Every finding on record at Complete Care at Arbors

Based on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the resident's call device was in reach and able to be used. The deficient practice was observed on the second-floor unit, for 2 out of 2 residents (Residents #53 and Resident 101) reviewed for the Environmental Task.The deficient practice was evidenced by the following:On 08/13/2026 at 9:43 AM during the initial tour, the surveyor observed Resident #53 and Resident # 101 both in their beds in the same room. The surveyor observed both residents' call devices on the floor and not within reach. On 08/14/2026 at 9:14 AM the surveyor observed Resident #101 in bed. At that time, the surveyor observed the call device out of reach from the resident. The call device was between the mattress and the foot board of the bed.During an interview with the surveyor on 08/18/2026 at 9:28 AM, the Rosewood Unit Manger Licensed Practical Nurse (UMLPN) said that call device should always within reach of the residents.During an interview on 08/18/2026 at 1:03 PM with the surveyor, the Director of Nursing said, all call bells should be within reach of the residents for safety issues, and it is how they can contact staff.A review of facility provide policy titled, Call Lights: Accessibility and Timely Response revealed, 6. The call system will be accessible to the resident while in their bed or other sleeping accommodations within the resident's room.NJAC 8:39-31.8(c)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean, sanitary and homelike environment for 1 of 2 units (Evergreen Unit room [ROOM NUMBER]) reviewed for the environment. This deficient practice was evidenced by the following: On 08/13/2026 at 10:32 AM during the initial tour of the facility in the Evergreen Unit, the surveyor entered room [ROOM NUMBER] and observed on the wall beside the B bed, that the wallpaper had come apart at the seams. The wallpaper was peeling and detaching from the wall. In addition, the wooden decorative chair rail, also located beside the B bed, had been repaired, but required painting and cosmetic finishing to restore its appearance. When the surveyor asked the resident how they felt about the peeling wallpaper and the chair rail, they stated it looked terrible and that the facility should have finished the job before moving anyone into the room, On 08/19/2026 at 1:09 PM, the survey team met with the facility Administration. The surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) who both acknowledged the resident rooms should all be in good repair and there should be no peeling wallpaper or other cosmetic issues. A review of the facility's Safe and Homelike Environment policy dated 9/1/2024 included In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment. 'Environment' refers to any environment in the facility that is frequented by residents, including (but not limited to) the resident's rooms, A 'homelike environment' is one that de-emphasizes the institutional character of the setting, to the extent possible. NJAC 8:39-31.4 (a)(f)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to accurately assess the status of a resident in the Minimum Data Set (MDS), an assessment tool. This deficient practice was identified for 1 of 36 sampled residents, (Resident #1) and was evidenced by the following:On 08/19/2026 at 9:53 AM, the surveyor interviewed Resident #1 who stated they go to dialysis three times a week, on Tuesdays, Thursdays and Saturdays at 9:30 AM. According to the admission Record, Resident #1 was admitted to the facility with diagnoses which included but were not limited to end stage renal disease (kidney disease) and Type 2 Diabetes Mellitus. A review of Resident #1's Order Summary Report (OSR) with active orders as of 08/20/2026 for Resident #1, included a physician's order (PO) initiated on 01/03/2026 for Dialysis days: Tuesday/Thursday/Saturday- pick up at 8:30 AM for 9:30 AM chair time. A review of the most recent quarterly MDS dated [DATE], reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated a fully intact cognition. A further review of Section O- Special Treatments, Procedures, and Programs; J1 for Dialysis was not indicated and did not reflect Resident #1 was receiving dialysis treatments. On 08/19/2026 at 11:55 AM, the surveyor interviewed the MDS Coordinator and together they reviewed the quarterly MDS. The MDS Coordinator confirmed Resident #1 was currently on dialysis and the MDS should reflect that status. She acknowledged it was an oversight on her part and the quarterly MDS dated [DATE] had been coded incorrectly. On 08/19/2026 at 1:09 PM the survey team met with the Facility Administration. At that time the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) both confirmed Resident #1 was currently receiving dialysis treatments and acknowledged the MDS Coordinator should ensure the accuracy of the MDS reports including the Special Treatments section. A review of the facility MDS 3.0 Completion policy implemented 10/9/25 included Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity. NJAC 8:39-11.1

Based on observation, interview and record review, it was determined that the facility failed to administer medication with an error rate of less than 5%. The surveyor observed 4 nurses administer medications for 7 residents; errors were observed for 1 of 7 residents (Resident #12). There were 25 opportunities for error with 2 errors observed resulting in an error rate of 8% as evidenced by the following:During the medication pass observation on 08/14/2026 from 9:16 AM until 9:41 AM, the surveyor observed the following: At 9:16 AM, the surveyor observed Licensed Practical Nurse #1 (LPN #1) prepare 7 medications for Resident #12, which included the following: 1. Doxycycline Hyclate 100 mg oral tablet, give one tablet by mouth two times a day; scheduled for 8:00 AM and administered 9:35 AM.2. Metoprolol Succinate ER 25 mg tablet, give one tablet by mouth one time a day; scheduled for 8:00 AM and administered at 9:35 AM. At 9:36 AM, the surveyor interviewed LPN #1 who acknowledged two of Resident #12's medications, Doxycycline and Metoprolol were administered late, they were scheduled for 8:00 AM and were given after 9:00 AM. LPN #1 stated the facility policy allowed medications to be administered one hour before or one hour after their scheduled administration time. On 08/19/2026 at 1:09 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON stated medications should be given as ordered by the physician at the time they were scheduled. The DON further added the nurses have an hour before and an hour after the scheduled medication time to give the medication to ensure resident safety. A review of the Medication Administration policy dated 09/01/2024 included Medications are administered by licensed nurses.as ordered by the physician and in accordance with professional standards of practice.12 (b) Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. NJAC 8:39-29.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain appropriate environmental controls for the storage of medications. The deficient practice was identified for 1 of 2 (Evergreen) medication rooms observed during the Medication Storage Task. The deficient practice was evidenced by the following: On [DATE] at 09:31 AM, the surveyor observed the Evergreen Medication Room. The surveyor was accompanied by the Unit Manager Licensed Practical Nurse, who unlocked the medication room door for the surveyor. At that time, the surveyor observed two plastic bags filled with medications that belonged to an unsampled, discharged resident. The resident was discharged in June of 2026. At the same time in the medication room, the surveyor observed deceased insects and debris on the window sill and the floor. The cabinet countertop in the room had white residual stains around the sink faucets. The countertop also had stains on the surface. On [DATE] at 1:02 PM during an interview with the surveyor, the Director of Nursing (DON) said the medications from the unsampled resident were going to be retrieved by their family. Secondly, the DON said she is unsure of a specific policy but there should be routine cleaning of the medication room. Lastly, she confirmed that housekeeping would be responsible for ensuring the medication room was cleaned. A review of the facility-provided policy titled, Medication Storage revised on [DATE] revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregations, and security. A review of the facility-provided policy titled, Pest Control Program implemented on [DATE] revealed that It is the policy of this facility to maintain and effective pest control program that eradicates and contains common household pests and rodents. N.J.A.C. S 8:39-29.4 (h)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have the lid closed for 1 of 3 garbage containers. This deficient practice was evidenced by: On 08/13/2026 at 9:24 AM the surveyor accompanied by the Food Service Director (FSD), observed the facility's outdoor trash disposal area. The surveyor observed one garbage container (GC) to the side of the facility along the facility's fence. The surveyor observed the GC to have opened lids and contained cardboard boxes exposed to the elements.On the same day and time, when asked if the lids should be opened on the GC the FSD said that the lid should be closed to keep pest away. During an interview on 8/19/2026 at 1:03 PM with the survey team the Licensed Nursing Home Administrator said, the lids for the dumpsters should remain closed and free from overflow to keep the area clean and free from pest.A review of the facility provided policy titled, Disposal of Garbage and Refuse with a review date of 004/13/2026 revealed, 7.Containers and dumpsters shall be kept covered when not being loaded. NJAC 8:39-19.3(c)

Based on observation, interview, and review of medical records, it was determined that the facility failed to provide necessary treatment services, consistent with professional standards of clinical practice by not a.) securing medications during medication administration observation for 1 of 3 nurses; b.) notifying a physician regarding a resident's refusal of medication for 1 of 1 residents (Resident #31); c.) applying skin protective devices as ordered by a physician for 1 of 2 residents (Resident #8) reviewed for pressure ulcers; and d.) destroying unused medication properly during medication observation for 1 of 3 nurses. Reference: New Jersey Statutes, 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, 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 task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. This deficient practice was identified by the following: 1. A review of the Admission Record face sheet (admission summary) indicated that Resident #31 was admitted to the facility with the diagnoses which included but were not limited to; displaced intertrochanteric fracture of the left femur. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated [DATE], reflected that the resident was cognitively intact and required maximum assistance with activities of daily living. On [DATE] at 9:10 AM, during medication administration observation for Resident #31, the surveyor observed Resident #31 lying in bed. The surveyor observed the Licensed Practical Nurse (LPN #1) offer Resident #31 the medication Lovenox injection (anticoagulant that thins the blood for the prevention of blood clots). The resident refused the injection. LPN #1 placed the medication, unsecured, on top of the medication cart and went into the resident's room and bathroom while the medication was out of the LPN's view. The surveyor interviewed LPN #1 and asked her if all medications should be secured in the cart and the LPN confirmed that all medications should be secured in the cart. The surveyor then asked LPN #1 why she left the Lovenox injection on the top of the medication cart and did not secure it in the cart, and the LPN admitted that she should have locked the medication in the medication cart because another resident could have taken it from on top of the cart. A review of the Physicians Orders (PO) dated [DATE], reflected an order for Lovenox injection solution prefilled syringe 40 milligrams per 0.4 milliliters (40 mg/0.4 mL); inject 0.4 ml subcutaneously one time a day for left femur (thigh bone) fracture prophylactic. A review of the [DATE] Medication Administration Record (MAR) revealed that Resident #31 had refused the Lovenox subcutaneous injections 19 out of 24 days in [DATE]. The medication was refused on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The surveyor reviewed Resident #31's Progress Notes (PN) and there was documentation that the resident's primary care physician (PCC) was notified one time on [DATE] at 9:59 AM, regarding the resident's refusal of the medication, however there was no documentation regarding the physician's response to the refusal. There was also documentation in the PN on [DATE] at 10:34 AM, that the resident refused the medication, however the note did not indicate that the physician was made aware. The surveyor reviewed the Physician Progress Notes (PPN) for [DATE], which included notes documented on [DATE], [DATE], [DATE], [DATE], and [DATE]. The notes did not include documentation that the physician was aware that the resident was refusing the anticoagulant medication Lovenox. A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated [DATE], that the resident was on anticoagulant therapy related to (r/t) post-surgery. Interventions included to: administer anticoagulant medications as ordered by physician and monitor for side effects and effectiveness every shift; and to monitor/document/report as needed (PRN) adverse reactions of anticoagulant therapy which included; blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. The ICCP did not indicate that the resident had behaviors of non-compliance with mediation usage. On [DATE] at 11:55 AM, the surveyor interviewed LPN #1, who stated that if a resident refused a medication on consecutive days, the assigned nurse was expected to call and notify the physician. LPN #1 stated that if the resident consistently refused the medication by day three, the nurse was responsible to call the physician to obtain an alternate medication or to get a discontinuation order for the medication. On [DATE] at 1:38 PM, the surveyor interviewed the Director of Nursing (DON), who stated that if the resident refused a medication after three days, the physician should have been notified to find out if an alternative could be ordered or to see if the medication could be discontinued. The DON continued to explain that there should have been documentation in the progress notes that the resident had been refusing Lovenox for multiple days in March, and there also should have been documentation that the physician was made aware and what the physician wanted to do about the refusals. On [DATE] at 11:53 AM, the surveyor interviewed the PCC, who stated that Resident #31 was high risk for deep vein thrombosis (DVT). The PCC stated that she knew that while the resident was in the acute care hospital that the resident was non-complaint with treatments, however she could not remember if she was notified that the resident refused the Lovenox at this facility. The PCC stated that if she was notified, she could have recommended an alternative such as compression stocking, because you cannot force resident to take something that they did not want to. On [DATE] at 9:29 AM, the surveyor interviewed the Pharmacy Consultant (PC), who stated that when she conducted the medical record review (MRR), she reviewed the MAR, physician orders, checked parameters and documented any discrepancies. The PC stated that she conducted an MRR review for Resident #31 and sent a separate report to the PCC on [DATE], regarding the resident missing doses of Lovenox. The PC stated that she did not know why the PCC stated that she was not aware the resident refused the medication. A review of the Pharmacy Consultant Report (PCR) dated [DATE], included the PC's recommendations: This resident has been refusing Lovenox. Please consider switching to an oral anticoagulant. On [DATE] at 10:14 AM, the DON stated that the facility reviewed and acted upon the PC's recommendations on [DATE], however they did not see the second page which contained the recommendations regarding the resident's refusal of the Lovenox, which was acted upon on [DATE], after surveyor inquiry. The DON stated that the PCC switched the medication to oral anticoagulant medication. 2. The Admission Record face sheet indicated that Resident #81 was admitted to the facility with the diagnoses which included but were not limited to; cerebral infarction (stroke) and contracture of the knee. The comprehensive MDS dated [DATE], reflected that Resident #81 had moderate cognitive impairment and was dependent on staff for activities of daily living (ADLs). The MDS also indicated that the resident had a pressure ulcer and was at risk for development of pressure ulcers. A review of the PO dated [DATE], reflected an order for heel boots to be applied bilaterally and to maintain and check for placement every shift. The boots were to be removed for care every shift for prophylaxis to check for redness. On [DATE] at 11:52 AM, the surveyor observed the resident lying in bed and was not wearing heel boots. On [DATE] at 11:30 AM, the surveyor observed Resident #81 lying in bed. The resident was interviewed at that time and stated that they were not wearing any heel boots on the feet. The resident lifted the blankets and showed the surveyor. A review of the resident's ICCP included a focus area dated [DATE], that the resident had actual skin breakdown. A review of the intervention dated [DATE], included that the resident was to wear bilateral heel boots while in bed and check placement every shift. On [DATE] at 11:44 AM, the surveyor interviewed the resident's Certified Nursing Assistant (CNA #1), who stated that Resident #81 was alert and oriented and able to answer questions appropriately. CNA #1 stated that the resident required total care for washing and dressing, had a wound on their left hip, utilized an air mattress, and wore no devices. A review of the Treatment Administration Record (TAR) dated [DATE], indicated that the nurse had signed that the heel boots were in place on the resident. On [DATE] at 11:45 AM, the surveyor observed Resident #81 not wearing bilateral heel boots as ordered by the physician. The surveyor interviewed the Registered Nurse (RN #1), who accompanied the surveyor to the resident's room, and RN #1 stated that the boots must be in the laundry. RN #1 then went to a closet in the hallway and obtained the boots. RN #1 had no explanation as to why she had signed in the TAR that the resident's bilateral heel boots were in place when they were not on. On [DATE] at 10:14 AM, the surveyor interviewed the DON, who stated that the heel boots should be applied as ordered by the physician and that if the resident refused to wear them, it should be documented in the PN. 3. On [DATE] at 9:10 AM, the surveyor conducted a medication observation on the Evergreen Unit with LPN #1. The surveyor observed a resident refuse a Senna laxative medication. After the resident's refusal, LPN #1 returned to the medication cart and threw the medication in the trash can. The surveyor asked LPN #1 what the process was for proper disposal of medication, and the LPN stated that she should have disposed the medication into the drug buster (used for pill disposal, destroys prescription medications safely, and safe disposal of medications). When asked why she threw the medication in the trash can, LPN #1 stated that she improperly disposed of the medication because she was nervous. On [DATE] at 10:14 AM, the surveyor interviewed the DON, who stated that medication should have been disposed in the drug buster not the trash can. A review of the facility's Medication Storage policy dated [DATE], included that during medication pass, medications must be under the direct observation of the person administering the medications and locked in the medication storage area/cart. A review if the facility's Resident Rights Regarding Treatment and Advance Directives policy dated [DATE], included that should a resident refuse treatment of any kind, the facility would document the following in the resident's chart: what the resident refused; the reason for the refusal; how the resident was educated regarding the consequences of the refusal; the offering of alternative treatments; the continuation of providing all other services; that the physician was notified of the refusal and the resident's response to education/offering of alternatives . A review of the facility's Use of Assistive Device policy dated [DATE], included that use of assistive device will be based on the resident's comprehensive care plan and that the nurse with responsibility for the resident would monitor for consistent use of the device. Refusals of use would be documented in the resident's medical record . A review of the facility's Destruction of Unused Drugs dated [DATE], included all unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations (refer to any state-specific requirements). 1. Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements .3. Prescription drugs may not be flushed down the toilet in accordance with EPA regulations. 4. Our facility utilizes Drug Busters to destroy unused, non-returnable medications . NJAC 8:,d+[DATE].2(b); 27.1(a); 29.4(h)

Based on observations, interviews, record review and other pertinent facility documentation it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection by ensuring a.) proper use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP) for 2 of 2 residents reviewed for EBP (Resident #81 and #397), b.) label and date piston syringe irrigation kit (a device intended for medical purposes that consists of a calibrated hollow barrel and a movable plunger) in a manner to prevent contamination for infection control identified for 1 of 1 resident reviewed for tube feeding (Resident #64), and c.) respiratory device tubing and mouthpiece/ mask were stored in protective covering identified for 1 of 2 residents (Resident #17) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. A review of the Admission Record (AR) face sheet (admission summary) indicated that Resident #81 was admitted to the facility with the diagnoses which included but were not limited to; cerebral infarction (stroke) and contracture of the knee. A review of the Minimum Data Set (MDS), an assessment tool dated 2/14/25, reflected that Resident #81 had moderate cognitive impairment and was dependent on staff for activities of daily living (ADLs). The MDS also indicated that the resident had a pressure ulcer and was at risk for development of pressure ulcers. On 3/23/25 at 10:57 AM, during initial tour, the surveyor observed a sign on the resident's door which indicated that Resident #81 was on enhanced barrier precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes). The signage indicated that staff were to wear personal protective equipment (PPE) such as an isolation gown and gloves. The surveyor observed PPE in a cart in front of the resident's door that contained gowns and gloves. The surveyor observed a Certified Nursing Assistant (CNA #1) providing direct resident care (bathing the resident in bed) wearing only gloves and not an isolation gown. At that time, the Licensed Practical Nurse/Unit Manager (LPN/UM #1) walked by the resident's room and was notified by the surveyor the breech in infection control. LPN/UM #1 then entered the resident's room. LPN/UM #1 also observed the CNA #1 not wearing the appropriate PPE while performing direct resident care. LPN/UM #1 stated that CNA #1 did not realize the resident was on EBP even though there was a visible sign on the door that specified what type of PPE to be applied when providing direct resident care. LPN/UM #1 confirmed that CNA #1 should have been wearing the appropriate PPE such as gown and gloves when caring for Resident #81. A review of the physician's order (PO) dated 2/19/25, reflected an order to maintain EBP related to a history of methicillin resistant staphylococcus aureus (MRSA). A review of the individual comprehensive care plan (ICCP) dated 2/7/24, indicated that the resident had actual skin breakdown with a goal to avoid infection and resolve wounds. A review of the facility's Enhanced Barrier Precautions policy dated 9/1/24, included that EBP refer to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities .initiation of EBP would be obtained for any resident who had wounds or indwelling medical devices . 51337 2. During the initial tour of the facility on 3/23/25 at 10:50 AM, the surveyor observed a sign by Resident #397's door which indicated that the resident was on EBP. The surveyor observed CNA #2 changing Resident #397 in bed. CNA #2 wore gloves with no gown. The surveyor asked CNA #2 what PPE they should be wearing when changing a resident with the EBP sign on the door. CNA #2 stated that they should have worn a gown and gloves. On 3/24/25 at 8:00 AM, the surveyor reviewed the medical record for Resident #397. A review of the AR face sheet indicated the resident was admitted to the facility with diagnoses including but were not limited to; acute kidney failure and dermatitis (skin irritation and rashes caused by genetic factors and others). A review of the most current quarterly MDS dated [DATE], reflected that the resident did not have any wounds but was at risk for developing pressure injuries. A review of the Order Summary Report dated active as of 3/23/25, included the following physician's orders (PO): A PO dated 10/17/24, that the resident required EBP for wound status every shift per protocol. A PO dated 3/21/25, to cleanse distal left lower leg ulcer with normal saline, cover with abdominal pad, then ACE wrap (an elastic bandage) every 72 hours for left leg ulcer. A review of the ICCP included a focus area revised on 8/27/24, that the resident required EBP related to a wound. Interventions included to post of signage outside resident's room indicating required PPE and high-contact activities that require the use of PPE. During an interview with the surveyor on 3/25/25 at 10:01 AM, LPN/UM #2 stated that if a resident was on EBP, staff had to wash their hands, and put on gloves, a gown, and a mask. LPN/UM #2 stated that prior to exiting the room, the staff had to remove the PPE and wash their hands again. During an interview with the surveyor on 3/25/25 at 11:18 AM, the Director of Nursing (DON) stated that EBP was utilized by staff during high contact activities such as changing residents with wounds. 3. During the initial tour of the facility on 3/23/25 at 10:17 AM, the surveyor observed Resident #17 sitting in their wheelchair in their room. On top of the resident's side table was a nebulizer (a device used to administer medication in the form of mist inhaled into the lungs), and the handheld mouthpiece attached was unlabeled, unbagged, and exposed to air. The tubing connecting the mouthpiece to the nebulizer was observed touching the plastic liner of the trash can in front of the side table. On 3/24/25 at 12:19 PM, the surveyor observed the resident's nebulizer on top of the side table with the handheld mouthpiece unlabeled, unbagged and touching the content of a plastic container. On 3/24/25 at 12:10 PM, the surveyor reviewed the medical record for Resident #17. A review of the AR face sheet indicated the resident was admitted to the facility with diagnoses including but were not limited to; acute respiratory failure with hypoxia (low level of oxygen in the body) and dementia (symptoms affecting thinking and social abilities). A review of the most current quarterly MDS dated [DATE], revealed the resident had a moderately impaired cognition. A further review of the MDS indicated the resident had not received any respiratory therapy during a seven day look back period. A review of the Order Summary Report dated active as of 3/26/25, included the following physician's order (PO): A PO dated 12/26/24, for ipratropium-albuterol solution 0.5-2.5 (3) milligram per 3 milliliters (3 mg/3 ml); inhale 3 ml orally via nebulizer every six hours for chronic obstructed pulmonary disease (COPD, a lung disease causing restricted airflow). During an interview with the surveyor on 3/25/25 at 10:01 AM, LPN/UM #2 stated that nebulizer masks/handheld device should be dated, labeled with the name of the resident, and stored in a plastic bag. During an interview with the surveyor on 3/26/25 at 12:37 PM, the DON stated that nebulizer masks/handheld device should be bagged with date and name of resident. A review of facility's Oxygen Safety policy dated implemented on 9/1/24, did not include the care and storage of nebulizers. 49094 4. On 3/23/25 at 10:40 AM, during the initial tour of the facility, the surveyor observed Resident #64 sleeping in their bed. The surveyor observed a piston syringe irrigation kit in a bag located on the resident's nightstand. On 3/24/25 at 12:07 PM, the surveyor observed LPN #1 administer Resident #64's tube feeding as per physician orders. The surveyor observed the piston syringe irrigation kit that LPN #1 used to administer the tube feeding was not labeled or dated. After LPN #1 completed the administration of the tube feeding, the surveyor interviewed LPN #1 who stated the piston irrigation kits were changed daily. LPN #1 stated the piston syringe bottle and container should have a date on it to indicate when it was opened. LPN #1 acknowledged that there was no date on the piston syringe bottle or the container it comes in. LPN #1 then stated it should be dated so we know when it was opened for infection control purposes. On 3/23/25 at 12:58 PM, the surveyor reviewed the medical record for Resident #64. A review of the AR face sheet reflected the resident was admitted to the facility with diagnoses which included but ere not limited to; dysphagia (difficulty swallowing), gastrotomy status (presence of gastrotomy feeding tube), and unspecified severe protein calorie malnutrition (consumes inadequate amounts of protein and calories). A review of the most recent quarterly MDS 1/6/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severe impairment cognition. A further review included the resident had a feeding tube while at the facility. A review of the Order Summary Report included a physician's order (PO) dated 4/10/24, for NPO (nothing by mouth) diet. A further review revealed a physician's order dated 4/25/24, for enteral tube feeding four times a day, Two Cal HN 237 ml bolus (single dose) via peg tube (flexible tube inserted through the skin and into the stomach) for a total volume of 948 ml. There was also a physician's order dated 4/1/24, to change piston syringe every night shift. On 3/25/25 at 10:35 AM, the surveyor interviewed LPN #2, who stated that the piston syringe irrigation kits should be changed every day. LPN #2 also stated that the bottle and the container were labeled with the resident's room number and dated. LPN #2 further stated it was important to label and date the irrigation kits, so the nurse knew when it had been opened and to make sure we were not using old dirty ones. On 3/25/25 at 11:23 AM, the surveyor interviewed LPN/UM #2, who stated the piston syringe irrigation kits were changed daily on the 11:00 PM to 7:00 AM shift. LPN/UM #2 stated that when the irrigation kits were opened by the nurse, they were to be dated. LPN/UM #2 further stated that the importance of dating the irrigation kits was to ensure the nurse did not use an old one and for contamination reasons. On 3/26/25 at 11:20 AM, the surveyor interviewed the DON, who stated that piston syringe irrigation kits were changed daily, every 24 hours, or if needed sooner. The DON stated that the 11: 00 PM to 7:00 AM nurse discarded the old irrigation kit and replaced it with a new one. The DON also dated that the irrigation kit once it was opened to ensure it was not being used over 24 hours. The DON stated that it should not be used over 24 hours due to infection control purposes. On 3/27/25 at 10:14 AM, the DON, in the presence of the Licensed Nursing Home Administrator, Regional Administrator, [NAME] President of Clinical Services, and the survey team, acknowledged that piston syringe irrigation kits should be dated when opened for infection control purposes. The DON stated that if a nurse saw an irrigation kit not dated, they were to discard it and get a new one. A review of the facility's Care and Treatment of Feeding Tubes policy date implemented 9/1/24 did not address piston syringe irrigation kits. NJAC 8:39-19.1; 19.4(a); 27.1(a)(e)

Complaint # NJ175184, NJ176084, NJ179637 Based on observations, interviews, and review of pertinent facility documents, the facility failed to ensure residents who required assistance with their daily activities of living (ADLs) a.) received incontinence care and b.) staff answered resident call systems to provide care and services. This deficient practice was identified for 1 of 4 residents reviewed for bowel and bladder (Resident #65); 2 of 8 residents observed during incontinence rounds (Resident # 29 and Resident #63); and on 1 of 2 nursing units (Rosewood). The evidence was as follows: 1. On 3/23/25 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated the unit today had five certified Nurse Aides (CNA) for 48 residents. On 3/23/25 at 10:26 AM, during the initial tour of the unit, the surveyor interviewed Resident #65 who was lying in their bed. The resident stated that they were saturated and had not been changed yet that morning. Resident #65 stated that they had to use incontinence briefs due to a stroke. The resident then showed the surveyor the brief that was soiled with urine. The resident then stated that they had not been changed all night. A review of Resident #65's most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/27/24, revealed that the resident had a brief interview for mental status (BIMS) score or 15 out of 15, which indicated a fully intact cognition. The MDS further revealed that the resident was incontinent of bowel and bladder and dependent on staff for toileting. On 3/24/25 at 9:45 AM, the surveyor observed Resident #65 lying in bed in their room. The resident stated, Thank you, I was changed this morning. The resident then stated that they were not changed until later in the afternoon yesterday (3/23/25). On 3/25/25 10:30 AM, the surveyor interviewed CNA #1, who stated that residents' incontinence briefs were changed every two hours. CNA #1 further stated that it was importance to change the resident every two hours to prevent skin breakdown and for skin integrity. On 3/26/25 at 11:20 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the schedule to change residents' incontinence briefs was specific to each resident and their needs. The DON also stated that they do not have specific time frames to change the resident's incontinence brief. On 3/27/25 at 10:14 AM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Administrator, [NAME] President of Clinical Services (VPCS), and the survey team, acknowledged that CNAs needed to ensure timely incontinence rounds were being completed. 2. On 3/23/25 at 10:34 AM, the surveyor observed the call device for Resident room [ROOM NUMBER] on at 10:34 AM. The nurse call device system at the nurse's station revealed it was activated for three minutes at 10:34 AM. The surveyor observed LPN/UM #1 enter the room at 10:41 AM. The nurse call device system present at the nurse's station revealed that Resident room [ROOM NUMBER]'s call device was activated for ten minutes when attended to at 10:41 AM. On 3/24/25 at 9:13 AM, the surveyor observed the call device for Resident room [ROOM NUMBER] on at 9:13 AM. The nurse call device system at the nurse's station revealed that the call device at 9:19 AM, had been activated for fourteen minutes at that time. During the surveyor observation, it was observed that multiple staff walked past the resident's room during the call device being activated. At 9:22 AM, the surveyor observed a staff member enter the room to assist the resident and turned the call device off. The call device was activated for seventeen minutes. On 3/24/25 at 9:29 AM, the surveyor observed the call device for Resident room [ROOM NUMBER]B was triggered on at 9:29 AM. The surveyor observed two staff walk by the resident's room on three occasions. At 9:40 AM, the surveyor observed a staff member enter the room to assist the resident and turned off the call device. On 3/27/25 at 10:14 AM, the LNHA, in the presence of the DON, Regional Administrator, VPCS, and the survey team, stated that call device response times were very serious. The LNHA further stated that weekly audits for call devices have been completed and the longest weight time was ten minutes. The LNHA further stated that no staff should walk by a call device light without seeing the need of the resident. A review of the facility's Call Lights: Accessibility and Timely Response policy with an implemented date of 9/1/24, included .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow resident to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response .10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 11. Process for responding to call lights: a. turn off the signal light in the resident's room .c. listen to the resident's request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel. d. inform the appropriate personnel of the resident's need . 51337 3. On 3/24/25 at 9:10 AM, the surveyor conducted with LPN/UM #1 an incontinence tour and observed the following: On 3/24/25 at 9:23 AM, the surveyor and LPN/UM #1 observed Resident #63 in bed. LPN/UM #1 exposed the resident's incontinence brief. The surveyor observed the incontinence brief was saturated with urine and had a strong urine odor. There was also moderate amount of formed and grayish substance on the brief that LPN/UM #1 acknowledged was a bowel movement. LPN/UM #1 stated that the resident needed to be changed. On 3/24/25 at 9:27 AM, the surveyor and LPN/UM #1 observed Resident #29 in bed. LPN/UM #1 exposed the resident's incontinence brief. The surveyor observed the incontinence brief to be saturated with urine. There was also large amount of formed brownish substance that the LPN/UM acknowledged was a bowel movement. The surveyor observed the skin around the resident's buttocks area was reddened. The resident stated that nobody changed them since the night before. LPN/UM #1 stated that the resident would be changed immediately. On 3/26/25 at 10:38 AM, the surveyor interviewed CNA #2, who stated that they changed the residents' incontinence briefs every two hours or as needed because the residents could develop urinary tract infections if they were not changed when they needed to. CNA #2 also stated that as soon as they started their shift at 7:00 AM, the CNAs did rounds with the CNAs from the 11:00 PM to 7:00 AM (night) shift and received reports. CNA #2 confirmed that the 7:00 AM to 3:00 PM (day) shift CNAs do the morning rounds and that the night shift CNAs did their last rounds at 5:00 AM. On 3/26/25 at 10:40 AM, the surveyor interviewed CNA #3, who stated that they checked the residents' incontinence briefs every two hours or more depending on how often the resident voided. On 3/26/25 at 10:42 AM, the surveyor interviewed CNA #1, who stated that they checked the residents every two hours. A review of the facility's Incontinence policy with an implemented date of 9/1/24, included .based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible . A review of the facility's Activities of Daily Living (ADLs) policy with an implemented date of 9/1/24, included .Care and services will be provided for the following activities of daily living: .3. Toileting .Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . A review of the facility's Nursing Services and Sufficient Staff policy dated implemented on 3/3/25, included .1. The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans . NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) maintain infection control to reduce the risk of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice during a wound care treatment and b.) ensure a treatment was administered in accordance with a physician order. This deficient practice was identified for 1 of 3 residents reviewed for pressure ulcer (Resident #46), and was evidenced by the following: Reference: CDC Recommendations for Hand Hygiene, updated 2/27/24, Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; after contact with blood, body fluids, or contaminated surfaces; immediately after glove removal. https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html#cdc_clinical_safety_best_practices_recomm-recommendations On 3/23/25 at 10:34 AM, the surveyor observed Resident #46 lying in bed on an air mattress. The Registered Nurse (RN) on duty stated that the resident had a sacral (the back) pressure ulcer (PU). On 3/24/25 at 12:31 PM, the surveyor observed the Licensed Practical Nurse (LPN) perform the PU treatment for the resident's sacral wound assisted by the Certified Nursing Assistant (CNA #1) and observed the following: During the wound care observation, the surveyor observed the LPN and CNA #1 wearing surgical masks, gowns, and gloves. The LPN's gown was observed untied on the top part. The resident was positioned on their left side lying on top of the soiled unfastened incontinence brief which was on top of a clean chuck pad. While the LPN was cleansing the resident's wound with a gauze pad and normal saline solution, the nurse's loose gown sleeve touch the soiled incontinence brief and clean chuck pad. Then the LPN dropped the gauze pad she was cleaning with onto the soiled incontinence brief, picked it up, and proceeded to use that pad to clean around the wound cavity. Then the LPN without changing her gloves or performing hand hygiene, removed a tube of zinc oxide from the treatment cart in the hallway, squeezed the cream onto her right hand, and applied it to the reddish skin around the wound. The LPN then changed her gloves and performed hand hygiene, and then used her gloved hands to remove a treatment tube from the treatment cart. The LPN then with the same gloved hands opened a package of collagen sprinkles (powder for wound care) and applied the powder directly to the wound and the edges of the packet were observed touching the wound bed. Without changing gloves and performing hand hygiene, the LPN took an unlabeled tube of honey wound gel, squeezed a dollop of gel onto a cotton-tipped applicator and applied the gel to the wound. The LPN used the same cotton-tipped applicator that was blood-stained from touching the wound bed, and applied more gel to the applicator. The contaminated tip of the applicator touched the tip of the treatment tube. The LPN then took a new cotton-tipped applicator and calcium alginate packing strips (wound dressing for drainage), and the LPN tried to apply the long packing strips inside the wound cavity using their left hand and the applicator. Parts of the packing strips were observed touching the soiled incontinence brief the resident was lying down on. The LPN picked up the parts of the strips that touched the soiled incontinence brief with the applicator. After a bundle of strips fell to the soiled incontinence brief, the LPN picked up those strips with her left gloved hand and placed the packing strips inside of the wound cavity with her gloved hand. Without changing gloves or performing hand hygiene, the LPN covered the packed wound with an ABD pad (a sterile dressing used for wound care). The resident was then turned to their back with the ABD pad underneath them and on top of the soiled brief. The LPN then removed her gloves, but did not perform hand hygiene. The LPN took a sanitizing wipe from the treatment cart and wiped down the scissors, honey wound gel tube, and zinc oxide cream tube with the same wipe. The LPN then cleaned the overbed table with the same sanitizing wipe used to clean the treatment tubes and scissors. The LPN discarded the sanitizing wipe, treatment table liner, gown, and gloves, and proceeded to wash hands. The LPN returned the unlabeled zinc oxide and honey wound gel tubes to first drawer of the treatment cart. After wound care was completed, the resident was turned to their right side and the soiled brief was rolled beneath them and thrown on the trash can by CNA #1. CNA #1 removed their gloves and washed their hands appropriately. CNA #1 put on a new pair of gloves and applied a new incontinence brief on top of the chuck pad used earlier for wound dressing. On 3/24/25 at 1:05 PM, the surveyor discussed their observed concerns from the wound care treatment with the LPN. The LPN stated that they should have changed gloves and performed hand hygiene between clean and unclean procedures. The LPN stated that they instructed CNA #1 to remove the soiled incontinence brief prior to the treatment, but the CNA did not remove it. The LPN stated that they tried not to touch the tip of the treatment tube with the blood-stained applicator, and she should have disposed it and used a new one. The LPN stated that she would label the gel tube and proceeded to write resident's name on the gel tube and returned it to the cart. The LPN stated that acetic solution 0.25% should have been used to cleanse the area around the wound prior to the application of other treatments as ordered. The LPN stated to the surveyor that they think they failed the test. On 3/24/25 at 1:09 PM, the surveyor discussed the wound treatment observation concerns with the Licensed Practical Nurse/Unit Manager (LPN/UM), who acknowledged that there were several lapses in terms of infection control that warranted the treatment to be redone. The LPN/UM stated that the soiled incontinence brief should have been disposed prior to the treatment to avoid cross contamination. The LPN/UM also stated that gloves should have been changed between clean and unclean procedures and that hand hygiene should have been performed before and after changing the gloves. The LPN/UM stated that acetic solution (acetic acid diluted in water to kill bacteria and promote healing of wounds) should have been applied after cleansing with saline solution. On 3/24/25 at 1:30 PM, the surveyor reviewed the medical record for Resident #46. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; pressure ulcer of the sacral region stage 4 (loss of full thickness of the skin exposing underlying structures like muscle, tendon, ligament, or bone) and paralytic syndrome following cerebral infarction (stroke with paralysis). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/31/24, revealed that the resident had a stage 4 PU and that the resident received PU care. A review of the Order Summary Report dated active as of 3/26/25, included a physician's order to cleanse the area of the sacrum with acetic solution 0.25%, apply zinc oxide cream to the periwound area, apply collagen sprinkles, apply medical grade honey gel, pack with calcium alginate, cover with ABD pad every day shift for sacral ulcer stage 4. A review of the March 2025 Treatment Administration Record (TAR) reflected that the ordered treatment was administered by the LPN on the day shift of 3/24/25. A review of the comprehensive individual care plan (ICCP) dated revised on 2/29/24, included a focus for enhanced barrier precautions because of wound with the goal for the resident not to have symptoms of infection. Interventions include that the wound care consultant recommended to continue treatment as ordered; on 8/1/23, the wound care consultant recommended to cleanse the sacral wound with normal saline solution (NSS), do not scrub or use excessive force; pat dry, apply collagen sprinkles then calcium alginate and ABD pad; cover with ABD pad daily, do not put tape directly to the skin, pressure ulcer improving. During an interview with the surveyor on 3/26/25 at 12:37 PM, the Director of Nursing (DON) stated that hand hygiene should be performed before and after gloves changes and gloves should be changed between clean and unclean procedures to prevent cross contamination and infection. A review of facility's Wound Treatment Management policy dated 9/1/24, included Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders . A review of facility's Personal Protective Equipment policy dated 9/1/24, included Policy Explanation and Compliance Guidelines: .4.a.iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn; .4.b.ii. Gowns should fully cover torso from neck to knees, arms to end of wrist, and wrap around the back. Fasten in back at neck and waist . NJAC 8:39 - 27.1(a)(e)

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure dialysis communication forms between the facility and the contracted dialysis facility were consistently completed. This deficient practice was identified for 2 of 2 residents reviewed for dialysis (Resident #25 and Resident #45), and was evidenced by the following: 1. On 3/23/25 at 10:32 AM, during initial tour of the facility, the surveyor observed Resident #45 seated in their wheelchair in the hallway. Resident #45 stated that they go to dialysis three times a week. On 3/24/25 at 12:52 PM, the surveyor reviewed the medical record for Resident #45. A review of the Transfer/Discharge Report face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but were not limited to; end stage renal disease (kidneys have permanently lost their ability to function), dependence on renal dialysis (relies on dialysis machine to filter their blood), and type two diabetes mellitus (body does not use insulin properly). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/28/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated a severe impairment cognition. A further review included the resident received dialysis while at the facility. A review of the Order Summary Report included a physician's order (PO) dated 3/20/25, for dialysis at [dialysis center name] on Tuesday, Thursday, and Saturday; seating time 6:00 AM. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 7/31/24, that the resident needed hemodialysis related to renal failure. Interventions included but were not limited to; encourage resident to go for scheduled dialysis appointments; resident receives dialysis (Tuesdays/Thursdays/Saturdays), monitor labs and report to the doctor as needed, and do not draw blood or take blood pressure in the arm with the graft. On 3/24/25 at 12:52 PM, the surveyor reviewed Resident #45's dialysis communication record that was sent with the resident on dialysis treatment days. The communication forms were reviewed for February and March 2025. The following dialysis communication forms were not completed by the facility's nurse upon return from dialysis: 2/14/25, 2/15/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25, 3/15/25, and 3/20/25. On 3/25/25 at 10:35 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated the dialysis communication form was completed by the nurse prior to departure and it was sent to dialysis with the resident. LPN #1 also stated that when the resident returned from dialysis, the nurse obtained vital signs, checked the bruit and thrill, reviewed the dialysis communication form and signed the bottom of the form indicating the nurse reviewed it. LPN #1 further stated the nurse reviewed the information from the dialysis center for medication changes, new orders, and the resident's weight. LPN #1 stated the purpose of the dialysis communication form was to have communication between the facility and the dialysis center. LPN #1 acknowledged that the dialysis communication forms should not have any blank sections, and the nurse should sign it upon the resident's return. On 3/25/25 at 11:23 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated when the resident was sent out to dialysis, their communication book went with them. LPN/UM #1 also stated that the nurse was responsible to review and sign the dialysis communication form when the resident returned from dialysis. LPN/UM #1 further stated that the purpose of the dialysis communication form was to see if there were any changes with the resident's medication, weight, and vital signs. LPN/UM #1 acknowledged that the dialysis communication forms should not have blanks and that the nurse should have signed the form upon return. On 3/26/25 at 11:20 AM, the surveyor interviewed the Director of Nursing (DON), who stated the purpose of the dialysis communication form was to ensure proper coordination of care for the resident. The DON further stated that when a resident went out to dialysis, the nurse was responsible to complete the Information from sending facility section with vital signs, and upon the resident's return, the nurse reviewed the form and signed the bottom of the form. The DON also stated if there were any new orders the nurse followed up with the physician. The DON acknowledged that the dialysis communication forms were not filled out completely on the following dates: 2/14/25, 2/15/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25, 3/15/25, and 3/20/25. On 3/27/25 at 10:14 AM, the DON, in the presence of the Licensed Nursing Home Administer (LNHA), Regional Administrator, [NAME] President of Clinical Services, and the survey team, stated dialysis communication forms should be reviewed and signed by the nurse upon the resident's return from dialysis. The DON acknowledged that the dialysis communication forms were not filled out completely. 33106 2. A review of the facility Admission Record face sheet for Resident #25 reflected that the resident was admitted to the facility with the diagnoses that included but were not limited to; end stage renal disease. A review of the comprehensive MDS dated [DATE], reflected that Resident #25 was cognitively intact and required maximum with activities of daily living. The MDS also reflected that the resident received dialysis. On 3/23/25 at 10:54 AM, during initial facility tour, the surveyor observed Resident #25 lying in bed. The resident was pleasant and stated that they had a central catheter for dialysis on the left side of their chest. The resident explained that they went out for hemodialysis on Tuesday, Thursday and Saturday. The surveyor observed a central catheter with dressing intact to the resident's left side of the chest. A review of the physician's order summary reflected a physician's order dated 1/7/25, for the resident to go out for hemodialysis on Tuesday, Thursday, and Saturday. A review of the ICCP reflected that the resident required dialysis with interventions that included: to monitor/document/report and signs or symptoms of infection to access site, monitor labs and report to doctor as needed and that the resident received dialysis on Tuesday, Thursday, and Saturday. On 3/24/25 at 11:43 AM, the surveyor attempted to review the resident dialysis communication book (communicate the information including the resident's status with the dialysis facility prior to and post dialysis). LPN/UM #2 was not able to locate the dialysis communication book. The surveyor interviewed the resident at that time, who stated that they usually took paperwork to the dialysis center for them to fill out and then the communication sheet went back to the nurses. The resident stated, They are always losing the communication book. On 2/24/25 at 12:00 PM, the surveyor interviewed the facility's Regional Clinical Nurse (RCN), who was also not able to locate the dialysis communication book and was only able to provide two dialysis communication sheets since January 2025, dated 1/1/25 and 1/14/25. On 3/27/25 at 10:14 AM, the surveyor interviewed the DON, who stated that the dialysis communication forms were an important form that was utilized as a form of communication between the dialysis center and the facility. The DON stated that the forms were an important part of the resident's clinical record and included vital signs, weighs and any procedures that were performed at the dialysis center. The DON stated that the nurse should assure that the forms in the dialysis book were kept as part of the resident's medical record. A review of the facility's Hemodialysis policy dated 9/1/24, included 5. the licensed nurse will communicate to the dialysis facility via telephone communication or written format, such as a dialysis communication form or other form . NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent records, it was determined that the facility failed to a.) ensure the accountability of the narcotic shift count logs were completed and b.) accurately account for and document the administration of controlled medications. This deficient practice was identified on 2 of 3 medication carts (Rosewood #1 and #4) reviewed and was evidenced by the following: On 3/25/25 at 10:20 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN), reviewed the Rosewood nursing unit's medication cart #1. The following was observed when the narcotic logbook was reviewed: The nurse's signature for the going off duty was missing on: 3/8/25 the 3:00 PM to 11:00 PM (evening) shift; 3/13/25 the 7:00 AM to 3:00 PM (day) shift; and 3/19/25 the evening shift. The nurse's signature for the coming on duty was missing on the 3/8/25 night shift. A further review of the declining inventory logs indicated that Resident #56 should have had 30 tablets of phenobarbital 32.4 milligram (mg) (a controlled medication used to treat seizures), but only 29 tablets were on hand. The LPN at that time, stated she administered the medication during the morning medication pass and failed to sign it out. The LPN further stated that controlled medications should be signed out immediately for each dose administered so that the narcotics were accounted for. On 3/25/25 at 11:35 AM, the surveyor, accompanied by the Registered Nurse (RN), reviewed the Rosewood nursing unit's medication cart #4. The following was observed when the narcotic logbook was reviewed: The nurse's signature for the incoming and outgoing nurse was blank for the 3/10/25 evening shift. A further review of the declining inventory logs indicated the following controlled medication doses that were administered and not signed out when compared to their corresponding Medication Administration Records (MAR): Resident #3: tramadol hydrochloride (hcl) 25 mg tablet (medication used to treat pain). Resident #17: lacosamide 200 mg tablet (medication used to treat seizures). Resident #33: pregabalin 25 mg capsule (medication used to treat seizures and nerve pain). Resident #42: lacosamide 50 mg tablet. Resident #46: oxycodone-acetaminophen 5-325 mg tabled (medication used to treat pain). Resident #397: oxycodone 5 mg tablet. At that time, the RN stated to the surveyor that the narcotic shift-to-shift accountability logs should not have any missing signatures and that the declining inventory logs should have been updated for each dose administered at the time of administration. The RN stated the reason was to maintain narcotic accountability, but it's time consuming to fill out narcotic declining inventory logs for each medication at the time of administration. On 3/25/25 at 12:15 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the expectation was that the shift-to-shift logs were completed and signed by the incoming nurse and outgoing nurse at the time of medication cart hand off, whether it be at shift change or otherwise. The DON stated that the requirement was that two licensed nurses completed the narcotic count together and signed the log which indicated that the count was completed and accurate. The DON stated that there should never be any missing signatures. The DON further stated that the declining inventory logs were used to keep accountability of narcotics administered and that each sheet should be filled out for each dose administered in real time, and that nurses were not to wait to sign out the dose later. A review of the facility's Controlled Substance Administration and Accountability policy with a revised date of 3/17/25, included in all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the medication administration record (MAR), controlled drug record, or other facility specified form and placed in the patient's medical record .nursing staff (2) must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services . NJAC 8:39-29.7(c)

Based on observation, interview, and review of facility policy, it was determined that the facility failed to properly store and secure medications. This deficient practice was observed in 1 of 3 medication carts reviewed (Rosewood #4), and was evidenced as follows: On 3/25/25 at 11:35 AM, the surveyor observed the Rosewood nursing unit's medication cart #4. The medication cart was next to the nurse's station and was unattended by any nursing staff. The cart was observed to be unlocked and had a bottle of acidophilus with pectin (a probiotic medication used to treat diarrhea) left unattended on top of the cart. At that time, the surveyor requested that the nurse assigned to the cart to be paged to come to the cart. The Registered Nurse (RN) assigned to the cart came out of a resident's room down the hall and approached the surveyor at the cart. The surveyor interviewed the RN who stated that medication should not have been left unattended and unsecured. The RN also confirmed that the medication cart should have been secured since it was left unattended. The RN further stated that she had worked at facilities where residents have tried to access medications. The surveyor did not observe any residents ambulating independently near the medication cart. On 3/25/25 at 12:15 PM, the surveyor interviewed the Director of Nursing (DON), who stated medications and medication carts should never be left unsecured and medications should not have been left on top of the medication cart when unattended. The DON stated medications should only be accessible to licensed nurses to ensure that residents and others cannot access medications. A review of the facility's Medication Storage policy with an implemented date of 9/1/24, included all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . NJAC 8:39-29.4(h)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 3/23/25 at 9:23 AM, during initial tour of the kitchen, the surveyor accompanied by the Head Chef, and observed the following: An opened container of bulk beef base. The beef base was not labeled with a use by date and contained a coffee mug that was used as a scooper in the beef base. A large, opened container of flour that contained a coffee mug left inside the flour to be used as a scooper. On 3/23/25 at 10:05 AM, the surveyor interviewed the Assistant Food Service Director (AFSD), who stated that the bulk beef base should have had a use by date on the container and the coffee mugs should not be used as scoopers. The AFSD acknowledged that scoopers should not be left in the flour or beef base for infection control purposes. On 3/27/25 at 10:13 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, acknowledged that the coffee mugs should not have been used and left in the flour and bulk beef base for infection control purposes. A review of the facility's provided and undated Dry Food policy did not include the proper use and storage of scoopers used in the kitchen to scoop out and measure dry ingredients. NJAC 8:39-17.2(g)

Based on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to ensure that the infection control practices for residents on transmission-based precautions (TBP) were followed to prevent the potential spread of infection by not utilizing contact precautions in accordance with facility policy and accepted national standards for 1 (one) of 2 (two) resident (Resident #79) reviewed for TBP and was evidenced by the following: According to the Admission Record, Resident #79 was admitted to the facility with the diagnoses that included but was not limited to C-diff (infection of the large intestine (colon) caused by the bacteria Clostridium difficile) and MRSA (methicillin-resistant Staphylococcus aureus, a type of bacteria that is resistant to several antibiotics). A review of the quarterly Minimum Data Set (MDS) an assessment tool that facilitated a resident's care dated 02/22/24 indicated that the resident was cognitively intact. On 05/01/24 at 10:28 AM, the surveyor observed a sign posted on Resident #79's door indicating that the resident was on enhanced barrier precautions (EBP). There were also signs posted to indicate what type of personal protective equipment (PPE) must be worn when caring for the resident. There was an isolation cart in front of the resident's door containing necessary PPE such as gloves and isolation gowns. The surveyor did not observed signs posted on the resident's door that the resident was on contact isolation. The resident was observed sitting in the wheelchair in his/her room. The resident was interviewed at this time and the resident stated that the staff only utilized the PPE such as gowns and gloves when they took direct care of her/him. Resident #79 stated that they were not aware of any infection that she/he had at this time. On 05/02/24 at 08:57 AM, the surveyor reviewed Resident #79's medical record which revealed the following information: The physician Order Summary Report (OSR) dated 02/21/24, indicated that Resident #79 was on Contact Isolation Precautions because the resident was positive for the infection c-diff (stool infection) and MRSA (methicillin-resistant Staphylococcus aureus, a type of bacteria that is resistant to several antibiotics) of wound. The OSR dated 02/21/24, indicated that Resident #79 required Enhanced Barrier Precautions for a diagnosis of ESBL (Extended Spectrum Beta-Lactamase (ESBL)-producing Bacteria) and MRSA every shift. The resident's Care Plan (CP) indicated that Resident #79 was on enhanced barrier precautions related to a wound, indwelling medical device and infection or colonization. The CP was initiated on 11/16/2023. Interventions included: -Clear signage must be posted on the door or wall outside of the resident room. indicating the type of precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high contact. resident care activities that require the usage of gown and gloves. Date Initiated: 11/16/2023. - EBP will in place for the duration of a residents stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Date Initiated: 11/16/2023. The CP also indicated that the resident was on Contact Isolation for the diagnoses of urinary tract infection and ESBL of the urine. The CP indicated that contact isolation was discontinued on 01/02/24, however there was still an active physician's order for the resident to be on contact isolation. The surveyor reviewed the Medication Administration Record (MAR) which contained a physician's order dated 02/21/24, for Resident #79 to be on contact isolation for c-diff and MRSA of the wound. The surveyor also observed that there were nurses' signatures documented on the MAR from April 2024 till present, which indicated that the staff were maintaining contact isolation for Resident #79. On 05/02/24 09:12 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that she had been employed in the facility for [AGE] years. CNA #1 stated that she was very familiar with Resident #79. She stated that Resident #79 required limited to extensive assistance with activities of daily living (ADLs). She stated that the resident was alert and oriented to person, place, and time. She stated that the resident was on EBP for MRSA in a foot wound. She stated that the resident had no bacteria in her urine and that personal protective equipment (PPE) only had to be worn during direct resident care only. She explained that a gown and gloves had to be worn only when in direct contact with the resident. She stated that it was important to wear PPE to prevent the spread of infection or protect the resident from acquiring an infection from the staff. On 05/02/24 at 09:15 AM, the surveyor was standing outside Resident #79's room and observed CNA#2 providing direct resident care (toileting) for Resident #79 in the resident's room. The CNA was only wearing a surgical mask and a pair of gloves. The surveyor did not observe the CNA wearing an isolation gown when providing direct resident care for Resident #79. On 05/02/24 at 09:20 AM, the surveyor interviewed CNA #2 who stated that she had been employed through the agency. CNA #2 stated that Resident #79 required limited assistance with ADLs. The surveyor asked the CNA why she was in the resident's room providing care and not wearing an isolation gown? CNA #2 stated that she was only wearing a glove and a mask. CNA #2 stated that she was not aware that the resident had an infection of any kind. The CNA accompanied the surveyor to Resident #79's room and CNA #2 stated that she did not notice the sign that was posted on the resident's door which indicated that the resident was on enhanced barrier precautions and that gloves and a gown were required when providing direct patient care. CNA #2 confirmed that she was not wearing an isolation gown when providing direct resident care for Resident #79 and added that she should have read the sign that was posted on the resident's door. On 05/02/24 at 09:27 AM, the surveyor interviewed the primary care Licensed Practical Nurse (LPN) who stated that she had been employed in the facility since July 2023. The LPN explained to the surveyor the difference of Enhanced barrier precautions and Contact precautions. She stated that Enhanced barrier precautions were provided to any resident with any access to the body such as tubes, wounds, IVs [intravenous], tracheostomy's etc. She stated that when a resident was on EBP, gown and gloves were to be worn only when providing direct resident care. She stated that when a resident was on contact precautions that meant the staff must wear the required PPE (gown and gloves) when entering the room, when in contact with the resident and when in contact with the resident's environment. She stated that it was important to adhere to what type of transmission-based precaution (TBP) a resident was on to prevent the spread of infection. The LPN then added that if Resident #79 had an order to be on contact isolation, then the sign on the resident's door should have specified that. The LPN confirmed that the precaution sign on the resident's door should have indicated that the resident was on contact isolation instead of enhanced barrier precautions. The LPN admitted that she did sign the MAR indicating that the resident was on contact precautions, however there was no sign on the resident's door nor were the staff following contact precautions when entering the residents room. On 05/02/24 at 09:38 AM, the surveyor interviewed the Licensed Practical Nurse/Infectionist Preventionist (LPN/IP) who stated that she had been employed in the facility for [AGE] years. The LPN/IP explained that EBP were required to protect residents with any kind of inner body access such as tubes, wounds, catheters, and IVs ect. She explained that application of PPE such as gowns and gloves were required when providing direct patient care. She stated then when a resident was on EBP, PPE would not have to be applied if only delivering a food tray or just going in to talk to the resident or to administer medications. She stated that when a resident was on contact isolation the staff were required to wear PPE prior to entering the room, when in direct contact with the resident and the resident's environment. She stated that when a resident was on contact precautions the resident had an active infection and it was important to wear the appropriate PPE to prevent the spread of infection. She stated that Resident #79 did not have an active infection. The surveyor asked the LPN/IP why the resident had a physician's order for contact precautions and she stated that that order should have been discontinued. She then added that if the order was not discontinued then Resident #79 should have still been on contact isolation and the sign posted on the resident's door should have indicated as such. She also stated that when CNA#2 was providing resident care this morning she should have been wearing a gown and gloves when providing direct resident care. She also added that the LPN should have questioned the physicians for contact precautions in the MAR and should not have signed the MAR that contact precautions were being done if she was not following the order. On 05/02/24 at 09:50 AM, the surveyor interviewed the Director of Nursing (DON) who stated that EBP were for residents with access to their external fluids. She explained that PPE such as gown and gloves were required for direct resident care to prevent transmission of infection to the resident. She stated that EBP was instituted to protect the resident from infection that could be transmitted from the staff. The DON then explained what contact precautions meant. She stated that contact isolation was required for specific microorganisms the resident had and that PPE such as gowns and gloves were required when in contact with the resident and the resident's environment. She stated that there was a confusion related to what type of TBP Resident #79 was on because there was an order for the resident to be on contact isolation as well as enhanced barrier precautions. She stated that if the resident had an order for contact precautions, then the sign posted on the resident's should have been posted on the resident's door should have reflected that. She also stated that if the nurses were signing the MAR that the resident was on contact precautions then the nurses should have been adhering to the order. She confirmed that when CNA #2 was providing direct resident care to Resident #79 she should have worn a gown and gloves. On 05/10/24 at 09:29 AM, the surveyor interviewed the LPN/IP who stated that the resident had a history of c-diff which was resolved on 2/27/24. The LPN/IP confirmed that the staff should have obtained a physician's order to discontinue the contact isolation. She stated that the resident's MRSA in the wound was colonized so there was no need for contact isolation. The LPN/IP continued to add that if there was no order to discontinue contact isolation and the nurses were documenting in the MAR that they were adhering to contact isolation, then nurses should continue to follow the order until the order was discontinued. The order for the resident to be on contact isolation was discontinued after surveyor inquiry. The facility policy titled, Enhanced Barrier Precautions dated 04/2024, indicated that the implementation of EBP will reduce transmission of resistant organisms by employing targeted use of gown and glove use during high contact resident care activities. The policy indicated that high-contact care activities included: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care and wound care. The Policy also described Contact Isolation which indicated that this type of TPB was used when pathogen transmission was not completely interrupted by standard precaution alone. Contact precautions were intended to prevent the transmission of infectious agents and gloves and gowns were required on entry to the resident's room. The policy indicated that gloves and gowns were to be applied before entry to the resident room and removed before exiting the resident's room. The facility policy titled, Categories of Transmission-Based Precautions dated 03/2021, indicated that Contact Precautions was implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the environmental surfaces or resident care items in the resident's environment. The policy also indicated that gowns, gloves, and handwashing was to be utilized while caring for resident or indirect contact with the residents environmental surfaces or resident care items in the resident's environment. NJAC 8:39-19.4 (m)(n), 27.1 (a)

Based on observation, interview, and medical record review, the facility failed to follow professional standards of clinical practice with respect to a.) obtaining a physician's order for the application of a treatment device utilized to manage a resident's edema, and b.) update the care plan to reflect a device utilized to manage edema for 1 of 22 residents reviewed (Resident #64). 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the Admission Record (AR), Resident #64 was admitted to the facility with the diagnoses which included but was not limited to; diabetes mellitus, cellulitis (infection of the skin) and edema (swelling). The admission Minimum Data Set (MDS) and assessment tool that facilitates a resident's care, indicated that the resident was cognitively intact and required maximum assistance with activities of daily living (ADLs). On 05/01/24 at 11:49 AM, the surveyor observed Resident #64 lying in bed and was observed with edema to the bilateral lower extremities. The surveyor observed that the resident was wearing ace bandages to bilateral lower extremities. The surveyor reviewed Resident #64's physician Order Summary Report (OSR) dated 04/26/24, which indicated that the resident was to have a compression stocking applied to the right leg in the morning and to be removed in the evening. The Treatment Administration Record (TAR) dated 04/26/24, contained a physician orders indicating that the resident was to have a compression stocking applied to the right leg in the morning and to be removed in the evening. There were no physician orders for the resident to have ace wraps applied to the bilateral lower extremities. The surveyor reviewed the resident's Care Plan (CP) which also did not indicate that the resident was to wear ace wrap bandages to the bilateral lower extremities to manage lower extremity edema. On 05/02/24 at 01:55 PM, the surveyor interviewed Resident #64 who stated that he/she had a history of bilateral lower extremity edema. Resident #64 stated that he/she was supposed to wear a compression stocking on the right lower leg and an ace wrap on the left lower leg. The resident stated that he/she had a wound on the left foot and had it wrapped in an ace wrap instead of a compression stocking. The resident then revealed that the staff had been wrapping both lower extremities with an ace wrap and that he/she had not been wearing a compression stocking to the right lower extremity. On 05/02/24 at 02:01 PM, the surveyor observed that the nurses were documenting in the TAR that they had applied and removed a compression stocking to the right lower extremity, however the resident was wearing ace wraps bandages to the bilateral lower extremities. The surveyor also observed that there was not a physician's order for the resident to be wearing ace wrap bandages to the bilateral lower extremities to manage the resident's edema. On 05/02/24 at 02:05 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who documented in the TAR that the resident refused to have the compression stocking applied to the resident's right lower extremity. The LPN then stated that the order should have been written for the ace wraps to be applied to the bilateral lower extremities and that she would get the ordered clarified to reflect the accurate devices that should have been applied. On 05/07/24 at 09:30 AM, the surveyor observed that the resident was lying in bed wearing bilateral ace bandage wraps to the lower extremities. The resident stated that he/she did not wear compression stockings to his right or left lower extremity. The surveyor reviewed the physician orders and the order still reflected that the resident was to have a compression stocking applied to the right lower extremity. There was not a physician's order to apply ace wraps bandages to the bilateral lower extremities. On 05/07/24 at 09:40 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that the nurses applied the ace wraps to the bilateral lower extremities and that she had not seen the resident wearing compression stockings. On 05/07/24 at 09:48 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated that she had been employed in the facility for approximately 1 (one) year. The LPN UM reviewed Resident #64's physicians orders in the presence of the surveyor and confirmed that the physicians order written was to apply a compression stocking to the right lower extremity in the morning and to remove the compression stocking in the evening. The LPN/UM stated that the resident had not been wearing the compression stockings and had been wearing ace wraps to the bilateral lower extremities to manage edema. The LPN/UM stated that the order should have been clarified to reflect that the resident was wearing ace wraps to the bilateral lower extremities. She also stated that the nurses should not be signing the TAR that they were applying and removing the compression device when the resident did not utilize it. The LPN/UM then stated that she would get the physician order clarified to reflect the appropriate devices that should be worn. The LPN/UM revealed that the resident had been wearing the ace wrap bandages to the lower extremities and that there should have been a physician's order to reflect the use of these ace bandages. On 05/07/24 at 09:54 AM, the surveyor interviewed the Director of Nursing (DON) who confirmed that if the resident was not utilizing the compression stocking to the right lower extremity, then the nurses should not have been documenting that they were applying and removing the compression stocking. She stated that any application of any devices or treatments need to have a physician's order and if the resident was wearing ace wraps to the bilateral lower extremities, then a physician's order should reflect the use of the device. The DON also stated that the use of ace wraps to the bilateral lower extremity to manage bilateral lower extremity edema should have been reflected in the resident's care plan. On 05/10/24 at 09:24 AM, the survey team met with the DON. The DON stated that the nurses should have notified the physician regarding the resident's refusal to wear the compression stocking to the right lower extremity and a physician's order should have been obtained for the application of ace wraps bandages to be applied to the resident's bilateral lower extremities. The facility policy titled, Medication Orders dated 01/2024 indicated that when recording treatment orders, specify treatment, frequency, and duration of the treatment. The facility policy titled; Physician Orders dated 03/2024 indicated that all medications and treatments orders are received from a credentialed practitioner before implementing. The policy also indicated that the physician's order must be written on the appropriate physician's order sheet and interim plan of care. The facility policy titled, Care Plans, Comprehensive Person-Centered dated 01/2024 indicated that that CP would contain services that were furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop and implement a baseline person-centered care plan to meet a resident's medical needs and b.) implement a focus and interventions that are specific to the resident's respiratory needs for 1 of 1 (Resident #148) investigated for respiratory care. The deficient practice was evidenced by the following: On 05/01/24 at 11:02 AM, during the initial tour, the surveyor observed Resident #148 lying in bed asleep receiving oxygen (O2) at two (2) liters per minute (lpm) via nasal cannula. On 05/02/24 at 11:03 AM, the surveyor observed Resident #148 lying in bed awake receiving oxygen at 2 lpm via nasal cannula. At that time, the surveyor interviewed the resident who stated that she received oxygen most the time. The surveyor reviewed the medical record for Resident #148. According to the Admission Record, Resident #148 was admitted to the facility with diagnoses that included, but were not limited to, congestive heart failure (heart muscle does not pump blood as well as it should), pulmonary hypertension (high blood pressure that affects the blood vessels in the lungs), and chronic kidney disease (kidneys are damaged and cannot filter the blood). According to the Entry Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, dated 04/24/24, Resident #148 had a Brief Interview for Mental Status Score (BIMS) of 15 out of 15, indicating he/she was cognitively intact. Section I of the MDS revealed that Resident #148's primary reason for admission was due to debility cardiorespiratory conditions (range of conditions that affect the heart and lungs). According to Section O: Special Treatments, Procedures and Programs reflected the resident received intermittent oxygen therapy on admission and while a resident. A review of Resident #148's Baseline Care Plan, initiated 04/29/2023, revealed that it did not address oxygen therapy as an intervention for the resident's respiratory needs. On 05/07/2024 at 10:22 AM, the surveyor interviewed the Licensed Practical Nurse/ Unit Manager (LPN/UM). The LPN/UM stated that the unit manager completed the baseline care plan upon admission and updated it as needed. The LPN/UM further stated that each department would complete their section of the care plan. When asked which areas should be included on the care plan, the LPN/UM stated we include skin care, falls, pain, and ADL's [Activities of Daily Living]. She then stated she would review the resident's medications and diagnosis and would add pertinent things to the care plan. The surveyor then asked if oxygen therapy should be on the care plan and the LPN/UM replied yes, if the resident was on oxygen there should be a care plan for it. The LPN/UM verified that oxygen therapy was not on resident #148's baseline care plan. On 05/07/2024 at 11:55 AM, the surveyor interviewed the Director of Nursing (DON) regarding the care plan process. The DON stated, the interdisciplinary team along with the social worker, risk management, physical therapy, and the dietician work together to create the care plans. Baseline care plan areas include falls, admitting diagnosis, medications, skin care, and pain. The surveyor then asked if oxygen therapy be included on the baseline care plan? The DON stated yes, if they are receiving oxygen or if they have a respiratory diagnosis. The DON confirmed that resident #148 should have a base line care plan for oxygen therapy. On 05/10/2024 at 09:28 AM, during a follow up interview the surveyor asked if resident #148 was receiving oxygen on admission if it should be on the baseline care plan and the DON stated, Yes, it should have been on the baseline care plan. The surveyor reviewed the facility policy titled, Care Plans - Baseline, updated 1/2024. The following was revealed under Policy Statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The following was revealed under Policy Interpretation and Implementation: 2. The Interdisciplinary Team will review the healthcare practitioners orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the residents immediate care needs including but not limited to: a. Initial goals base on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable. N.J.A.C. 8:39-11.2 (e)2

Complaint #: NJ 166493 Based on interview, record review, and review of facility documents, it was determined that the facility failed to thoroughly investigate a facility acquired pressure ulcer for 1 of 3 residents (Resident #146) reviewed for pressure ulcers. This deficient practice was evidenced by the following: The surveyor reviewed the closed record for Resident #146. According to the Admission Record, Resident #146 was admitted with diagnoses which included, but were not limited to, COVID-19, major depressive disorder, severe protein-calorie malnutrition, and unspecified dementia. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/02/23, included the resident had a Brief Interview for Mental Status score of 06, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident did not have any unhealed pressure ulcers upon admission to the facility. Review of a progress note, dated 07/04/23, revealed, opened area to left buttock noted . new treatment of Santyl [topical cream to remove dead tissue] and foam border gauze noted. Review of the care plan, revised 08/03/23, included a focus of potential for skin breakdown r/t [related to] a recent surgery and immobility. Left buttocks unstageable pressure ulcer, and an intervention, dated 07/04/23, for treatments and dressings as ordered per physician. Review of the Wound Care Consultant report, dated 07/10/23, included recommendations for the Left Buttock wound to include, daily wound care with normal saline cleanse, apply Santyl, cover with silicone foam dressing. On 05/08/24 at 1:00 PM, the surveyor requested all incident/accident reports with complete investigations for Resident #146 for July 2023. During an interview with the surveyor on 05/09/24 at 9:00 AM, the Licensed Nursing Home Administrator (LNHA) stated the facility did not have any incident/accident reports for Resident #146. During an interview with the surveyor on 05/09/24 at 9:26 AM, the Certified Nursing Assistant (CNA) stated that if a resident obtained a facility acquired pressure ulcer, she would report it to the nurse. The CNA further stated that she would be required to write a statement including any details of the skin injury. The CNA explained it was important for the facility to investigate facility acquired pressure ulcers because they need to know how it was obtained. During an interview with the surveyor on 05/09/24 at 9:30 AM, the Licensed Practical Nurse (LPN) stated that if a resident obtained a facility acquired pressure ulcer, the nurse would report it to the supervisor. The LPN further explained that it would be important for the facility to investigate all facility acquired pressure ulcers so that the appropriate interventions could be implemented. During an interview with the surveyor on 05/09/24 at 9:37 AM, the LPN/Unit Manager (LPN/UM) stated if a resident obtained a facility acquired pressure ulcer, the nurse would have to complete an investigation to determine how the wound developed and to initiate interventions. During an interview with the surveyor on 05/09/24 at 11:15 AM, the Director of Nursing (DON) stated that if a resident obtained a facility acquired pressure ulcer, the wound team would be alerted. The DON further stated that the nurse would complete an incident report and obtain statements from staff. The DON explained that it was important to investigate facility acquired pressure ulcers to determine the cause of the wound. When asked about the missing incident/accident report for Resident #146, the DON verified that the nurse who discovered the facility acquired pressure ulcer should have initiated the incident report. Review of the facility's Accidents and Incidents - Investigating and Reporting policy, updated 01/2024, included, The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident, and, The following data, as applicable, shall be included on the Report of Incident/Accident form: the nature of the injury/illness (e.g. bruise, fall, nausea, etc.). NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order for oxygen therapy. This deficient practice was identified for 1 of 1 resident (Resident #148) reviewed for respiratory care. This deficient practice was evidenced by the following: On 05/01/24 at 11:02 AM, during the initial tour the surveyor observed Resident #148 lying in bed sleeping receiving oxygen (O2) at two (2) liters per minute (lpm) via nasal cannula. On 05/02/24 at 11:03 AM, the surveyor observed Resident #148 lying in bed awake receiving oxygen at 2 lpm via nasal cannula. At that time, the surveyor interviewed the resident who stated that she received oxygen most the time. The surveyor reviewed the medical record for Resident #148. According to the Admission Record, Resident #148 was admitted to the facility with the following but not limited to diagnoses: congestive heart failure (heart muscle does not pump blood as well as it should), pulmonary hypertension (high blood pressure that affects the blood vessels in the lungs), and chronic kidney disease (kidneys are damaged and cannot filter the blood). According to the Entry Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, dated 4/24/24, Resident #148 had a Brief Interview for Mental Status Score (BIMS) of 15 out of 15, indicating they were cognitively intact. Section I of the MDS revealed Resident #148 had an active diagnosis of congestive heart failure, pulmonary hypertension, and chronic kidney disease. Section I also revealed that Resident #148's primary reason for admission was due to debility cardiorespiratory conditions (range of conditions that affect the heart and lungs). According to section O: Special Treatments, Procedures and Programs reflected the resident received intermittent oxygen therapy on admission and while a resident. A review of Resident #148's April 2024 Physician Order Summary Report (POS) located in the electronic medical record (EMR) did not include any orders for oxygen therapy. On 05/07/2024 at 10:22 AM the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated there should be a physician's order for anyone receiving oxygen because it was considered a treatment. The surveyor and LPN/UM reviewed the physician's orders in the EMR. The LPN/UM confirmed that a physician's order for oxygen 2 lpm via nasal cannula every 24 hours as needed for SOB[shortness of breath]/wheeze (a high-pitched whistling sound made while breathing) was written on 05/02/2024. The LPN/UM further stated that there should have been an physician's order written for the oxygen on 04/24/2024. On 05/07/24 at 11:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated any resident that needed oxygen therapy needed to have a physician's order. The DON confirmed that on 04/24/2024 resident #148 was receiving oxygen at 2 lpm via nasal cannula and did not have a physician's order on that date. The DON further stated there should have been a physician's order written on that date for the oxygen. On 05/10/2024 at 09:28 AM, the Director of Nursing stated in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team, if a resident is on oxygen therapy there needs to be a physicians order. The DON confirmed that resident #148 did not have a physician's order for oxygen therapy. A review of the facility's Oxygen Administration policy, dated updated 10/2019, included, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. N.J.A.C. 8:39-11.2 (e)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to label, date, and store potentially hazardous foods appropriately to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] at 10:24 AM, the surveyor in the presence of the Food Service Director (FSD), toured the kitchen and observed the following in the dry storage pantry: 1. Two (2) packs of 12 bread that was identified as hamburger buns, had a used by date of [DATE]. 2. A bag of [NAME] couscous toasted pasta was opened and not dated. 3. A bag of instant nonfat dry milk was opened with a used by date of [DATE]. On [DATE] at 11:08 AM, the surveyor interviewed the FSD who stated that everything should have an opened date, used by date, and received by date on it. He stated that anything that came into the kitchen should have a sticker with the date it was received on it, a sticker for when it was opened and a used by date sticker. He explained anything opened and was a bulk item such as the couscous had a six (6) months expiration. The FSD confirmed there should be an opened date sticker on the couscous, to show when it was opened and when to use it by. He then confirmed that the 2 packs of 12 hamburger buns dated [DATE] and the instant nonfat dry milked dated [DATE] should have been discarded. The FSD concluded that the items were discarded on [DATE]. On [DATE] at 09:31 AM, the Licensed Nursing Home Administrator (LNHA) stated in the presence of the Director of Nursing (DON), the Regional LNHA, the Infection Preventionist (IP) and the survey team that the FSD generally conducted a walk through on Wednesdays to check for all expired items and that everything would have been discarded and labeled by then. A review of the facility's Food Storage policy, undated, included All foods will be properly stored in a safe, sanitary manner. Dry Storage 2. Plastic containers with tight-fitting covers will be used for storing products such as grains, sugar, dried vegetables and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. 4. All foods will be stored either wrapped or in closed storage containers and be clearly dated and labeled. A review of the facility's Dry Food policy, undated, included 2. Immediately after delivery all products will be dated for proper rotation. A review of the facility's Dating and Labeling policy, undated, included All foods are to be labeled and dated appropriately to ensure food safety regulations are followed. 1. Upon receiving and storing, all items must be labeled with the name of food and received date. Once opened, the label must be updated with the current date and a use by date of 3 days (including date opened) unless indicated on labeling and dating protocol. 3. All items with an expired use by date must be discarded immediately. NJAC 8:,d+[DATE].2(g)

COMPLAINT#: NJ 0, NJ 7 Based on interviews, medical record (MR) review, and review of other pertinent facility documentation on 1/15/21, 1/20/21, and 1/27/21, it was determined that the facility failed to provide services necessary to prevent physical harm for a resident (Resident #2) with a known history and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 expressed to the Licensed Practical Nurse (LPN #1) at approximately 11:40 p.m. that the resident's family member did not want him/her to go home, and the resident was not sure if he/she wanted to live anymore. LPN #1 stayed with Resident #2 for approximately 5 minutes and then left Resident #2 alone. At 11:57 p.m., approximately 17 minutes later, while walking past the resident's room, the Certified Nursing Assistant (CNA #1) found Resident #2 hanging off the bed with knees on the floor and yelled for the nurse. LPN #1 responded and found Resident #2 had the call bell cord wrapped around his/her neck two times. The nurse removed the call bell cord around Resident 2's neck and placed the resident backdown into bed on the back. Resident #2 had committed suicide. The facility neglected to implement the care plan interventions to monitor for target behaviors, which included to monitor, document, and report to the Medical Doctor (MD) any ongoing signs and symptoms of Depression, such as sadness, crying, suicidal ideation, and worthlessness, and negative mood or comments. There was no documented evidence in the care plan that interventions were evaluated for their effectiveness. In addition, the facility neglected to provide psychotherapy services for the resident, and the facility failed to provide all staff educational training for behavioral mood changes and suicide ideation/prevention for a resident dealing with Depression. The facility also failed to follow its policies and procedures titled Depression- Clinical Protocol, Suicide Threats, Physician's Notification for Consultation, and Behavior Assessment, Intervention and Monitoring. This placed Resident #2 and all other residents experiencing symptoms of Depression and the will not to live anymore at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified on 1/20/21 at 3:35 p.m. and reported to the Administrator and the Director of Nursing (DON). The Administrator and DON were presented with the IJ template that included information about the issue. The IJ was lifted on 1/20/21 at 5:09 p.m. when the facility submitted an acceptable Removal Plan. On 1/27/21, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating all facility staff on Suicidal Risk Evaluation and auditing all residents' charts who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Twelve of those residents were referred for evaluation and psychotherapy services. This deficient practice was evidenced by the following: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool dated 11/19/20, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14/15, which indicated the resident was cognitively intact. Also, in the MDS under Section D D0200 Resident Mood Interview (PHQ-9), a depression screen revealed Resident #2 showed little interest and pleasure in doing things and had episodes of feeling down, depressed, or hopeless. The depression screen indicated that Resident #2 had a total of thirteen episodes of feeling down, depressed or hopeless, and had trouble falling asleep or sleeping too much, and feeling tired or having little energy, present at least once for several days. Review of the Facility's Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by the healthcare facilities to report incidents dated 12/8/20, with an event date of 12/5/20 and a time of event of 11:57 p.m., revealed the following: According to the Timeline of Events (TLE) indicated on 12/5/20 at 11:40 p.m., LPN #1 went into Resident #2's room to flush the Resident's Peripherally Inserted Central Catheter (PICC) line. The TLE indicated Resident #2 appeared to be upset after a recent phone call with a family member about discharge, and LPN #1 offered Resident #2 reassurance. The TLE also revealed that at 11:57 p.m., the Certified Nursing Assistant (CNA #1) entered Resident #2's room while doing rounds and found Resident #2 on both knees next to the bed, and called LPN #1 to the room. The TLE also indicated that LPN #1 found the call bell around Resident #2's neck; the LPN removed the call bell from around Resident 2's neck. The resident was assessed was not responding and oxygen was applied, and the LPN did not resuscitate the resident due to the DNR (Do Not Resuscitate) status. Further review of the TLE noted that the Director of Nursing (DON), the Administrator, and the local police department were notified. Resident #2 was pronounced dead by the Medical Examiner between 2:10 a.m. and 2:13 a.m. Review of the Individual Statement Form (ISF) dated 12/6/20, written by CNA #1 showed I saw the resident half out of bed, I called for the nurse to help me when we position (him/her) back on the bed, we found the call bell wrapped around [his/her] neck. A review of the ISF dated 12/6/20, written by LPN #1, revealed that on 12/5/20 at 11:40 p.m., LPN #1 went into Resident #2's room to unhook the resident's antibiotic and flushed the resident's PICC line with normal saline and [MEDICATION(S)]. The ISF further revealed that Resident #2 appeared to be upset about a conversation on the phone with a relative. At 11:57 p.m., the CNA called the nurse and mentioned the resident looked like he/she was getting out of bed. LPN #1 went into Resident #2's room and checked on the resident. The ISF also indicated both of Resident #2's knees were on the floor, with the right side of the resident's body leaning against the bed. When the nurse slightly repositioned the resident, the nurse noticed that the call bell cord was around the resident's neck. The nurse then removed the cord around the resident's neck and was helped by a male CNA to place the resident back in bed on his/her back. Further review of the ISF also showed that Resident #2 was assessed for pulse and respiration. The ISF also showed the sternal rub was performed, and oxygen was administered at 5 liters per minute by nasal cannula. However, Resident #2 had no heart rate and or respirations present. According to the ISF, there were no attempts to resuscitate Resident #2 due to a Do Not Resuscitate/ Do Not Intubate status. A review of the Electronic Medical Record(EMR) revealed the following: Resident #2's Care Plan (CP) dated 11/23/20 showed the following: Under: Focus: I use antidepressant medication (s) r/t (related to) my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . sad mood 3). excessive sleeping. Under: Goal showed I will be free from discomfort or adverse reactions r/t antidepressant therapy through the review date. Under Interventions included: Monitor/document/report to MD (medical doctor) prn (whenever necessary) ongoing s/sx (signs or symptoms) of Depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. (negative) mood/comments, slow movement, agitation, disrupted sleep, fatigue, . changes in weight, appetite, . attention-seeking . anxiety, constant reassurance. A review of the Order Summary Report revealed the following: [MEDICATION(S)] ([MEDICATION(S)]) Tablet 15 mg (milligram). Give 1 tablet by mouth (PO)at bedtime related to Unspecified Recurrent Major Depressive Disorder. A review of the December 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Progress Notes( PN) dated 12/5/20 at 12:15 p.m., written by LPN #2, revealed that Resident #2 refused medication on the 7:00 a.m. to 3:00 p.m. shift. There was no documentation in Resident #2's Medical Record (MR) to support that the LPN notified the MD that the resident refused his/her medications. A review of the PN dated 12/5/20 at 11:00 p.m., written by LPN #1, showed Resident #2 refused all by mouth medication on the 3:00 p.m. to 11:00 p.m. shift. There was no documentation in Resident #2's MR that the LPN notified the MD that the resident refused medications, including the antidepressant. During an interview on 1/15/21 at 12:12 p.m., with the Administrator and the DON, the DON stated that when a resident refuses medications, the doctor needs to be notified. The Administrator stated that it should be documented in the resident's PN if the doctor was notified. During a telephone interview on 1/20/21 at 10:12 a.m., LPN #1 stated Resident #2 refusing meds [medications] was a change. LPN #1 stated that he was made aware by the 7:00 a.m. to 3:00 p.m. shift nurse that Resident #2 refused his/her medications. LPN #1 indicated, Resident #2 also refused his/her medications on the 3:00 p.m. to 11:00 p.m. shift; however, LPN#1 stated that he did not notify the MD. The PN also revealed that on 12/5/2020 at 11:57 p.m., LPN #1 and CNA #1 went to check on Resident #2; the resident had both knees on the floor with the right side of the resident's body leaning against the bed. When the nurse slightly repositioned the resident, the nurse noticed that the call bell cord was around the resident's neck. The PN also revealed that the LPN removed the cord from around Resident #2's neck. CNA #2 assisted the LPN to place Resident #2 back into bed in the supine position. Resident #2 was checked by LPN #1 and LPN #2 for pulse, respiration, and any response. The LPN's also performed sternal rub, but Resident #2 had no reactions or response. Further review of the PN revealed, No audible heat sound or respiration was present, even with oxygen @ 5L (liters)/min (minute) via (by) nasal cannula. During an interview on 1/15/21 at 10:20 a.m., the Unit Manager (UM) stated if a resident reported that the resident wanted to harm himself/ herself or the resident was not sure he/she wanted to live anymore; the first thing she would do is make sure the resident was safe. The UM explained she would question the resident to determine if the resident has a plan. The UM further explained she would then make sure the resident was safe by putting the resident's bed into the lowest position so the resident will not push himself/ herself off the bed. The UM also stated that she would remove any sharp objects in the room and any cords such as the call bell, phone, and bed control cords. Also, the UM stated she would notify the DON and the MD. During an interview on 1/15/21 at 11:25 a.m., the Social Worker (SW) indicated that Resident #2 was admitted for rehabilitation services and to be transitioned to long-term care (LTC). The SW stated Resident #2 family member said they could not take the resident back home. The SW further explained that at times Resident #2 seemed really upset having to stay in a LTC facility. During an interview on 1/15/21 at 12:52 p.m., CNA #1 stated she was told previously by the nurse to show some extra care towards Resident #2, the resident was upset because the family member did not want him/her back home. CNA #1 stated she was not assigned to Resident #2 on 12/5/21 when the resident committed suicide. According to CNA #1, she heard Resident #2 yelling during the beginning of the shift, which was unusual behavior for the resident. CNA #1 explained later in the shift while walking down the hallway she observed Resident #2 halfway out of bed while walking past Resident #2's room. The CNA said, I thought it was a behavior thing, and called LPN #1. CNA #1 explained LPN #1 and another CNA (CNA #2) responded to Resident #2's room; both of the resident's knees were on the floor, and the resident had the cord wrapped around the neck. CNA #1 also stated Resident #2 was pale in color. During a telephone interview on 1/15/21 at 1:50 p.m., CNA #2, who was from an agency company, stated he was assigned to Resident #2 on 12/5/20 when the resident committed suicide but was not aware that the resident was depressed. CNA #2 explained he became aware of the resident's behavior after the incident occurred. CNA #2 indicated the facility did not educate him on mood changes, behaviors, and suicide risk / prevention prior to the incident. On 1/15/21 at 1:36 p.m., the DON provided the Surveyors with 19 certificates of completion for a training on Suicide Risk, two of which were completed by LPN's and two by CNA's prior to Resident #2 committing suicide on 12/5/20. However, LPN #1 was not included in this training. The DON stated this training was not in response to Resident #2 committing suicide. The DON also stated there was no mandatory staff education provided for staff related to suicide risk or prevention that was held prior to Resident #2 committing suicide. The DON stated LPN #1 was not provided with the training on suicide risk after Resident #2 committed suicide. During the telephone interview on 1/20/21 at 10:12 a.m., LPN #1 stated he was not educated on suicide prevention. LPN #1 explained he went into Resident #2's room at 11:40 p.m. to flush the Resident's IV (Intravenous) line. Resident #2 had just gotten off of the phone with the resident's family member and told the LPN, my [wife/husband] doesn't want me back home. I don't want to live anymore. The LPN stated Resident #2 was broken-hearted and crying. The LPN indicated Resident #2 was upset, and it was a drastic change for the resident. LPN #1 stated it was almost like Resident #2 was throwing a fit. LPN #1 continued to explain he has never seen Resident #2 in this manner and stayed with the resident to calm [him/her] down, and he told Resident #2 he would call the resident's family member to get to the bottom of it. LPN #1 stated he did not know what happened during the conversation that the resident had on the phone and that something must have pushed him/her 'over the edge. The LPN stated Resident #2 calmed down within five minutes, took a deep breath and closed his/her eyes. LPN #1 then left the room and told the incoming nurse, we might have to call (Resident #2's) family just to give (the resident) peace of mind to ensure him/her everything will be okay. LPN #1 further explained he did not know what Resident #2 meant when the resident said I am not sure I want to live anymore and sometimes residents are quick to say certain things and do not mean it. When asked by the Surveyors why he did not notify Resident #2's physician after the resident stated he/she was not sure that he/she wanted to live anymore and was upset and crying like, the LPN stated, We should have called the doctor and should not have left Resident #2 alone in his/her room. According to LPN #1, CNA #1 called him to Resident #2's room, he found Resident #2 with the right side of the resident's body on the bed, and the resident's head turned towards the wall. The call bell cord was wrapped around Resident #2's neck two times. LPN #1 stated, the protocol is to call the doctor, which we didn't do. The LPN also stated, I was not supposed to leave a resident alone who said I am not sure if I want to live anymore. During an interview on 1/20/21 at 12:19 p.m., in the presence of the Administrator, the DON stated if someone believed life is not worth living anymore, you would have to investigate further the person's feelings at the time and ask what do you mean by that? A review of the Consultation report dated 11/20/20 by the Gerontology group, completed by the Nurse Practitioner (NP), showed the resident had a Mild Cognitive Impairment (MCI) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, Resident #2 had increase depression related to separation from the resident's family member. Further review of the Consultant Report revealed a Mood Scale total evaluation score of 8/15, which indicated that the resident might be depressed. The Consultation evaluation also revealed the following: The resident felt that his/her life was empty. Most of the time, the resident did not feel happy. The resident often felt helpless. The resident did not think it was wonderful to be alive. The resident felt pretty worthless and felt his/her situation was hopeless. Further review of the consultation report specified recommendations for Resident #2 as follows: (1) Continue [MEDICATION(S)] 15 mg at HS (hour of sleep). (2) Provide Psychotherapy (3) Arrange more frequent video zoom visits with [family member]. During an interview on 1/20/21 at 11:15 a.m. the NP who evaluated the resident stated Resident #2's depression scale was elevated due to (the resident) not seeing (his/her) family. The NP stated Resident #2 would have benefited from Psychotherapy because the resident had MCI and was depressed. The NP indicated if a resident made the statement I do not want to live anymore, this should be investigated further by asking the resident questions such as do you have a plan? The NP explained that regardless of the resident's statements and symptoms, the facility's protocol should still be followed. A review of Resident #2's EMR and documents provided by the facility for review revealed no documented evidence that the resident was ordered Psychotherapy, nor was there a reason why this therapy was not provided to the resident. During an interview on 1/15/21 at 11:25 a.m., the Social Worker (SW) stated he referred Resident #2 for psychology services but the resident was not seen. However, the SW was unable to provide proof that Resident #2 was referred for services. During an interview on 1/20/21 at 12:19 p.m., in the DON's presence, the Administrator stated the Psychologist who comes to the facility to do the Psychotherapy was sick and could not make the appointment. During an interview on 1/27/21 at 12:16 p.m. in the Regional Nurse Consultant (RNC) and the DON's presence, the Administrator stated she was not sure if the Psychotherapy group was aware of the referral. The Administrator further explained that she requested the list of residents recommended for psychotherapy from the company but did not receive the list. Nevertheless, the Administrator was unable to provide proof that Resident #2 was referred for psychotherapy services. During an interview on 1/27/21 at 12:16 p.m., in the Administrator and the DON's presence, the RNC stated the PHQ9 screening is done upon admission; therefore, the SW should have been keeping track of Resident #2. Review of the facility policy titled Depression- Clinical Protocol updated 10/19, revealed the following: Under Assessment and Recognition included 2 The nurse shall assess and document/ report the following: e. If suicidal ideation is present, follow facility policy/ protocol for suicide threats; 3. Using appropriate screening tools, the staff will screen residents for Depression on admission and subsequently, if suggested by changes in mood, function, or behavior. 4. Staff will observe residents for possible signs and symptoms of Depression; especially individuals who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Signs and symptoms may include, among others, depressed mood most of the day, almost every day; . thoughts of death or suicide; feeling of helplessness, worthlessness, or hopelessness; . changes in sleep pattern or appetite; or avoidance of social interactions. b. Examples of risk factors for Depression include alcohol or substance abuse, current use of a medication associated with a high risk of Depression . new admission or change in environment, and new stressful losses including loss of autonomy, privacy, functional status, a body part or a family member or friend. Under Treatment/Management included 1. The staff will provide pertinent non-pharmacological interventions for the individual with Depression; for example, address related environmental, spiritual, and family issues. A review of the facility policy titled Suicide Threats, updated 10/20, revealed the following: Under Policy Statement included Resident suicide threats shall be taken seriously and addressed appropriately. Under Policy Interpretation and Implementation 3. A staff member should remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident. 4). After assessing the resident in more detail, the Nurse Supervisor / Charge Nurse shall notify the Resident's Attending Physician and responsible party and shall seek further direction from the Physician. 5). All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the Resident behavior immediately. Review of the facility's policy titled Physician Notification for Consultations adopted 11/18 under Policy Statement: revealed, It is the policy of . to notify the Physician for a resident having consultation of supportive services. A consultation is defined as supportive service provided with an expert or professional, such as a specialist or medical doctor, to seek advice or recommendations in a patient's physical, mental, and psychosocial status. Review of the facility policy titled Behavior Assessment, Intervention and Monitoring updated 10/19, revealed the following: Under Management included 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies will be implemented immediately, if necessary, to protect the resident and others from harm. On 1/27/21, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating all facility staff on Suicidal Risk Evaluation and auditing all residents' charts who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Twelve of those residents were referred for evaluation and psychotherapy services. N.J.A.C:8:39-11.2 (b) N.J.A.C:8:39-4.1(a)(5)

C#: NJ 0, NJ 7 Based on interviews, medical record reviews and review of pertinent facility documentation on 1/15/21, 1/20/21 and 1/27/21, it was determined that the facility failed to revise and implement care plan interventions for a resident (Resident #2) with a Depressive disorder who demonstrated mood and behavioral changes in the presence of staff and then committed suicide. This deficient practice was evident in 1 of 3 care plans reviewed as evidenced by the following: According to the Admission Record Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the admission Minimum Data Set (MDS), dated [DATE], Resident #2 had a Brief Interview for Mental Status score of 14/15, which indicated the resident was cognitively intact. The resident's mood interview, PHQ-9 (a depression screening), indicated that the resident had 12-14 days (nearly everyday) of feeling down, depressed or hopeless. Review of Resident #2's Care Plan revealed a Focus initiated on 11/23/20, for the resident's use of antidepressant medication (s) resulted to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan further revealed a Goal initiated 11/23/20 with a target date of 2/11/21, which revealed the resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The Interventions initiated 11/23/20 included for nursing to monitor/document/report to medical doctor as needed ongoing signs and symptoms of depression unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guild, suicidal ideation, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears attention seeking concern with body functions, anxiety, constant reassurance. Another Intervention initiated 11/23/20 revealed for certified nurse aide and nursing to report to the nurse signs and symptoms the following: confusion, mood change, change in normal behavior, hallucinations/delusions, social isolation, suicidal ideations, withdrawal, decline in ability to help with/do activities of daily living, continence, cognitive function, constipation, fecal impaction, no voiding, shuffle gait, rigid muscles, difficulty ambulating, balance problems, [CONDITION(S)], appetite loss, weight loss, muscle cramps, nausea/vomiting. A Care Conference note dated 11/17/20 revealed the attendance at the meeting included nursing, therapy, activities, dietary, social services and Resident #2's family member by telephone. The Mood/Behaviors/[CONDITION(S)] Drug Use (Antidepressant) section revealed Resident #2 took [MEDICATION(S)] (an antidepressant medication) 15 milligrams related to major depressive disorder and was referred to a gerontology group and psychology for added support, and under Discharge Planning the resident was to transition to long term care. On 1/15/21 at 11:25 AM the surveyors interviewed the facility social worker (SW) who stated the gerontology group completed resident [CONDITION(S)] medication management and the other group was the psychology group that met with the residents weekly. He stated he completed the PHQ-9 which is the depression screen part of the MDS which referred to the resident's mood for the past two weeks and he stated he authored the Care Conference note. He stated it was discussed at the care conference meeting that the resident was not returning home. He further stated Resident #2's family member was adamant that Resident #2 could not return home. The SW further stated that Resident #2 was agitated at times because the family member was unable to care for him/her. The SW stated he did not participate in the development of the resident's care plan and it was not part the interdisciplinary team meeting. On 1/20/21 at 9:44 AM, the surveyors interviewed the Material Data Set (MDS) Coordinator (MDS). She stated she was responsible for completing Resident #2's care plan and developed care plans for areas that triggered on the MDS. The MDS Coordinator stated she was not present at the resident's care plan meeting that was held on 11/17/20. In the presence of two surveyors, the MDS Coordinator reviewed Resident #2's Care Plan with the Focus of Antidepressant Medication(s) and confirmed she completed the care plan. She stated the care plan was a computer template based on the triggered areas on Resident #2's MDS and suicidal ideations was included in the care plan template. She stated the purpose of the resident care plan was to guide anyone who provided care for a resident and the care plan would let the caregiver know what the resident's care needs were. The surveyors inquired as per the care plan, what should have been done when Resident #2 expressed that he/she did not want to live anymore. She stated when Resident #2 stated he/she did not want to live, that that would have been considered a negative mood or comment and it should not have been ignored and it should have been reported to the physician. A review of the Progress Note dated 12/5/20 at 23:40 (11:40 PM) written by Licensed Practical Nurse (LPN #1), revealed Resident #2 appeared to be upset about a conversation with a family member. The PN also revealed Resident #2 verbalized to LPN #1 My [family member] does not want me back home, I'm not sure if I want to live anymore. Further review of the PN showed LPN #1 offered one on one support for the resident and offered to call the family to talk to them to find out what exactly happened. During a telephone interview on 1/20/21 at 10:15 AM, LPN #1 stated during that encounter with Resident #2 that he could clearly see that Resident #2 was upset about something to do with his/her family. He stated that during the shift on 12/5/20 at 22.22 (10:22 PM), Resident #2 refused to take his/her medications and LPN #1 tried to encourage the resident to take them. LPN #1 stated it was almost like Resident #2 was throwing a fit. LPN #1 stated this behavior was not exhibited by Resident #2 prior to the phone call that the resident received from the family member. LPN #1 stated he did not know what happened during the conversation that the resident had on the phone and that something must have pushed him/her 'over the edge. He stated that after the phone call Resident #2 was really upset and was crying, and that he had never seen the resident like that. He stated it almost seemed out of the blue for Resident #2 to act like that and that the behavior was a definitely a change in mood for the resident. LPN #1 stated he told Resident #2 that he would call the family to try to see what happened and it looked like the resident had calmed down. He stated he did not call the resident's physician and instead endorsed to the next shift that the next shift may need to reach out the family (not the physician) because the resident was really upset and that LPN #1 had never seen the resident cry like that. The surveyors inquired to LPN #1 if he should have contacted the resident's physician after resident #2 stated he/she did not want to live and was upset and crying like he had never seen before. LPN #1 stated that he should have called the physician and Resident #2 should not have been left alone. The Behavioral Assessment, Interventions and Monitoring policy, updated 10/2019 revealed under Management, the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident from harm. The Care Plans, Comprehensive Person-Centered policy, updated 10/2020 revealed a Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident. NJAC 8:39- 27.1(a)

COMPLAINT # NJ Based on observation, interviews, and review of the medical record, as well as other pertinent facility documentation on 4/27/17 and 5/2/17, it was determined that the facility failed to conduct a timely and thorough investigation as well as failed to follow their own policy titled Abuse Prevention, for 1 of 3 sampled Residents reviewed for abuse, (Resident #1), after a Certified Nursing Assistant (CNA #1) reported an allegation of physical abuse (forcefully grabbing a Residents arm and pushing into their chest) by CNA #2 to the Licensed Practical Nurse (LPN #1) on 4/11/17, at approximately 6:15 A.M. The facility staff failed to immediately initiate an investigation and CNA #2 continued to provide care for Residents from 6:15 A.M. until 7:21 A.M., at which time CNA #2 left the building at the end of their shift. This deficient practice placed Resident #1, as well as all other Residents at risk for an Immediate Jeopardy (IJ) situation. The IJ was identified on 5/2/17, as an IJ Past Non Compliance (PNC) for 4/11/17. The IJ PNC was lifted when the facility provided an acceptable Plan of Correction (POC) that included staff re-education for Abuse. This deficient practice was evidenced by the following; 1. According to the Admission Record Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 3/17/17, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8/15, indicating that Resident #1 had moderately impaired cognition. The MDS included documentation that Resident #1 required assistance with all Activities of Daily Living (ADLs). A review of a Facility Reportable Event Record/Report (FRE) dated 4/17/17, with an event date of 4/11/17, revealed that CNA #1 alleged that CNA #2 had forcefully grabbed resident's (Resident #1) arm and pushing it into their chest and using bad language and saying inappropriate things. A review of a facility form titled Abuse Investigation Reporting Form undated and unsigned, reflected under the Reported To Administrator (Date and Time), as well as the Reported to DON (Director of Nursing) (Date and Time) sections, indicated that the Administrator and DON were notified of the allegation 4-11-17 upon arrival in the morning. The form went on to reveal under the Outcome of Internal Investigation section that CNA #2 was taken off this resident's assignment permanently. Additional inservice provided to CNA #2 regarding abuse, sensitivity and pain. A review of a facility Individual Statement Form signed and dated 4/11/17, revealed that the abuse allegation involving CNA #2 was reported by CNA #1 to LPN #1 at approximately 6:15 A.M. There was no documentation in the facility investigation as to what the facility did with CNA #2 at the time the allegation of abuse was reported to LPN #1. During an interview with the Administrator and the DON on 4/27/17 at 12:10 P.M., the Administrator stated As far as I know CNA #2 would still have been providing care to other Residents. The DON stated The Supervisors have autonomy to determine if the situation requires the employee to be sent home or not and they will call me and we will discuss the situation. I found out about the allegation that morning. During an interview with LPN #1 on 4/27/17 at 12:25 P.M., LPN #1 stated This was immediately reported to me by CNA #1 and I wrote down everything CNA #1 said to me word for word and I told CNA #1 to report this to the 11:00 P.M.-7:00 A.M. shift Supervisor. LPN #1 went on to say I do not know if CNA #1 reported this to the Supervisor, I did not do anything with CNA #2. LPN #1 also stated CNA #2 continued to provide care to Residents. and I did nothing with CNA #2 as I did not know what the facility protocol was. LPN #1 went on to say; I was uncomfortable with the situation and stayed and spoke with the Assistant Director of Nursing (ADON). During an interview with the Administrator and DON on 4/27/17 at 1:00 P.M., the Administrator stated I can't be 100% sure if CNA #2 continued to provide Resident care after being accused of abuse. The Administrator went on to say I am assuming CNA #2 continued to provide care. I did not specifically ask this. By the time the 11:00 P.M.-7:00 A.M Supervisor heard about the incident the CNAs were gone. The Administrator stated The policy is to safeguard the Residents. During an interview with CNA #2 on 5/2/17 at 9:03 A.M., CNA #2 stated Of course I went into other Resident rooms to finish my rounds after providing care for Resident #1, roughly 4-5 more people. CNA #2 went on to say that they were not aware of the allegation until the DON and ADON met with them later that day. During an interview with the ADON on 5/2/17 at 9:43 A.M., the ADON stated The Social Worker told me about the allegation when I arrived that day between 9:00-9:30 A.M The ADON went on to say I did not talk to LPN #1 at all. During an interview with CNA #1 on 5/2/17 at 10:02 A.M., CNA #1 stated I immediately told LPN #1, and LPN #1 was writing down what I said and that he/she would report it to who he/she needed to. CNA #1 went on to say that LPN #1 did not tell me to tell the Supervisor, that was not mentioned at all. CNA #1 went on to say that The Supervisor was on the unit assisting LPN #1 with Resident blood sugars during the time that I was reporting the incident to LPN #1. During an interview with the Social Worker (SW) on 5/2/17 at 10:29 A.M., the SW stated that LPN #1 handed me a statement that one CNA (CNA #1) reported another CNA (CNA #2) of abusing one of our Residents. This was probably 8:15 A.M. and I told the ADON. The SW went on to say that While the ADON was speaking to LPN #1, I was interviewing Residents on the Evergreen unit and there were no reports of abuse or neglect by the aides. This included Resident #1. During a telephone interview with the 11:00 P.M.-7:00 A.M. shift Supervisor on 5/2/17 at 10:38 A.M., the Supervisor stated that they were notified by LPN #1 of the allegation of abuse after 7:30 A.M., after the shift was done. I gave LPN #1 a statement form to fill out, and told LPN #1 to follow up with the ADON. The Supervisor went on to say that Yes I assisted with obtaining blood sugars for LPN #1 and nothing was said about the incident at that time. During an interview with the Administrator and DON on 5/2/17 at 11:50 A.M., the Administrator said Yeah my staff did not do the right thing. The Supervisor was never brought into the conversation with CNA #1 and LPN #1. On 5/2/17 at 11:50 A.M. the surveyor, in the presence of the Administrator, observed a video recording date stamped 4/11/17, of the hallways and Nurses station on the Evergreen unit. At 6:09:34, both CNA #1 and CNA #2 were observed to enter Resident #1's room on the 10 hallway. CNA #1 was observed to exit the room at 6:15:19, and walk towards the nurses station. CNA #2 exited the room at 6:15:40, and walked towards the nurses station. At 6:16:24, CNA #1 walked past LPN #1's medication cart on the 40 hallway and then went back when LPN #1 had returned to the medication cart. It appeared that CNA #1 was talking while LPN #1 was writing on paper. The Supervisor was observed to pass by both CNA #1 and LPN #1 with a medication cart at 6:17:36, who were still talking and writing, and there was no verbal interaction observed on the video, between the Supervisor, CNA #1, and/or LPN #1. At that time, the Supervisor went down to the end of the 40 hallway. The Supervisor then came back up the hallway at 6:18:24, and went to LPN #1's medication cart, appeared to say something, and then turned and went back down the 40 hallway. Both CNA#1 and LPN #1 were at the medication cart at that time. At 6:23:00, CNA #1 was observed on the video to go into the unit kitchen, return to the hallway, and then go down the hallway and hand something to the Supervisor and return back to the medication cart with LPN #1. At 6:16:47, the video showed a linen cart being pushed by CNA #2 on the 20 hallway and stop at a Resident room. CNA #2 entered the Resident room. At 6:38:48, the Food Service Director was observed on the 20 hallway. At 6:42:00, CNA #1 was seen coming out of a Resident room on the 20 hallway. At 6:50:00, the Supervisor was seen walking up the 20 hallway. At 6:54:00, CNA #2 was observed exiting the room that was entered at 6:16:47. At 6:56:00, CNA #2 was observed to enter another Resident room. CNA #2 was then observed to exit that Resident room at 7:10:35, and walk towards the nurses station to the 40 hall leaving the linen cart and walking towards the 30 hall. This was the last time CNA #2 was observed on the unit video. At 7:20:23, both CNA #1 and CNA #2 were observed at the time clock punching out and walking away together. A review of the facility Time Clock Record dated 4/10/17, reflected that CNA #2's Time In was recorded at 11:00 P.M. and Time Out was recorded at 7:21 A.M. During a follow-up telephone interview with CNA #1 at 1:12 P.M. on 5/2/17, CNA #1 stated I didn't think or realize that I had to tell other people as I had already reported this to my nurse. A review of a facility policy titled Abuse Prevention undated, revealed under section E. Protect An investigation is immediately initiated. An accused employee is to be removed immediately from caring for the Resident and may be involuntarily suspended if warranted by the Supervisor . The Past Non-Compliance for 4/11/17, was corrected when the facility provided evidence that the following POC corrective actions were implemented: 1. CNA #2 was re-educated on sensitivity training and facility abuse protocol. 2. CNA #2 was re-assigned to the Rosewood Unit and instructed to not provide care to Resident #1. 3. All Residents who were interviewable on the Evergreen unit were interviewed by the Social Worker with no reports of abuse or neglect. The Social Worker also spoke with Resident #1 who stated that they did not feel abused and had never been abused while in the facility. 4. The DON went to the unit and examined Resident #1 and found no marks, signs of redness or skin breakdown noted. 5. The 11:00 P.M.-7:00 A.M. shift Supervisors were instructed to monitor CNA #2 and the care provided to Residents by CNA #2. 6. Resident #1's Care Plan was updated to include 2 person care and that if the Resident becomes agitated that staff is to ensure the Residents safety and leave the Resident for 15-20 minutes to allow Resident to calm down and then re-approach with calm even tone. 7. All staff were provided re-education on Abuse and Sensitivity Training on 4/11/17. NJAC 8:39 4.1(a) 5

C# Based on observation, interview and record review, it was determined that the facility failed to provide adequate supervision to prevent the elopement of a resident. Resident #8 eloped from the facility, fell , and sustained fractures and injuries requiring sutures and hospitalization . This deficient practice occurred for 1 of 9 residents (Resident #8) reviewed who suffered major injuries as evidenced by the following: Medical record review indicated Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The "Elopement Risk Assessment" dated 2/3/14, indicated that Resident #8 ambulated with the assistance of one and was "unable to independently come to a standing position." The assessment also revealed Resident #8 had "no history" of falls in the prior six months, was "confined to a chair and oriented" and was a "low risk for wandering." The initial Resident Assessment Instrument (RAI) dated 2/10/14 indicated Resident #8 had not been observed walking in her room and required the extensive assistance of one staff with ambulation on and off the nursing unit. The RAI also noted that Resident #8 did not fall prior to admission and did not exhibit wandering behaviors. During the initial tour on 4/21/14, the Unit Manager (UM) described Resident #8 as alert and "interviewable." The UM stated that this "soft spoken" resident had a fall at home then had a fall at the facility and required sutures to this resident's hand. On 4/22/14 at 9:40 a.m., the surveyor observed Resident #8 in the physical therapy room. When interviewed at this time, the resident stated that he/she had remembered seeing the surveyor the day before in the facility's main dining room. When interviewed by the surveyor on 4/22/14 at 9:41am, the Physical Therapy Assistant (PTA) stated that Resident #8 had "some expressive aphasia" but was able to answer questions appropriately including questions related to the resident's past fall in the facility's parking lot. According to the Physical Therapy Discharge Summary dated 3/31/14, Resident #8 was able to walk 20 feet with minimal assistance on 2/3/14. As of 3/21/14, Resident #8 was able to walk 300 feet with a rolling walker and supervision. On 4/22/14 at 11:40 a.m., the surveyor observed Resident #8 in the main dining room. The surveyor observed that the resident had a wanderguard alarm on his/her right wrist. This alarm device would emit a loud sound if the resident attempted to leave the building. When interviewed by the surveyor at this time, Resident #8 stated that the device was applied to prevent him/her from leaving the building. The resident stated that he/she fell outside the last time that he/she left the building. Resident #8 stated that he/she left the building because he/she "wanted to go home." A progress note dated 3/8/14 at 6:56 a.m. in the medical record of Resident #8, revelaed the resident was observed "in wheelchair with bag packed to go home." The resident was returned to his/her room and was diverted with television. On that same day, a plan of care identifying Resident #8 as "an elopement risk related to an attempt to leave facility unattended" was initiated by the facility. The interventions for this plan of care included the application of a wanderguard, distracting the resident from wandering with activities and the placement of the resident's picture at the reception area. In a progress note dated 3/14/14 at 12:00 p.m., a facility Licensed Practical Nurse (LPN) documented Resident #8 had "packed all (his/her) belongings" then placed them on his/her wheelchair before walking down the hallway. This note indicated that the resident was redirected and placed in front of the nurses station for "monitoring." In a progress note dated 3/14/14 at 3:18 p.m., the Social Worker (SW) documented that Resident #8 was outside of the SW's office. When spoken to by the SW at that time, the resident stated that he/she "wants to go home." The SW documented that she spoke with the resident then took him/her to get a sweater on the way to therapy. In a progress note dated 3/21/14 at 4:40 p.m., Resident #8 fell in the facility parking lot and was bleeding from the left forehead and had a bruise on the left hand. The resident was described as "moaning." A progress note dated 3/22/14 at 1:56 a.m. indicated that Resident #8 was admitted to the local hospital "with fall, possible syncope and facial fx." The "Reportable Event Record/Report" submitted to the Department of Health on 3/24/14, Resident #8 had walked out of the front door of the facility at 4:40 p.m. on 3/21/14. Once outside of the facility, Resident #8 "had falling on her face in the parking lot." This reportable form also indicated that Resident #8 had a bed alarm, which the resident removed prior to leaving the facility and a wanderguard that had been on the resident's wheelchair. The form revealed that Resident #8's photo was "posted at the front desk" which was located in the lobby by the facility's front door. The narrative that was submitted to the Department of Health on 3/26/14, the facility's Director of Nursing (DON) documented that Resident #8 was last seen by the staff lying in bed watching TV on 3/21/14 at approximately 4:30 p.m. An alarm was attached to the right upper sleeve of the resident's clothing. The resident "apparently" got up out of bed and detached the alarm from his/her clothing "so it did not sound." The facility's hallway cameras recorded the resident leaving his/her room, "walking straight down the hallway and out the front door." The DON documented that Resident #8 had been walking with assistance in therapy but not on the nursing unit. This documentation revealed that a facility employee saw the resident in the parking lot and called for help. The resident was transported to the local hospital was admitted with a "left hand skin tear and facial fracture." The DON documented that prior to this elopement, Resident #8 "resisted" a wanderguard on his/her person so the wanderguard was placed on the resident's wheelchair. The hospital records indicated Resident #8 was admitted to the hospital on [DATE]. The hospital history and physical report indicated that Resident #8 "had broken out of" the facility and had fallen in the parking lot. This record also indicated that the CT Scan of the facial bone that was performed during the hospitalization indicated that Resident #8 suffered a "fracture in the anterior and posterior lateral wall of the left maxillary sinus, fracture in the lateral wall of the left orbit, fracture in the inferior wall and left orbit without orbital herniation, and fracture of the left zygomatic arch". The resident also suffered "a laceration on the left upper eyebrow that was sutured." Resident #8 was readmitted to the facility on [DATE]. According to her readmission assessment from the same date, the resident was observed by the staff to have bruising and eight sutures above the left eye, bruising on the left side of the face from "eyebrow to chin", and a "large bruise" on the resident's left shoulder. In addition, Resident #8 had bruising, swelling and "multiple sutures" from third digit on palmer side to the mid area of the the dorsal side of his/her left hand. The resident's left upper and forearm were "swollen and bruised" and both knees had large bruises. When interviewed by the surveyor on 4/23/14 at 4:45 p.m., the facility's Administrator (LNHA) stated that on the day that Resident #8 eloped from the facility, the receptionist was at the the front desk by the front door of the facility. The LNHA added that the resident's picture was at the receptionist's desk too but the phone had rung at the front desk and the receptionist looked away at something on the desk as Resident #8 walked out of the facility's front door. When interviewed by the surveyor on 4/24/14 at 9:50 a.m., the DON stated that the resident "got out of bed and walked right out of the building" and that the staff did not know that Resident #8 could walk that well. The DON stated that the resident had previously attempted to get out of bed and out of the wheelchair but not out of the facility. When interviewed by the surveyor on 4/25/14 at 11:20 a.m., the facility staff member who found Resident #8 on the ground outside of the facility, stated that she had been driving out of the facility grounds when she observed "a body face down on the ground" by the security "arm" of the exit lane. This staff member stated that she identified the "body" on the ground as a resident (Resident #8) of the facility by looking at the resident's identification bracelet. The staff member stated that Resident #8 was "responsive but bleeding from the head". The resident was dressed, wearing a jacket and had his/her cell phone and glasses in his/her hand. On 4/25/14 at 11:35 a.m., the surveyor and the Maintenance Director were outside of the front entrance of the facility. When interviewed at this time, the Maintenance Director stated that it was "about 50 yards" from the front door of the facility to the spot where Resident #8 was found. NJAC 8:39-27.1(a)