created a stressful environment for other residents. ADON #2 stated that the only way the facility had limited the encounters with the resident was their proactiveness. Per ADON #2, Resident #105 had had more than ten incidents with staff and residents during which the resident physically assaulted staff and residents. ADON #2 stated that Resident #105 attacked residents and staff unprovoked. ADON #2 stated the facility had attempted to transfer the resident to another facility deemed more appropriate for the resident's care but were met with resistance. He gave an instance of when the facility sent the resident to [facility name omitted] which operated a psychiatric long-term care program, and Resident #105 was sent back within seven days with four-point restraints. He stated that no facility wanted to take responsibility for Resident #105. Addressing Resident #105's assault on Resident #197, ADON #2 stated that, following the incident on 06/02/2021, Resident #105 was sent to [facility name omitted], psychiatric hospital, where the resident was admitted and managed until the resident returned on 08/02/2021. ADON #2 stated that Resident #105 had their medication regimen adjusted at the psychiatric hospital prior to the resident's return to the facility. ADON #2 acknowledged that per the facility's record on Resident #105, the resident's aggressive behaviors continued upon the resident's return from the hospital. ADON #2 verified there was no adjustments in Resident #105's care plan which reflected the facility intervened in ensuring Resident #105 did not continue to abuse residents at the facility. Addressing the incident when Resident #105 was noted to have inappropriately touched Resident #198 on 08/13/2021, ADON #2 stated that the interaction was considered behavioral. Per the ADON, it was not uncommon for residents on the behavior unit to touch each other inappropriately. ADON #2 added Resident #105 was referred to the psychiatrist following the incident. The ADON, however, recanted his statement after reviewing the pertinent record and acknowledged there was nothing in the record that showed that the psychiatrist was made aware of Resident #105's inappropriate sexual behavior exhibited towards Resident #198. Addressing the incident on 10/07/2021 when Resident #105 was noted to have pulled Resident #234's hair, ADON #2 verified there was no documented assessment of Resident #234 by a nurse. Per the ADON, it was important to evaluate Resident #234 after the resident was physically assaulted, so that the resident was adequately monitored, and necessary treatment was given to address the aftermath of the encounter on the resident. ADON #2 stated that he interviewed the AA (the individual who witnessed the incident firsthand) on 10/08/2021 at approximately 6:30 PM. ADON #2 reiterated the AA's description of the incident as reported above. Per the ADON, when an abuse situation happened, the facility did two incident reports (one for the aggressor and the other for the victim) and two progress notes (assessments), and the family members of the two residents were contacted. The ADON stated that the facility investigated the abuse, did a reportable, and liaised with the medical director and the psychiatrist. He acknowledged the facility did not investigate the abuse instances perpetrated by Resident #105 to Residents #197, #198, and #234. ADON #2 stated that without an investigation, the facility was unable to identify the root cause of the perpetrated abuse instances. Therefore, they were unable to put a plan in place to ensure the residents at the facility were free from abuse. ADON #2 stated that the facility's interdisciplinary committee (IDC) had not met to address the situation with Resident #105. During an interview on 10/09/2021 at approximately 9:15 AM, Assistant Director of Nursing (ADON) #2 confirmed that no interventions were implemented after Resident #105 returned on 08/02/2021 from the psychiatric stay. ADON #2 verified that the facility failed to implement measures specified by the Abuse, Neglect, or Exploitation Policy after Resident #105's initial occurrence on 06/02/2021, which failed to protect residents from being abused. On 10/10/2021 at 10:06 AM, the Nursing Home Administrator stated that it was important for the residents at the facility to be free of abuse, as it was their right. The nursing home administrator (NHA) stated that a different set of eyes sees the same situation differently. The NHA stated that he was not on the [NAME] Unit every day. Per the NHA, he had relied on ADON #2 to take care of the situations on the unit. The NHA stated that he had heard of incidents on abuse perpetrated by Resident #105 towards staff and residents. The NHA stated he had not seen Resident #105 being aggressive during his rounds. The NHA stated that he was majorly concerned about residents on the unit not eloping. The NHA stated that when an abuse incident was reported to be repeatedly perpetrated by the same resident, he relied on nursing staff to tell him what they (referring to nursing staff) had done and their input on what they thought the facility should do differently. The NHA stated that he expected an investigation into all abuse allegations. Per the NHA, investigation was key to identifying the trigger for the aggressor and it helped direct the proper intervention, which helped to ensure residents at the facility continued to be free from abuse. The NHA stated that he was not of the impression that the facility did not respond to the situation with Resident #105 accordingly. The surveyor informed the NHA that the contact phone numbers of the two psychiatrists who cared for Resident #105 were not on file. The NHA promised to facilitate an interview with the psychiatrists but failed to do so after repetitive reminders. The facility's policy titled, Abuse, Neglect or Exploitation, with an effective date of 10/2020, indicated, The protection of patient rights is a key fundamental patient right. We will monitor and take action to protect and ensure that those rights are maintained. When abuse, neglect or exploitation is suspected or discovered, immediate corrective action will be taken . Physical abuse-actual injury: hitting, slapping, pinching, pushing, kicking . Sexual abuse: sexual coercion, non-consensual sexual contact, or sexual harassment. Based on the plan that was provided to the surveyors, removal of IJ occurred on 10/09/2021 at 10:39 PM. Onsite verification was conducted on 10/10/2021 to verify that the facility had implemented the Removal Plan. The onsite verification revealed the facility had transferred Resident #105 to the hospital for psychiatric evaluation. The facility started retraining all staff who worked on the [NAME] Unit on abuse which included identifying, reporting, and role of each employee in investigating abuse. New Jersey Administrative Code 8:39- 4.1(a)(5)

Based on observations, record reviews, interviews, and facility policy review, it was determined the facility failed to implement their abuse policy to prohibit and prevent abuse by failing to put interventions in place to prevent further abuse perpetrated by Resident #105 towards three (Residents #197, #198, and #234) of three residents reviewed for resident-to-resident abuse. Resident #105 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #105 punched Resident #197 on 06/02/2021, resulting in an emergency room visit and stitches to Resident #197's upper lip. Resident #105 had inappropriate sexual contact with Resident #198 on 08/13/2021. Resident #105 pulled Resident #234's hair on 10/07/2021. Staff reported that Resident #105 got agitated and aggressive unprovoked. The facility staff stated that Resident #105 grabbed residents inappropriately and hit residents and staff. Staff stated that residents and staff were fearful of Resident #105. The Assistant Director of Nursing stated that Resident #105's behaviors created a stressful environment for other residents and staff. Following each of these identified incidences, the facility failed to implement any measures which prevented and ensured there were no repeated situations that put other residents at risk of physical or sexual assault from Resident #105. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate jeopardy (IJ) was related to State Operations Manual, Appendix PP, S483.12(b)(1) (The facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property) at a scope and severity of K. The IJ began on 08/02/2021 when Resident #105 returned to the facility after the resident was sent to a psychiatric long-term care following a physical assault on Resident #197. Although the record indicated Resident #105 continued to exhibit aggressive behaviors which included grabbing, hitting, and using vulgar languages on staff and residents upon the resident's return from the psychiatric setting, the facility failed to put measures in place to prohibit and prevent abuse perpetrated by Resident #105. The resident assaulted two additional residents respectively on 08/13/2021 and on 10/07/2021. On 10/09/2021 at 6:18 PM, an immediate jeopardy (IJ) was identified. At 9:55 PM, the facility administrator was provided with the completed IJ template and notified of the existence of an IJ for abuse. The Administrator signed the template and returned the original to the survey team. A Removal Plan was requested. On 10/10/2021, the survey team conducted an onsite verification to verify the Removal Plan had been implemented. Resident #105 had been removed from the facility on 10/10/2021. The facility continued to train staff on recognizing and preventing, reporting, and investigating abuse. The IJ continued until 10/10/2021 at 6:17 PM, when the survey team verified the elements of the Removal Plan had been implemented. The noncompliance remained on 10/10/2021 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the facility continuing in-servicing with facility staff. Findings included: The October 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], indicated the resident's cognition was moderately impaired with a SAMS (Staff Assessment for Mental Status). The resident required physical assistance of two persons to dressing and toileting. The resident required physical assistance of one person for personal hygiene. The resident required assistance with setup for bed mobility and eating. The resident exhibited behavioral symptoms such as kicking, hitting, pushing, scratching, grabbing and sexual abuse directed towards others. The resident's identified symptoms put others at significant risk for physical injury. The resident significantly intruded on the privacy or activity of others. The resident exhibited the behaviors four to six times daily. The resident currently resided in a locked behavior unit. A review of Resident #105's medical record indicated a behavior care plan, dated 02/24/2020, indicated under the focus portion of the plan that Resident #105 resisted care and was combative (hitting/punching/slapping) with staff and at times requires additional certified behavioral technician (CBT) for provision of care. The focus portion also indicated Resident #105 wanders and the resident becomes very intrusive with peers, yells, curses, and threatens peers. Resident #105 takes food from peers' trays at times, becomes verbally and physically aggressive. The intervention portion of the care plan, last revised 02/27/2020, included the following: allow behaviors to continue in a safe manner if it assists with keeping Resident #105 calm, staff to monitor the effectiveness of techniques and report any changes to nurse, doctor, or interdisciplinary committee (IDC) team, offer appropriate seating areas to reduce agitation and over-stimulation, and offer distraction and remove from area when becoming agitated. The record revealed the facility did not re-evaluate the effectiveness of the care plan and ensured to integrate measures other than those already in place after Resident #105 physically assaulted Resident #197 on 06/02/2021, after Resident #105 physically assaulted and sexually assaulted Resident #198 on 08/13/2021, and after Resident #105 physically assaulted Resident #234 on 10/07/2021. Resident #105's care plan had not been updated past 02/27/2021. Observations conducted during the survey from 10/06/2021 through 10/09/2021 revealed Resident #105 was not monitored and was by themself. The resident was always observed in the personal spaces of other residents with closed fist, threatening to punch them. Resident #105 continuously said derogative language, such as using the F-word and B-word towards staff and residents. The resident grabbed staff when they walked by the resident. The observations revealed staff sat at the nurses' station and at the lounges across the unit and were not able to protect other residents should Resident #105 decide to assault a resident. On 10/06/2021 at 3:29 PM, Resident #105 was heard saying the F word which was directed at staff and residents on the [NAME] Unit. Resident #105 approached the surveyor with a closed fist, threatening to punch the surveyor during this time. On 10/07/2021 at 11:05 AM, Resident #105 aggressively grabbed the Rehab Assistant (RA) by his left arm when the RA walked by the resident. The following three resident-to-resident abuse incidents occurred involving Resident #105: 1. Review of a facility incident report, dated on 06/02/2021, indicated it was reported by an unidentified eyewitness that Resident #197 was propelling themself in their wheelchair on the [NAME] Unit hallway trying to get past Resident #105. The incident report indicated Resident #197 told Resident #105 to excuse them, and Resident #105 responded by punching Resident #197 with a closed fist, which caused a laceration to Resident #197's upper lip. The incident report indicated Resident #197 required an emergency room visit to get their upper lip sutured. The incident report indicated that the facility sent Resident #105 to a psychiatric long-term care, where Resident #105 was admitted from 06/02/2021 through 08/02/2021. Although the 08/02/2021 hospital discharge record indicated that Resident #105 returned to the facility with an order of an antipsychotic ([MEDICATION(S)] 5 milligram [mg] tablet, give one tablet [5mg] by oral route three times per day) added to the resident's medication regimen, the nursing progress notes indicated that Resident #105 continued to exhibit aggressive behaviors. Upon Resident #105's return to the facility and the documented continued aggressive behaviors of the resident, the facility failed to address the unprovoked physical assault Resident #105 directed towards Resident #197 by failing to put a measure in place to prevent future physical assault directed by Resident #105 to other residents at the facility. There was no evidence in the record that the facility followed up with Resident #197 to know how the interaction with Resident #105 made the resident feel. Resident #105's care plan was not updated to reflect any new intervention. The October 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two persons for transfer. During an interview on 10/09/2021 at 1:50 PM, Resident #197 stated they frequently had a nightmare about the situation (referring to the assault incident perpetrated by Resident #105 against them). The resident stated they stayed in their room when Resident #105 was in the common area. Resident #197 stated that Resident #105 was a monster who tormented women. The resident stated that facility staff did not interview Resident #197 about the incident after Resident #197 returned from the hospital. 2. Review of a facility incident report, dated 08/13/2021, indicated it was reported by an unidentified eyewitness that Resident #105 was sexually inappropriate with Resident #198. Per the report, Resident #105 was observed to have touched Resident #198 on their buttocks while Resident #198 was walking in an unidentified hallway. It was noted in the report that when Resident #198 questioned why Resident #105 touched them inappropriately, Resident #105 pushed Resident #198 to the floor. A review of Resident #198's medical record indicated the facility assessed Resident #198 in this case to rule out any injury. There was documentation of a follow-up communication with Resident #198 to know how the resident felt following the interaction with Resident #105. Review of Resident #105's medical record indicated a monthly psychology follow-up was done on 09/14/2021 at 10:45 AM, after the incident. The medical record did not indicate the facility made the psychiatrist aware of the inappropriate sexual behavior Resident #105 exhibited towards Resident #198. Resident #105 continued to be reported, per nursing progress notes, to exhibit aggressive behaviors. However, the facility did not devise an intervention to ensure other residents at the facility continued to be free of abuse from Resident #105. The record indicated Resident #105 continued to abuse vulnerable residents and staff and posed a safety risk verbally and physically. Resident #105's care plan was not updated to reflect any new intervention. The October 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was independent with activities of daily living. 3. A review of Resident #105's medical record indicated a nursing note written by Registered Nurse (RN) #11 on 10/07/2021 at 1:58 PM. Per the note, Resident #105 was reported to be pacing the unit, charging at staff and residents. The note indicated that Resident #105 pulled on Resident #234's hair while Resident #234 sat at the table in the lounge area of the unit. There was no documentation of a nursing assessment completed with Resident #234 to determine the resident's state of mind or whether the resident was in pain after the encounter. Resident #105's care plan was not updated to reflect any new intervention. On 10/10/2021 at 3:39 PM, the Activity Aide (AA) stated that he witnessed the encounter between Resident #105 and Resident #234 firsthand. Per the AA, he was sitting with a group of residents on A lounge (an enclosed common area on the [NAME] Unit) during a group activity when he saw Resident #105 come into the lounge, made eye contact with Resident #234, and yanked a bulk of Resident #234's hair such that Resident #234's head tilted abruptly towards the side of the pull. The AA stated that Resident #234 yelled out, ''Ouch, Ouch, in a manner that was consistent with discomfort/pain. The AA stated that the incident happened quickly, and he was unable to intervene before Resident #105 laid their hand on Resident #234's hair. Per the AA, Resident #105 punched the AA in the chest and arm a couple of times when the AA stood up to intervene. The AA stated that when he thought he had successfully redirected Resident #105 out of the lounge and was headed to the nurses station to report the situation to the nurse, Resident #105 made their way back into the lounge through another door which accessed the lounge from another side of the unit and physically assaulted Resident #234 again in the same manner as described above. The AA stated that nursing staff came to intervene and successfully removed Resident #105 into the resident's room. The AA stated he reported the incident to RN #11 exactly how it unfolded. He verified that RN #11 did not come into the lounge to assess Resident #234 following the incident. The October 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/07/2021 at 11:39 AM, the RA stated that Resident #105 had been aggressive towards staff and residents since the resident's admission. On 10/07/2021 at 2:25 PM, Licensed Practical Nurse (LPN) #7 stated that Resident #105 was aggressive, combative, and not easily redirectable. LPN #7 stated that Resident #7 liked to say racial slurs and derogatory speech. She stated that Resident #105 got into other residents' personal space. LPN #7 stated that the resident had grabbed, hit, and punched staff and residents. LPN #7 stated, You need to know how to speak, in order to not get the resident agitated. LPN #7 reviewed Resident #105's care plan and acknowledged Resident #105's care plan related to the resident's behavior had not been updated after it was formulated on 02/24/2020 through 02/27/2020. LPN #7 stated that she had no remarks about the intervention portion of Resident #105's care plan which read, Allow behaviors to continue in a safe manner if it assists with keeping Resident #105 calm. On 10/07/2021 at 3:15 PM, Certified Behavioral Therapist (CBT) #1 stated that Resident #105 was aggressive towards residents and staff. He stated that Resident #105 insulted staff and residents with profanity. CBT #1 stated that the resident had hit staff and residents and was a safety concern to self and other residents. On 10/09/2021 at 9:00 AM, Assistant Director of Nursing (ADON) #2 stated that Resident #105 had been very challenging with the resident's care. ADON #2 stated that Resident #105's behaviors created a stressful environment for other residents. ADON #2 stated that the only way the facility had limited the encounters with the resident was their proactiveness. Per ADON #2, Resident #105 had had more than ten incidents with staff and residents during which the resident physically assaulted staff and residents. ADON #2 stated that Resident #105 attacked residents and staff unprovoked. ADON #2 stated the facility had attempted to transfer the resident to another facility deemed more appropriate for the resident's care but were met with resistance. He gave an instance of when the facility sent the resident to [facility name omitted] which operated a psychiatric long-term care program, and Resident #105 was sent back within seven days with four-point restraints. He stated that no facility wanted to take responsibility for Resident #105. Addressing Resident #105's assault on Resident #197, ADON #2 stated that, following the incident on 06/02/2021, Resident #105 was sent to [facility name omitted], psychiatric hospital, where the resident was admitted and managed until the resident returned on 08/02/2021. ADON #2 stated that Resident #105 had their medication regimen adjusted at the psychiatric hospital prior to the resident's return to the facility. ADON #2 acknowledged that per the facility's record on Resident #105, the resident's aggressive behaviors continued upon the resident's return from the hospital. ADON #2 verified there was no adjustments in Resident #105's care plan which reflected the facility intervened in ensuring Resident #105 did not continue to abuse residents at the facility. Addressing the incident when Resident #105 was noted to have inappropriately touched Resident #198 on 08/13/2021, ADON #2 stated that the interaction was considered behavioral. Per the ADON, it was not uncommon for residents on the behavior unit to touch each other inappropriately. ADON #2 added Resident #105 was referred to the psychiatrist following the incident. The ADON, however, recanted his statement after reviewing the pertinent record and acknowledged there was nothing in the record that showed that the psychiatrist was made aware of Resident #105's inappropriate sexual behavior exhibited towards Resident #198. Addressing the incident on 10/07/2021 when Resident #105 was noted to have pulled Resident #234's hair, ADON #2 verified there was no documented assessment of Resident #234 by a nurse. Per the ADON, it was important to evaluate Resident #234 after the resident was physically assaulted, so that the resident was adequately monitored, and necessary treatment was given to address the aftermath of the encounter on the resident. ADON #2 stated that he interviewed the AA (the individual who witnessed the incident firsthand) on 10/08/2021 at approximately 6:30 PM. ADON #2 reiterated the AA's description of the incident as reported above. Per the ADON, when an abuse situation happened, the facility did two incident reports (one for the aggressor and the other for the victim) and two progress notes (assessments), and the family members of the two residents were contacted. The ADON stated that the facility investigated the abuse, did a reportable, and liaised with the medical director and the psychiatrist. He acknowledged the facility did not investigate the abuse instances perpetrated by Resident #105 to Residents #197, #198, and #234. ADON #2 stated that without an investigation, the facility was unable to identify the root cause of the perpetrated abuse instances. Therefore, they were unable to put a plan in place to ensure the residents at the facility were free from abuse. ADON #2 stated that the facility's interdisciplinary committee (IDC) had not met to address the situation with Resident #105. During an interview on 10/09/2021 at approximately 9:15 AM, Assistant Director of Nursing (ADON) #2 confirmed that no interventions were implemented after Resident #105 returned on 08/02/2021 from the psychiatric stay. ADON #2 verified that the facility failed to implement measures specified by the Abuse, Neglect, or Exploitation Policy after Resident #105's initial occurrence on 06/02/2021, which failed to protect residents from being abused. On 10/10/2021 at 10:06 AM, the Nursing Home Administrator stated that it was important for the residents at the facility to be free of abuse, as it was their right. The nursing home administrator (NHA) stated that a different set of eyes sees the same situation differently. The NHA stated that he was not on the [NAME] Unit every day. Per the NHA, he had relied on ADON #2 to take care of the situations on the unit. The NHA stated that he had heard of incidents on abuse perpetrated by Resident #105 towards staff and residents. The NHA stated he had not seen Resident #105 being aggressive during his rounds. The NHA stated that he was majorly concerned about residents on the unit not eloping. The NHA stated that when an abuse incident was reported to be repeatedly perpetrated by the same resident, he relied on nursing staff to tell him what they (referring to nursing staff) had done and their input on what they thought the facility should do differently. The NHA stated that he expected an investigation into all abuse allegations. Per the NHA, investigation was key to identifying the trigger for the aggressor and it helped direct the proper intervention, which helped to ensure residents at the facility continued to be free from abuse. The NHA stated that he was not of the impression that the facility did not respond to the situation with Resident #105 accordingly. The surveyor informed the NHA that the contact phone numbers of the two psychiatrists who cared for Resident #105 were not on file. The NHA promised to facilitate an interview with the psychiatrists but failed to do so after repetitive reminders. The facility's policy titled, Abuse, Neglect or Exploitation, with an effective date of 10/2020, indicated, PROCEDURE: I. IDENTIFICATION AND REPORTING. A. Responsibilities of Employees: 1. Immediately notify your Supervisor or Nurse Manager if you identify an incident of: a. Actual or suspected abuse, neglect, exploitation or misappropriation of property .4. Complete an occurrence report .B. Responsibilities of Supervisory Staff. 1. Review the allegations with your Department Director or Administrator .II. PROTECTION. A. Protection of an abused or neglected resident is a key responsibility of all employees. Action must be taken immediately in the event of any actual or suspected abuse or neglect .III. INVESTIGATION AND FOLLOW-UP. A. Responsibilities of Employees. 1. Provide accurate information .C. Responsibilities of [NAME] President, Administrator, and Risk Management .6. Analyze occurrences to determine whether changes are needed to prevent reoccurrence. 7. Institute corrective measures as needed. 8. Conduct follow up performance improvement activities, if appropriate. TRAINING. A. Responsibilities of the Clinical Education and Organizational Development & Service Excellence Departments: 1. Conduct orientation and annual training on the following topics to all employees and contracted agents. C. Individual responsibility with respect to: i. Protecting the rights of patients .iii. Intervening in situations that could lead to abuse. Iv. Reporting suspected and/or actual incidents of abuse .VI. PREVENTION. A. Responsibilities of All Individuals - (employees and contracted agents). 2. Intervene in situations that could lead to abuse .C. Responsibilities of Supervisors. 1. Monitor: a. Patients with history of aggressive/inappropriate behaviors and participate in care planning through the IDC / Treatment Team Based on the plan that was provided to the surveyors, removal of IJ occurred on 10/09/2021 at 10:39 PM. Onsite verification was conducted on 10/10/2021 to verify that the facility had implemented the Removal Plan. The onsite verification revealed the facility had transferred Resident #105 to the hospital for psychiatric evaluation. The facility started retraining all staff who worked on the [NAME] Unit on abuse which included identifying, reporting, and role of each employee in investigating abuse. New Jersey Administrative Code 8:39-4.1(a)(5)

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to update person-centered care plans to reflect changes in interventions for three (Residents #152, #105, and #213) of 39 residents reviewed for care planning. The facility failed to update the accident/falls care plans with additional interventions after falls occurred for Resident #152 and Resident #213, which could have prevented Resident #152 from falling and sustaining a fracture. The facility also failed to update the behavior care plan for Resident #105. This had the potential to affect all residents. Findings included: 1. A review of Resident #213's quarterly Minimum Data Set (MDS), dated [DATE], indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. The resident had one fall with injury. A review of a fall risk assessment titled, Morse Fall Scale Assessment, dated 08/17/2021, indicated Resident #213 was at moderate risk for falling. There was no other Morse fall scale completed after that date. A review of Resident #213's care plans, dated 08/31/2021, indicated the resident was at risk for falls, as evidenced by a history of falls, with the last fall on 09/18/2021. Interventions included the following: maintain bed in low position, tab alarm for safety to bed and wheelchair at all times, encourage to use appropriate assistive devices, encourage use of appropriate fitting, non-skid shoes, observe for unsafe behavior, remind to use the call light, and assist with toileting and meeting daily needs. The effective dates for the interventions were 08/31/2021. The care plan did not indicate any additional interventions to prevent falls after 08/31/2021. A review of Resident #213's progress notes indicated the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . An x-ray was obtained for complaints of back and hip pain, which indicated no injury. Following the fall on 09/10/2021, the care plan was not updated to reflect any new interventions. A review of Resident #213's progress notes revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes indicated the fall occurred in the hallway next to the resident's wheelchair and was unwitnessed. There was no injury documented. Following the fall on 09/18/2021, the care plan was not updated to reflect any new interventions. An observation of Resident #213 on 10/07/2021 at 7:52 AM revealed the resident sitting on the edge of the bed. The resident was observed to be very hard of hearing. There was no tab alarm (used to indicate if a resident is rising from a seated position), and the bed was not in the low position. An observation of Resident #213 on 10/08/2021 8:38 AM revealed the resident sitting on the edge of the bed. The resident became frustrated when answering questions. There was no tab alarm, and the bed was not in the low position. There was a fall mat next to the bed. On 10/08/2021 at 10:24 AM, an interview was conducted with Assistant Director of Nursing (ADON) #2. When asked if new interventions were put into place after the resident fell on [DATE], ADON #2 stated no. ADON #2 stated that the facility's interdisciplinary team met and concluded no interventions were needed. When asked if any interventions were put into place after the second fall on 09/18/2021, ADON #2 stated the interdisciplinary team did not feel any additional interventions were warranted. When asked if a new Morse fall scale assessment was completed after either fall, ADON #2 stated, no. When asked if the fall which occurred on 09/18/2021 may have been avoided if interventions were put into place after the fall that occurred on 09/10/2021, the ADON #2 stated, maybe. ADON #2 stated they would update the care plans. When asked why the tab alarm was not in place on 10/07/2021 and 10/08/2021, ADON #2 stated they were not sure but would in-service staff. When asked if ADON #2 was aware that per facility policy a Morse fall risk assessment was to be completed after each fall to identify risk areas, ADON #2 stated, no. ADON #2 confirmed there was only one fall risk assessment completed for Resident #213, which was on admission (08/17/2021). During an interview on 10/10/2021 at 1:38 PM, the Administrator stated the expectation was that everything should be updated in the residents' care plans. A review of facility's policy and procedure titled, Interdisciplinary Care Planning and Assessment, revised 01/2021, indicated, care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. A review of facility's policy and procedure titled, Resident Safety Program - Fall Prevention, revised 07/2021, indicated, Procedure: A. A Morse Scale Falls Risk Assessment is completed upon admission and readmission, significant change assessment, quarterly assessment and after each fall event. B. Interventions are implemented based on risk areas identified by the falls risk assessment. The fall prevention/intervention guide may be utilized to assist in identifying and implementing appropriate interventions. C. Risk for falls and/or injury is identified and addressed in the resident's individualized treatment plan. D. Falls will be reviewed weekly by the interdisciplinary team and interventions adjusted and care plans updated as necessary. 2. The facility admitted Resident #152 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was a 5 out of 15, which indicated the resident was severely cognitively impaired. Since the previous assessment, the resident had one fall with no injury and two falls with injury. A review of the resident's care plan, last updated on 09/21/2021, indicated Resident #152 was at risk for falls related to poor safety awareness secondary to cognitive loss regarding Alzheimer's disease. The care plan also indicated the following: assistance need with activities of daily living; resident attempts to transfer to toilet; old compression fractures; use of antidepressants, pain, and cardiac medications; a fall on 09/12/2021 resulting in left humerus, left radial, and left femoral neck fractures. Interventions for the falls included the following: - Physical and occupational therapy referrals for changes in functional mobility, with an effective date of 09/26/2018. - Reminding Resident #152 to call for assistance with activities of daily living, especially transfers, with an effective date of 09/26/2018. - Observation for unsafe behavior, with an effective date of 09/26/2018. - Non-slip footwear, with an effective date of 10/04/2018. - Encouragement for use of hip guards, with an effective date of 04/25/2019. - Blood pressure and pulse monitoring weekly, with an effective date of 09/13/2019. - Pad sensor alarm to bed and chair, with an effective date of 05/12/2020. - Floor mats at bedside, with an effective date of 07/06/2021. There were no interventions listed on the resident's care plan regarding any falls that occurred in 2021, except for floor mats at bedside. A review of an injury and accident report indicated that on 06/09/2021 at 8:00 AM, the resident had an unwitnessed fall. Resident #152 stated the resident fell in their bedroom. A certified nursing assistant noticed a small abrasion on the back of the resident's head, behind the left ear, while showering the resident the same morning after the fall. The resolution listed on the report was that Resident #152 was educated on calling for help. Resident #152 stated, I just want to use the bathroom. The report indicated staff would continue to monitor and encourage the resident to use the call light. Following the fall on 06/09/2021, the care plan was not updated to reflect any new interventions. A review of a nursing progress note, dated 06/09/2021 at 2:45 PM, described the note as the initial fall-focused note and detailed the same information provided in the injury and accident report. At the end of the note, the writer had the option to list, New safety interventions added after this fall, and this section was left blank. A review of a nursing progress note, dated 06/09/2021 at 11:10 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify any new interventions. A review of a progress note, dated 06/15/2021 at 3:36 PM, indicated the interdisciplinary team met regarding the fall on 06/09/2021. The new intervention initiated was alarm to chair. According to the care plan, the intervention of alarm to chair was already listed on the care plan with an initiated date of 05/12/2020. A review of an injury and accident report indicated that on 06/29/2021 at 2:00 PM, the resident had an unwitnessed fall. Resident #152 was found lying on the left side of their body on the floor between the door and the bed. Resident #152 was transferring themselves from the bed to the wheelchair. The wheelchair brakes were not locked. The resolution listed on the report indicated the resident stated, I forgot to lock my brakes. Resident #152 was educated on calling for assistance, and staff would continue to monitor. Following the fall on 06/29/2021, the care plan was not updated to reflect any new interventions. A review of a progress note, dated 06/29/2021 at 4:23 PM, detailed the same information provided in the injury and accident report. No new interventions were added, and additional comments were made stating that safety education was provided to the resident on locking the wheelchair brakes and using the call bell for assistance. A review of a nursing progress note, dated 06/29/2021 at 10:37 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify any new interventions. A review of a nursing progress note, dated 06/30/2021 at 11:31 AM, described the note as the second follow-up fall-focused note. New orders were received for an x-ray for cervical, thoracic and lumbar spine, and bilateral hips due to the resident complaining of pain. The additional interventions initiated and response to new interventions were left blank. A review of a physician's progress note, dated 07/01/2021 at 2:59 PM, indicated the resident had a vertebral compression fracture of the L1/T12 site with an indeterminate age. New orders were given for pain medication and an orthopedic consult. A review of a progress note, dated 07/06/2021 at 12:13 PM, indicated the interdisciplinary team met regarding the fall on 06/29/2021. The new intervention initiated was floor mats. A review of an injury and accident report indicated that on 07/15/2021 at 11:50 AM the resident had an unwitnessed fall. Resident #152 spilled milk in their lap, self-ambulated to the bathroom without calling for help, and the resident's tab alarm alerted staff. Resident #152 was found on the floor, sitting with their back against the wall and their legs out in front of them. Resident #152 reported they just went down while trying to get to the toilet. There was no resolution given. Following the fall on 07/15/2021, the care plan was not updated to reflect any new interventions. A review of a progress note, dated 07/15/2021 at 2:40 PM, detailed the same information provided in the injury and accident report. The new interventions added were to educate the resident on the use of the call bell and calling for help. A review of a nursing progress note, dated 07/15/2021 at 11:50 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify any new interventions. A review of a nursing progress note, dated 07/16/2021 at 6:54 AM, described the note as the second follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank. A review of a progress note, dated 07/20/2021 at 10:01 AM, indicated the interdisciplinary team met regarding the fall on 07/15/2021. The new intervention initiated was to remind the resident to call for assistance. A review of a social service progress note, dated 08/19/2021 at 4:23 PM, indicated the resident had cognitive impairment shown by memory loss, impaired decision-making skills, and episodes of confusion. A review of an injury and accident report indicated that on 09/12/2021 at 2:00 PM, the resident had an unwitnessed fall. Staff heard a loud bang, and Resident #152 screamed out. Staff noted the resident lying on the floor in the doorway of their bedroom, lying on the left side of their body with their left arm behind them. Resident #152 then turned themselves over onto their stomach. Resident #152 was transferred to the emergency room at 2:45 PM the same day. The resolution listed on the report was that the resident was transferred to the emergency room for evaluation of injuries, and the resident's care plan would be updated upon return. A Root Cause Analysis (RCA) would be completed to address the resident's fall, and an action plan would be created. A review of a progress note, dated 09/12/2021 at 2:00 PM, detailed the same information provided in the injury and accident report. No new interventions were added. A review of a Root Cause Analysis document indicated the document was completed on 09/30/2021 related to the fall on 09/12/2021 with major injury. Resident #152 sustained a left hip femoral neck fracture, impacted intra-articular left distal radius fracture, and a comminuted proximal left humeral head fracture. The Problem indicated Resident #152 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #152 was last observed resting in their low bed with a fall mat on the floor and a tab alarm attached to the resident. Resident #152 removed the tab alarm and exited their bed. Resident #152 left their walker at the bedside and ambulated toward the doorway. Resident #152 fell due to ambulating without their walker and known gait instability. Resident #152 was diagnosed with a urinary tract infection during the hospital stay. The first part of the facility's action plan consisted of continuing to use the low bed, fall mat at bedside on the floor, fall socks, to move furniture away from the head of the bed to prevent injury, and to apply hip guards. The second part of the facility's action plan consisted of consideration of using a pad sensor alarm while the resident was in bed and to offer the resident fluid every shift to prevent dehydration. The third part of the facility's action plan consisted of providing frequent reminders for the resident to use their walker when ambulating. Resident #152 would use their wheelchair during recovery, with the goal of ambulating with a walker. The care plan was not updated to reflect any new interventions, following the root cause analysis. In an interview on 10/09/2021 at 8:40 AM, Assistant Director of Nursing (ADON) #1 stated the care plan should be updated and the interdisciplinary team had guidelines for interventions. ADON #1 stated, As long as we have some type of alarm in place and appropriate footwear, we make sure to provide education on call light use. ADON #1 stated that the facility had prevented numerous falls for Resident #152 and .there was really no other intervention we could put into place. We could get a sitter . During an interview on 10/10/2021 at 1:38 PM, the Administrator stated the expectation was that everything should be updated in the residents' care plans. A review of facility's policy and procedure titled, Interdisciplinary Care Planning and Assessment, revised 01/2021, indicated, care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. A review of facility's policy and procedure titled, Resident Safety Program - Fall Prevention, revised 07/2021, indicated, Procedure: A. A Morse Scale Falls Risk Assessment is completed upon admission and readmission, significant change assessment, quarterly assessment and after each fall event. B. Interventions are implemented based on risk areas identified by the falls risk assessment. The fall prevention/intervention guide may be utilized to assist in identifying and implementing appropriate interventions. C. Risk for falls and/or injury is identified and addressed in the resident's individualized treatment plan. D. Falls will be reviewed weekly by the interdisciplinary team and interventions adjusted and care plans updated as necessary. 3. The October 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], indicated the resident's cognition was moderately impaired with a SAMS (Staff Assessment for Mental Status). The resident required physical assistance of two persons for dressing and toileting. The resident required physical assistance of one person for personal hygiene. The resident required assistance with setup for bed mobility and eating. The resident exhibited behavioral symptoms such as kicking, hitting, pushing, scratching, grabbing, and sexual abuse directed towards others. The resident's identified symptoms put others at significant risk for physical injury. The resident significantly intruded on the privacy or activity of others. The resident exhibited these behaviors four to six times daily. The resident currently resided in a locked behavior unit. A review of Resident #105's medical record indicated a behavior care plan, dated 02/24/2020, indicated under the focus portion of the plan that Resident #105 resisted care and was combative (hitting/punching/slapping) with staff and at times requires additional certified behavioral technician (CBT) for provision of care. The focus portion also indicated Resident #105 wanders and the resident becomes very intrusive with peers, yells, curses, and threatens peers. Resident #105 takes food from peers' trays at times, becomes verbally and physically aggressive. The intervention portion of the care plan, last revised 02/27/2020, included the following: allow behaviors to continue in a safe manner if it assists with keeping Resident #105 calm, staff to monitor the effectiveness of techniques and report any changes to nurse, doctor, or interdisciplinary committee (IDC) team, offer appropriate seating areas to reduce agitation and over-stimulation, and offer distraction and remove from area when becoming agitated. A review of a facility incident report, dated 06/02/2021, indicated it was reported by an unidentified eyewitness that Resident #197 was propelling themself in their wheelchair on the [NAME] Unit hallway trying to get past Resident #105. The incident report indicated Resident #197 told Resident #105 to excuse them, and Resident #105 responded by punching Resident #197 with a closed fist, which caused a laceration to Resident #197's upper lip. The incident report indicated Resident #197 required an emergency room visit to get their upper lip sutured. A review of a facility incident report, dated 08/13/2021, indicated it was reported by an unidentified eyewitness that Resident #105 was sexually inappropriate with Resident #198. Per the incident report, Resident #105 was observed to have touched Resident #198 on their buttocks while Resident #198 was walking in an unidentified hallway. It was noted in the incident report that when Resident #198 questioned why Resident #105 touched them inappropriately, Resident #105 pushed Resident #198 to the floor. A review of a progress note, dated 10/07/2021, indicated Resident #105 pulled on Resident #234's hair. During an interview with the Activity Assistant (AA) on 10/10/2021 at 3:39 PM, the AA stated that he witnessed the encounter firsthand. Per the AA, Resident #105 pulled Resident #234's hair such that it caused Resident #234's head to tilt abruptly towards the side of the pull and the resident yelled out in a sound that indicated discomfort or pain. Per the AA, Resident #105 had a repeat encounter with Resident #234 within a space of a few minutes. The AA stated that he reported his observations to the nurse on the shift. A review of Resident #105's medical record indicated that for each of the identified incidents of abuse perpetrated by Resident #105 towards the identified residents, the facility failed to reassess Resident #105 and put new interventions in place to prevent further abuse. Specifically, a review of Resident #105's behavior care plan revealed the care plan was formulated between 02/24/2020 through 02/27/2020. There was no amendment to the resident's care plan to reflect that the facility attempted to address what the trigger was for Resident # 105 and to ensure that the resident did not continue to abuse other residents at the facility. During an interview on 10/07/2021 at 2:25 PM, Licensed Practical Nurse (LPN) #7 stated that Resident #105 was aggressive, combative, and not easily redirectable. LPN #7 stated that Resident #105 liked to say racial slurs and derogatory speech. She stated that Resident #105 got into other residents' personal space. LPN #7 stated that the resident had grabbed, hit, and punched staff and residents. LPN #7 stated, You need to know how to speak, in order to not get the resident agitated. LPN #7 reviewed Resident #105's care plan and acknowledged Resident #105's care plan related to the resident's behavior had not been updated after it was formulated on 02/24/2020 through 02/27/2020. LPN #7 stated that she had no remarks about the intervention portion of Resident #105's care plan which read, Allow behaviors to continue in a safe manner if it assists with keeping Resident #105 calm. During an interview on 10/09/2021 at 9:00 AM, Assistant Director of Nursing (ADON) #2 stated that Resident #105 had been very challenging with the resident's care. ADON #2 stated that Resident #105's behaviors created a stressful environment for other residents. The ADON verified there was no adjustment in Resident #105's care plan which reflected the facility intervened in ensuring Resident #105 did not continue to abuse residents at the facility. Specifically, ADON #2 verified that following Resident #105's initial encounter with Resident #197 as noted above, the facility had not reviewed or implemented new measures to ensure that Resident #105 did not continue to abuse residents at the facility. During an interview on 10/10/2021 at 3:02 PM, the Nursing Home Administrator (NHA) stated that when an abuse incident was reported to be repeatedly perpetrated by the same resident, he relied on nursing staff to tell him what they had done and their input on what they thought the facility should do differently. The NHA stated that he expected an investigation into all abuse allegations. Per the NHA, investigation was key to identifying the trigger for the aggressor, and it helped direct the proper intervention which helped to ensure residents at the facility continued to be free from abuse. A review of facility's policy and procedure titled, Interdisciplinary Care Planning and Assessment, revised 01/2021, indicated, care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. New Jersey Administrative Code S 8:39-11.2(e)2

Based on observations, record reviews, facility policy review, and interviews, it was determined that the facility failed to ensure fall assessments were completed and interventions were put into place to decrease the likelihood of falls for 3 (Residents #161, #152, and #213) of 7 residents reviewed for falls. This failed practice resulted in Resident #152 falling and sustaining a fracture. Findings included: 1. The facility admitted Resident #152 with diagnoses of Alzheimer's disease and brain cancer. The annual Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was a 5 out of 15, which indicated the resident was severely cognitively impaired. Since the previous assessment, the resident had one fall with no injury and two falls with injury. A review of the resident's care plan, which was last updated on 09/21/2021, revealed Resident #152 was at risk for falls. Interventions for the falls included the following: - Physical and occupational therapy referrals for changes in functional mobility, with an effective date of 09/26/2018. - Reminding Resident #152 to call for assistance with activities of daily living, especially transfers, with an effective date of 09/26/2018. - Observation for unsafe behavior, with an effective date of 09/26/2018. - Non-slip footwear, with an effective date of 10/04/2018. - Encouragement for use of hip guards, with an effective date of 04/25/2019. - Blood pressure and pulse monitoring weekly, with an effective date of 09/13/2019. - Pad sensor alarm to bed and chair, with an effective date of 05/12/2020. - Floor mats at bedside, with an effective date of 07/06/2021. There were no interventions listed on the resident's care plan regarding any falls that occurred in 2021, other than the floor mats at bedside. A record review of the fall assessments indicated that on 06/29/2021 and 08/25/2021, Resident #152 was at a moderate risk for falls, and on 09/20/2021, the resident was at a high risk for falls. A review of an injury and accident report indicated that on 06/09/2021 at 8:00 AM, the resident had an unwitnessed fall. Resident #152 stated they fell in their bedroom. A certified nursing assistant noticed a small abrasion on the back of the resident's head, behind the left ear, while showering the resident the same [MEDICATION(S)] the fall. The resolution listed on the report was that Resident #152 was educated on calling for help. Resident #152 stated, I just want to use the bathroom. The report indicated staff would continue to monitor and encourage the resident to use the call lights. A review of a nursing progress note, dated 06/09/2021 at 2:45 PM, described the note as the initial fall-focused note and detailed the same information provided in the injury and accident report. At the end of the note, the writer had the option to list, New safety interventions added after this fall, and this section was left blank. A review of a nursing progress note, dated 06/09/2021 at 11:10 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify any new interventions. A review of a progress note, dated 06/15/2021 at 3:36 PM, indicated the interdisciplinary team met regarding the fall on 06/09/2021. The new intervention initiated was alarm to chair. According to the care plan, the intervention of alarm to chair was already listed on the care plan with an initiated date of 05/12/2020. A review of an injury and accident report indicated that on 06/29/2021 at 2:00 PM, the resident had an unwitnessed fall. Resident #152 was found lying on the left side of their body on the floor between the door and the bed. Resident #152 was transferring themselves from the bed to the wheelchair. The wheelchair brakes were not locked. The resolution listed on the report indicated the resident stated, I forgot to lock my brakes. Resident #152 was educated on calling for assistance, and staff would continue to monitor. A review of a progress note, dated 06/29/2021 at 4:23 PM, detailed the same information provided in the injury and accident report. No new interventions were added, and additional comments were made stating that safety education was provided to the resident on locking the wheelchair brakes and using the call bell for assistance. A review of a nursing progress note, dated 06/29/2021 at 10:37 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify any new interventions. A review of a nursing progress note, dated 06/30/2021 at 11:31 AM, described the note as the second follow-up fall-focused note. New orders were received for an x-ray for cervical, thoracic and lumbar spine, and bilateral hips due to the resident complaining of pain. The additional interventions initiated and response to new interventions were left blank. A review of a physician's progress note, dated 07/01/2021 at 2:59 PM, indicated the resident had a vertebral compression fracture of the L1/T12 site with an indeterminate age. New orders were given for pain medication and an orthopedic consult. A review of a progress note, dated 07/06/2021 at 12:13 PM, indicated the interdisciplinary team met regarding the fall on 06/29/2021. The new intervention initiated was floor mats. A review of an injury and accident report indicated that on 07/15/2021 at 11:50 AM, the resident had an unwitnessed fall. Resident #152 spilled milk in their lap, self-ambulated to the bathroom without calling for help, and the resident's tab alarm alerted staff. Resident #152 was found on the floor, sitting with their back against the wall and their legs out in front of them. Resident #152 reported they just went down while trying to get to the toilet. There was no resolution given. A review of a progress note, dated 07/15/2021 at 2:40 PM, detailed the same information provided in the injury and accident report. The new interventions added were to educate the resident on the use of the call bell and calling for help. A review of a nursing progress note, dated 07/15/2021 at 11:50 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify new interventions. A review of a nursing progress note, dated 07/16/2021 at 6:54 AM, described the note as the second follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank. A review of a progress note, dated 07/20/2021 at 10:01 AM, indicated the interdisciplinary team met regarding the fall on 07/15/2021. The new intervention initiated was to remind the resident to call for assistance. A review of a social service progress note, dated 08/19/2021 at 4:23 PM, indicated the resident had cognitive impairment shown by memory loss, impaired decision-making skills, and episodes of confusion. A review of an injury and accident report indicated that on 09/12/2021 at 2:00 PM, the resident had an unwitnessed fall. Staff heard a loud bang, and Resident #152 screamed out. Staff noted the resident lying on the floor in the doorway of their bedroom, lying on the left side of their body with their left arm behind them. Resident #152 then turned themselves over onto their stomach. Resident #152 was transferred to the emergency room at 2:45 PM the same day. The resolution listed on the report was that the resident was transferred to the emergency room for evaluation of injuries, and the resident's care plan would be updated upon return. A Root Cause Analysis (RCA) would be completed to address the resident's fall, and an action plan would be created. A review of a progress note, dated 09/12/2021 at 2:00 PM, detailed the same information provided in the injury and accident report. No new interventions were added. A review of a progress note, dated 09/20/2021 at 4:01 PM, indicated the resident returned from the hospital with a left humerus fracture. A review of a Root Cause Analysis document indicated the document was completed on 09/30/2021 related to the fall on 09/12/2021 with major injury. Resident #152 sustained a left hip femoral neck fracture, impacted intra-articular left distal radius fracture, and a comminuted proximal left humeral head fracture. The Problem indicated Resident #152 had a history of gait instability and was found lying in the doorway of their assigned room. Resident #152 was last observed resting in their low bed with a fall mat on the floor and a tab alarm attached to the resident. Resident #152 removed the tab alarm and exited their bed. Resident #152 left their walker at the bedside and ambulated toward the doorway. Resident #152 fell , due to ambulating without their walker and known gait instability. Resident #152 was diagnosed with a urinary tract infection during the hospital stay. The first part of the facility's action plan consisted of continuing to use the low bed, fall mat at bedside on the floor, fall socks, move furniture away from the head of the bed to prevent injury, and apply hip guards. The second part of the facility's action plan consisted of consideration of using a pad sensor alarm while the resident was in bed and to offer the resident fluid every shift to prevent dehydration. The third part of the facility's action plan consisted of providing frequent reminders for the resident to use their walker when ambulating. Resident #152 would use their wheelchair during recovery with the goal of ambulating with a walker. On 10/08/2021 at 3:15 PM, Assistant Director of Nursing (ADON) #1 provided the injury and accident reports, as well as any fall assessments, for the resident within the last six months. ADON #1 verified there were three fall assessments that had been completed on the resident, which were 06/29/2021, 08/25/2021, and 09/20/2021. There were no fall assessments for 06/09/2021 or 07/15/2021. In an interview on 10/09/2021 at 8:40 AM, ADON #1 stated it was the facility's policy to complete a fall assessment after each fall, which was completed by the interdisciplinary team (IDT), and there should have been one completed after each fall for Resident #152. ADON #1 stated the care plan should be updated and the IDT team had guidelines for interventions. ADON #1 stated, As long as we have some type of alarm in place and appropriate footwear, we make sure to provide education on call light use. ADON #1 stated that the facility had prevented numerous falls for Resident #152 and .there was really no other intervention we could put into place. We could get a sitter . During an interview on 10/10/2021 at 1:39 PM, the Administrator stated the expectations of the facility was to provide care to prevent falls from occurring and to intervene after a fall to try to prevent further falls. The Administrator stated a fall should be documented in an incident report, and the interdisciplinary team would review the fall and seek to find interventions to prevent further falls. The Administrator also stated the interventions should be updated in the care plans and was disappointed they were not. Review of the facility's policy and procedure titled, Resident Safety Program/Fall Prevention, revised on 07/21, revealed, Policy: All residents who are at risk for falls will be identified through a comprehensive assessment process. This risk will be addressed in the resident's individualized treatment plan and evaluated through the IDC process .Procedure: A Morse Scale Falls Risk Assessment is completed upon admission and readmission, significant change assessment, quarterly assessment and after each fall .F. Falls will be reviewed weekly by the IDC team using the IDC team fall event review note, interventions adjusted, and care plans adjusted as necessary. 2. The facility admitted Resident #161 with diagnoses of history of falling, muscle weakness, and age-related [CONDITION(S)]. The quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 14 out of 15, which indicated the resident was cognitively intact. Since the previous assessment, the resident had one fall with no injury, two falls with injury, and one fall with major injury. A review of the resident's care plan, with a revision date of 08/31/2021, indicated the resident was at risk for falls that resulted in right hip surgery on 05/2021 and multiple rib displacements on 08/2021 and pain. Interventions listed included the following: - Observe Resident #161 for unsafe behavior and redirect accordingly, with an effective date of 5/26/2021. - Resident #161 to use comfortable, proper fitting non-skid shoes, with an effective date of 5/26/2021. - Monitor Bowel and Bladder needs, with an effective date of 05/26/2021. - Provide adequate lighting, with an effective date of 05/26/2021. - Encourage current activity level, with an effective date of 05/26/2021. - Tab alarm to bed and chair, with an effective date of 06/03/2021. - Pad alarm to bed and chair, with an effective date of 07/06/2021. - Keep bed in low position and call bell within reach, with an effective date of 07/06/2021 - Provide assistance as needed for activities of daily living (ADL), with an effective date of 07/06/2021. - Observe for signs of discomfort and monitor resident for complaints of pain and follow pain interventions as per doctor's orders, with an effective date of 07/06/2021. - Hip protectors at all times except for care, with an effective date of 07/07/2021. - Pressure relieving scoop mattress, with an effective date of 08/20/2021. - Keep call bell within reach, remind and encourage resident to use it before getting out of bed, with an effective date of 08/31/2021. A review of all of the resident's assessments indicated the resident had one fall assessment, which was completed on the day the resident was admitted , on 05/18/2021. There were no other fall assessments in the resident's electronic health record. A review of an injury and accident report indicated that on 06/01/2021 at 12:15 AM, the resident had an unwitnessed fall. The resident was found on the floor at bedside and stated they fell on their way back from the bathroom. The resolution listed on the report was that the resident was alert, awake, oriented, and able to make needs known. Resident #161 stated they fell on their way from the bathroom and believed it was their shoe that caused the fall. Staff were re-educated on monitoring the resident's footwear. The facility was to follow up with the resident's family member on providing appropriate footwear for the resident. A tab alarm was to remain in place as an intervention. A review of an injury and accident report indicated that on 07/06/2021 at 7:15 PM, the resident had an unwitnessed fall. The nurse was notified that the resident was lying on the floor on their left side in front of their closet. The resident's right shoe was off as well as the right side of the resident's pants. Resident #161 remained verbal and alert. Resident #161 stated, I was just standing still, and I don't know what happened. I just fell down. The resident was assessed, and there was bruising and a scrape on the resident's left elbow and left knee. Resident #161 complained of moderate pain to their left elbow and knee. There was no swelling or deformities noted. The resident was educated on safety. There was no resolution listed. A record review of an injury and accident report indicated that on 08/11/2021 at 8:30 PM, the resident had an unwitnessed fall. There was screaming heard coming from Resident #161's room, and the resident was found lying on their back beside their bed. Resident #161 stated they were trying to transfer themselves to the wheelchair, it moved, and they slid to the floor. Resident #161 sustained bruises to their upper back. The resolution listed on the report was to have an x-ray completed, which indicated multiple injuries noted to the rib area. Resident #161 was re-educated on the need to use the call bell for assistance. A tab alarm was to remain in place as an intervention. In an interview on 10/06/2021 at 3:48 PM, Resident #161 stated that it had been hard adjusting to moving into a nursing home facility. When asked if the resident had had any falls or hospitalization s since being admitted , the resident looked away from the surveyor and denied any falls or hospitalization s since being admitted . On 10/08/2021 at 3:15 PM, ADON #1 provided the injury and accident reports, as well as any fall assessments, for the resident within the last six months. ADON #1 verified there was only one fall assessment that had been completed on the resident, on 05/18/2021. In an interview on 10/09/2021 at 8:50 AM, ADON #1 stated Resident #161 should have had a fall assessment completed after each fall. In an interview on 10/10/2021 at 2:40 PM, the Administrator stated the Resident #161 should have had a fall assessment completed after each fall. During an interview on 10/10/2021 at 1:39 PM, the Administrator stated the expectations of the facility was to provide care to prevent falls from occurring and to intervene after a fall to try to prevent further falls. The Administrator stated a fall should be documented in an incident report, and the interdisciplinary team would review the fall and seek to find interventions to prevent further falls. The Administrator also stated the interventions should be updated in the care plans and was disappointed they were not. 3. A review of Resident #213's quarterly MDS Minimum Data Set (MDS), dated [DATE], indicated diagnoses including hypertension, [CONDITION(S)], diabetes, personal history of traumatic fracture, and muscle weakness. The resident's Brief Interview for Mental Status (BIMS) score was 13, which indicated no cognitive impairment. The MDS indicated the resident had one fall with injury. A review of a fall risk assessment titled, Morse Fall Scale Assessment, dated 08/17/2021, indicated Resident #213 was at moderate risk for falling. There was no other Morse fall scale assessment completed after that date. A review of #213's care plans, dated 08/31/2021, indicated the resident was at risk for falls, as evidenced by a history of falls, with the last fall on 09/18/2021. Interventions included the following: maintain bed in low position, tab alarm for safety to bed and wheelchair at all times, encourage to use appropriate assistive devices, encourage use of appropriate fitting, non-skid shoes, observe for unsafe behavior, remind to use the call light, and assist with toileting and meeting daily needs. The effective dates for the interventions were 08/31/2021. The care plan did not indicate any additional interventions to prevent falls after 08/31/2021. A review of Resident #213's physician's orders, dated October 2021, indicated an order for a tab alarm to chair and bed at all times. The order date was 08/17/2021. There was no order for a low bed A review of Resident #213's progress notes indicated the resident sustained a fall on 09/10/2021. The note indicated the fall occurred in the resident's room at 7:45 PM and was unwitnessed. An x-ray was obtained for complaints of back and hip pain, which indicated no injury. There was no documentation to indicate if the tab alarm was in place at the time of the fall. A review of Resident's #213 IDT (interdisciplinary team) investigation dated 09/13/21 confirmed no interventions were put into place after the fall on 09/10/21. A review of Resident #213's progress notes indicated the resident sustained another fall on 09/18/2021 at 9:00 PM. The notes indicated the fall occurred in the hallway next to the resident's wheelchair and was unwitnessed. There was no injury documented. There was no documentation to indicate if the tab alarm was in place at the time of the fall. A review of Resident's #213 IDT investigation dated 09/24/21 confirmed no interventions were put into place after the fall on 09/18/21. An observation of Resident #213 on 10/07/2021 at 7:52 AM revealed the resident sitting on the edge of the bed. There was no tab alarm (used to indicate if a resident was rising from a seated position), and the bed was not in the low position. An observation of Resident #213 on 10/08/2021 at 8:38 AM revealed the resident sitting on the edge of the bed. There was no tab alarm, and the bed was not in the low position. There was a fall mat next to the bed. On 10/08/2021 at 10:24 AM, an interview was conducted with Assistant Director of Nursing (ADON) #2. When asked if new interventions were put into place after the resident fell on [DATE], ADON #2 stated, no. ADON #2 stated that the facility's interdisciplinary team met and concluded no interventions were needed. When asked if any interventions were put into place after the second fall on 09/18/2021, ADON #2 stated the interdisciplinary team did not feel any additional interventions were warranted. When asked if a new Morse fall scale assessment was completed after either fall, ADON #2 stated, no. When asked if the fall which occurred on 09/18/2021 may have been avoided if interventions were put into place after the fall that occurred on 09/10/2021, the ADON #2 stated, maybe. ADON #2 stated that the care plan would be updated. When asked why the tab alarm was not in place on 10/07/2021 and 10/08/2021, ADON #2 stated they were not sure but would in-service staff. ADON #2 stated the CNA had all the interventions on the Kiosk, which is where they document. When asked if ADON #2 was aware per facility policy a Morse fall risk assessment was to be completed after each fall to identify risk areas, ADON #2 stated, no. ADON #2 confirmed there was only one fall risk assessment completed for Resident #213, which was on admission (08/17/2021). During an interview on 10/08/2021 at 7:31 PM, a family member for Resident #213 stated the resident had sustained multiple falls at home. The family member stated that they and other family members were concerned about Resident #213's safety. During an interview on 10/10/2021 at 1:39 PM, the Administrator stated the expectations of the facility was to provide care to prevent falls from occurring and to intervene after a fall to try to prevent further falls. The Administrator stated a fall should be documented in an incident report, and the interdisciplinary team would review the fall and seek to find interventions to prevent further falls. The Administrator also stated the interventions should be updated in the care plans and was disappointed they were not. Review of the facility's policy and procedure titled, Resident Safety Program/Fall Prevention, revised on 07/2021, revealed, Policy: All residents who are at risk for falls will be identified through a comprehensive assessment process. This risk will be addressed in the resident's individualized treatment plan and evaluated through the IDC process .Procedure: A Morse Scale Falls Risk Assessment is completed upon admission and readmission, significant change assessment, quarterly assessment and after each fall .F. Falls will be reviewed weekly by the IDC team using the IDC team fall event review note, interventions adjusted, and care plans adjusted as necessary. New Jersey Administrative Code S 8:39-27.1(a)

Complaint #: NJ Based on observation, interview and record review, it was determined that the facility failed to notify a physician of a resident's refusal to take a medication which required adjustment of the dosage to maintain a specific blood level, for 1 of 4 sampled residents (Resident #1). Resident #1 missed 3 of 5 consecutive daily doses of the medication [MEDICATION NAME] (Anticonvulsant), and in the morning of the 6th day appeared to have a [MEDICAL CONDITION], which required hospitalization . This deficient practice is evidenced by the following: All interviews and record reviews were conducted on 2/10/2014 unless otherwise stated. 1. According to a Facility Face Sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 9/16/2013, documented a BIMS (Basic Interview Mental Status) score of 99. This score (99) denotes that Resident #1 could not complete the interview. Further documentation indicated that Resident #1 was severely cognitively impaired and never or rarely made decisions. Additional documentation reflected that Resident #1 required assistance with all activities of daily living (ADLs). The surveyor observed the following physician orders dated 9/9/2013: "[MEDICATION NAME] 50 mg (milligrams), chewable tablet, Chew 6 tablets (300 mg) by oral route every other day, (to start 9/10/2013) alternate with [MEDICATION NAME] 50 mg (milligrams), chewable tablet, Chew 8 tablets (400 mg) by oral route every other day (to start 9/9/2013)." The time of administration was slated for 9:00 p.m. On continued surveyor review of Resident #1's closed medical record, the surveyor observed the following documentation in a nursing note, dated and timed 9/16/2013, 7:43 p.m.: "...refused 9:00 p.m. meds, spit the meds out." There was no documentation to support that the physician was notified. In a nursing note, dated and timed 9/18/2013, 8:01 p.m.: "...refused 9:00 p.m. meds, spit the meds out." There was no documentation to support that the physician was notified. On review of the September 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"n/a" (not available). [MEDICATION NAME] (Anticonvulsant), [MEDICATION NAME] (Calcium Channel Blocker) and [MEDICATION NAME] (Benzodiazepine) were not administered on 9/16/2013, 9/19/2013 and 9/20/2013. The reason documented for the medications not administered at 9:00 p.m. on 9/16/2013 and 9/20/2013 was "Refused", and the reason documented for the medications not administered at 9:00 p.m. on 9/19/2013 was "spit out med". On 2/10/14 at 10:30 a.m., the surveyor conducted an interview with a Registered Nurse (RN #1) and asked about medication refusals by residents. RN #1 stated: "We do our best to get them to take the medications, we cannot force them to do what they don't want to do." The surveyor then asked RN #1 if she would ever report medication refusal to a physician. RN #1 stated: We would make at least 2 attempts (to get the resident to take it), then call the physician." The surveyor also asked what would be done if a medication was not available when it was time to be administered. RN #1 stated: "We have a Pixis (a medication backup source), but if the medication is not in there we would call the pharmacy for a stat delivery." [MEDICATION NAME] was not listed as in the Pixis system on the medication list that was provide to the surveyor. On 2/10/14 at 10:40 a.m., the surveyor conducted an interview with RN #2 and asked about medication availability and medication refusals. RN #2 stated: "I can't force them (residents) to take medicine, I'd let charge nurse know, then let the doctor know especially if it was an important med like cardiac, blood pressure, diuretics, insulin. If the medication is not available in the Pixis, I would call the pharmacy." A nursing note, dated and timed 9/21/2013, 12:12 p.m.: "At 11:35 a.m...(Resident #1) was sitting in w/c (wheelchair) and became unresponsive, very stiff with generalized shaking, drooling and color cyanotic. Placed (Resident #1) back to bed. BP (blood pressure) 190/80, Apical pulse 104, R (respirations) 20, pOx (pulse oximetry) 90% on RA (room air). Unresponsive to verbal and tactile stimulation. Rapid Response called. 911 called. Non-rebreather (oxygen mask) applied at 15 liters/minute, pOx 98%. O2 (oxygen) decreased to 5 liters. pOx 96%. (Family) arrived...Paramedics arrived at 11:50 a.m. At 11:50 a.m. BP 184/80. Color pink. At 12 noon, (Resident #1) responding by opening eyes when (Resident #1's) name called. At 12 noon, (Resident #1) transferred to hospital via paramedics. Doctor notified." The surveyor conducted an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 2/10/14 at 3:55 p.m. and asked about the facility policy on refusal of medications. The DON stated: "After this happened (not taking medication for 2 (consecutive) days with Resident #1), we discussed the policy on not reporting to the doctor until after 3 doses of medication are missed. We thought that using nursing judgement was the way to go and will be doing this." On review of the facility policy titled, "Change in a Resident's Condition or Status", dated 7/2013, the policy documented: "The Nurse Supervisor/Designee will notify the resident's attending physician/designee when: The resident repeatedly refuses treatment or medication (i.e. three or more consecutive times." The DON then replied, "We have to change the policy though." The surveyor reviewed hospital records and observed the following documented on the form "Emergency Department Physician Documentation" dated 9/21/2013: "Patient has a past medical history significant for [MEDICAL CONDITION] disorder...(patient) had apparently refused taking medications...today the patient had a witnessed grand mal [MEDICAL CONDITION], witnessed by the nursing staff. Patient was brought to the ER (emergency room ) post ictal (confusion that follows a [MEDICAL CONDITION]), unable to give any history." Patient is noted to have sub-therapeutic [MEDICATION NAME] level. [MEDICATION NAME] level ([MEDICATION NAME]) was less than 0.4 (normal limits are 10.0 - 20.0). Additional documentation stated: "Load with [MEDICAL CONDITION] medication intravenously and then orally. admitting [DIAGNOSES REDACTED]." NJAC 8:39 - 13.1 (d)