Every finding on record at Complete Care at Hamilton, LLC

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following:On 09/02/2025 at 10:30 AM, the surveyor in the presence of the Food Service Director (FSD) toured the kitchen and observed the following: 1. In the reach in refrigerator the surveyor observed 3 blocks of pre-sliced cheese wrapped in plastic film with no open date or use by date and a foil covered plate of breakfast foods with no label, opened or use by date. The FSD stated all opened or left over foods should have a prepared or opened on date and a use by date to prevent residents from receiving spoiled or expired foods. The FSD confirmed that the unlabeled foods would be discarded.2. In the walk-in cooler, the surveyor observed a tray of souffle cups of individually portioned canned fruits and pureed canned fruits. Neither the containers nor the tray was labeled with open dates or use-by dates. The FSD stated all opened foods should be labeled with opened and use by dates to prevent residents from receiving spoiled or expired foods. The FSD confirmed that the unlabeled food would be discarded.3. On a rolling cart near the tray assembly line, the surveyor observed several stacks of plate covers that were wet nested. The FSD confirmed this cart, and the covers were in place to be used on the upcoming lunch service. The FSD confirmed that dishware and serving vessels should not be wet nested to prevent the growth of bacteria. The FSD assigned a staff member to remove the covers for rewashing immediately.On 9/8/2025 at 10:30 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional [NAME] President of Clinical Services to discuss the above observations and concerns. The administration confirmed that all opened and prepared foods need to be labeled with an open date and a use by date to prevent residents from receiving expired or spoiled foods. The DON acknowledged that wet nesting of dishes should not occur to prevent bacterial growth.A review of the facility's policy Food Safety Requirements dated 9/1/24 revealed . Practices to maintain safe refrigerated storage include labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so that it is used by its use-by date, or frozen (where applicable)/discarded.On 9/10/25 at 1:00 PM, the surveyor team met with the LNHA and DON. No further information provided by the facility.NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to obtain a physician's order for the administration of oxygen therapy and failed to ensure that respiratory equipment was stored in accordance with infection control measures for 1 of 2 residents reviewed for respiratory care (Resident # 44). This deficient practice was evidenced by the following:Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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 wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 09/02/2025 at 12:00 PM, the surveyor observed a portable oxygen tank in room [ROOM NUMBER] on the left side of Resident #44's bed. The surveyor observed that the oxygen tank was heavily soiled with a brown substance, and the undated nasal cannula tubing was on the floor. On 9/2/25 at 12:30 PM, the surveyor observed Resident #44 in the 1st floor nursing unit in front of the nurses' station. The resident did not respond to the surveyor's greeting. A review of Resident #44's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; epilepsy (a disorder in which nerve cell activity in the brain is disturbed which causes seizures ), chronic obstructive pulmonary disease (a group of lung conditions that cause airflow obstruction and breathing problems) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain.) A review of the resident's current Physician Order Summary report reflected that there was no physician's order for the use of Oxygen. A review of Resident #44's annual Minimum Data Set (MDS), an assessment tool, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated severe cognitive impairment. Further review of the MDS in Section O did not indicate that the resident received Oxygen Therapy. A review of Resident #44's individualized care plan (ICP) with an initiated date of 8/24/22; revised date of 7/14/24, and a target date of 7/14/25, that included a focus area that the resident had an alteration in respiratory status due to chronic obstructive pulmonary disease with interventions that included but were not limited to; to administer oxygen as needed per physician order, to monitor oxygen saturation on room air and on oxygen, and to monitor oxygen flow rate and response. On 9/2/25 at 12:32 PM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) acknowledged that the oxygen tubing was not dated, on the floor, and that the oxygen tank was heavily soiled with insects flying around it. The LPN stated that she should have discarded the oxygen tubing this morning when she first saw it on the floor. On 9/3/25 at 12:16 PM, during an interview with the surveyor, the LPN stated that the resident did not have an order for oxygen and was not sure why it was in his/her room yesterday. The LPN stated that it may have been administered when the resident had seizures. On 9/9/25 at 12:55 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional Nurse to discuss the above observations and concerns. The DON confirmed that Resident #44 should have had a physician's order for the administration of oxygen per the resident's ICP and that the oxygen tubing should be dated and stored in a plastic bag for infection control measures. A review of the facility's policy, Oxygen Administration, dated 5/2025, reflected .Oxygen is administered under the orders of a physician, except in the case of an emergency. In such a case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control .The resident's care plan shall identify the interventions for oxygen therapy . 8:39-31.4 (a)

Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to monitor the nutritional status for 1 of 2 residents reviewed (Resident #2), specifically by not following a physician's orders for monitoring of Resident #2's weights.The deficient practice was evidenced by the following:On 9/3/25 at 11:29 AM, the surveyor observed Resident #2 in bed with the head of bed elevated, eye opened and not verbal.A review of Resident #2's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; Anoxic brain damage ( an injury to the brain caused by lack of oxygen), functional quadriplegia (the loss of functional use of the upper and lower body), gastrostomy for enteral feeding (full nutrition is provided through a tube directly into the resident's stomach) and aphasia (the inability to produce or understand speech) A review of Resident #2's annual Minimum Data Set (MDS), an assessment tool, reflected that the resident was severely cognitively impaired.A review of the resident's Physician Order Summary report reflected the following physician's orders (POs): 1. obtain the resident's weight one time a week on Fridays for a 4 week period initiated on 8/16/24; 2. PO dated 8/16/2024 to weigh resident on day shift every month on the 1st day of the month and 3. a PO dated 12/24/2024 to weigh resident on the day shift every month on the 1st day of the month. A review of Resident #2's medical record did not indicate that a weight was obtained on 9/6/2024 as required by order #1. The medical record did not indicate a weight was obtained on 10/1/2024 or 11/1/2024 as required by order #2. The medical does not indicate a weight was obtained on 1/1/2025, 3/1/2025 or 5/1/2025 as required by order #3.On 9/5/2025 at 10:00 AM, the surveyor interviewed the unit manager (UM) for the 1st floor. The UM verbalized weights were done at least monthly on all residents and more frequently if ordered. The UM stated that the Certified Nursing Assistants (CNAs) would weigh the residents and reports the finding to the UM or to the nurse assigned to the resident. The UM or the Nurse assigned to the resident would record the weights in the resident's medical record. On 9/5/2025 at 10:10 AM, the surveyor interviewed the facility's registered dietician RD. The RD stated that the CNAs were responsible for obtaining resident weights and reporting the findings to the UM or the nurse assigned to the resident's care. The UM or the floor nurse recorded the weights in the resident's medical record after being reviewed by the RD. The RD acknowledged that following a PO and obtaining weights was important for residents who receive enteral nutrition. On 9/5/2025 at 11:00 AM, during an interview with the surveyor, the Director of Nursing (DON) confirmed that a physician's order for a specific weight schedule should be followed accurately. The DON acknowledged that monitoring weights was important in monitoring resident's nutritional status.On 9/9/2025 at 11:10 AM, the surveyor met with Licensed Nursing Home Administrator (LNHA) and DON to discuss the above observations and concerns. The LNHA and DON confirmed that the weights were not taken per the PO.A review of the facility policy, Weight monitoring reflected in section #5 A weight monitoring schedule will be developed upon admission for all residents and. Weights should be recorded at the time they were obtained. NJAC 8:39- 27.2(a)

Complaint #NJ 401472 Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to a.) maintain a homelike environment that was clean, safe, and sanitary in 3 out of 24 resident rooms (rooms 114,116, and 123) and b.) ensure that personal clothing items, specifically socks, were returned after being laundered to 5 out of 5 residents who attended the resident council meeting (Resident #25, 67, 70, 83, 85). Additionally, Resident # 96 complained that their socks were not returned after being laundered. This deficient practice was evidenced by the following:1. On 9/2/2025 at 11:06 AM, the surveyor observed in room [ROOM NUMBER] a broken dresser drawer, peeling paint with exposed plaster and sheet rock to the right of the sink. On 9/2/25 at 12:00 PM, the surveyor observed in room [ROOM NUMBER]-2 a portable oxygen tank heavily soiled with rust and a brown substance, with a swarm of flying insects around the oxygen tank. The surveyor observed the wall by the headboard was cracked with exposed sheet rock and was heavily soiled with a brown substance. The armoire was observed to have had broken drawers and large cracks with missing pieces. On 9/4/25 at 8:07 AM, the surveyor observed that the bathroom floor in room [ROOM NUMBER] was heavily soiled with a brown substance around the base of the toilet. Additionally, the toilet was soiled with a yellow substance, and the toilet paper dispenser was heavily rusted. The metal panels on the bottom of the door, both inside and outside, were also heavily soiled with a brown material. On 9/4/25 at 8:43 AM, the surveyor and the Director of Housekeeping (DHK) entered room [ROOM NUMBER] and observed an unpleasant, offensive smell in the bathroom. They noted the floor was soiled with a yellow material, and a large plastic bag was on the floor full of soiled linens, with insects swarming the bag. The DHK and the surveyor also observed that the garbage can was overflowing with trash, which was also scattered on the floor. The surveyor and DHK further observed that in room [ROOM NUMBER]-3 the floor was soiled with food and liquids, and the bedside table had a sticky yellow substance on it with flying insects swarming the area. On 9/4/25 at 8:45 AM, during an interview with the surveyor, the maintenance staff member acknowledged the broken armoire in room [ROOM NUMBER] and the disrepair of the wall behind the bed. The maintenance staff member stated that the facility was aware of the broken dresser and had ordered a new one about 2 months ago and had also ordered new panels for the areas behind the headboards. On 9/4/25 at 8:50 AM, during an interview with the surveyor, the Director of Maintenance (DOM) stated that the facility staff were responsible for listing repairs that needed to be done in the book that was kept at the nurses' station. At that time, the surveyor and DOM reviewed the book and observed that no repairs had been documented for rooms 114, 116, or 123, but confirmed that the concerns in all three rooms should have been addressed. On that same date, at that same time, the DHK confirmed that rooms [ROOM NUMBERS] needed cleaning and that the rooms and bathrooms failed to meet the clean, comfortable, homelike environment standards. 2.) On 9/4/25 at 8:07 AM, during an interview with the surveyor, Resident #96 stated that they were missing all of their socks. The resident further stated that he/she had mentioned it to the housekeeping staff and nursing staff many times, but they still had not returned the socks. On 9/4/25 at 10:30 AM, the surveyor conducted the Resident Council meeting with 5 residents whom the facility chose to attend. All 5 residents stated that they were missing socks. They further stated that they had informed the housekeeping staff and the nursing staff but still had not received their socks back. The 5 residents stated it had been over a month since their socks went missing. On 9/8/25 at 8:10 AM, during an interview with the surveyor, in the presence of the Housekeeping Director (HKD), the housekeeping staff member responsible for laundry stated that several residents had complained to her that their socks were not returned after being laundered. The housekeeping staff stated that she was very busy and had not had time to pair or deliver the residents' socks in over a month. At that time, the HKD also confirmed that the residents had complained to her several times about their missing socks. The surveyor toured the laundry room and observed five large plastic bags full of residents' personal socks, which the DHK and housekeeping staff member acknowledged was unacceptable. On 9/8/25 at 10:05 AM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing, and the VP of Clinical Operations. The VP of Clinical Operations stated that she had observed the five large bags of residents' socks in the laundry room and that it was unacceptable. A review of the facility's policy, Laundry Delivery, reflected .Laundry is done and returned within 24-72 hours . A review of the facility's policy, Handling Clean Linen, dated 9/1/24, reflected .It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary manner . A review of the facility's policy, Safe and Homelike Environment, dated 10/1/24, reflected .In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing residents to use their personal belongings . A review of the facility's policy, Environmental Services Inspection, reflected .It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis. NJAC 8:39 31.4 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 1 of 22 residents reviewed for accommodation of needs (Resident #96), and was evidenced by the following: On 09/04/25 at 8:07 AM, the surveyor observed Resident #96 in bed. The surveyor observed the Resident's call light pull cord (used to summon staff for assistance) affixed to the upper aspect of the right-side rail, not within his/her reach. The resident stated, There should be a string around here somewhere, but I can't seem to find it, so I can't call for help. The surveyor reviewed the medical record for Resident #96. A review of the admission Record reflected the Resident was admitted to the facility with diagnoses that included but were not limited to; diabetes mellitus (too much sugar in the blood), malignant neoplasm of the breast (cancer of the breast), and osteoarthritis (a degenerative joint disease) of the right knee. A review of Resident #96's Quarterly Minimum Data Set (MDS), an assessment tool dated 8/25/25, revealed Resident #96 had a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed that the resident required maximum assistance from staff for activities of daily living care. A review of Resident #96's Individualized Care Plan (CP) initiated on 7/13/25 had a focus that indicated the resident was at risk for falls, with interventions that included but were not limited to: ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 9/4/25 at 8:18 AM, the surveyor showed the Certified Nursing Assistant (CNA) assigned to Resident #96's care the call light pull cord affixed to the upper aspect of the right-side rail, not within the resident's reach. The CNA confirmed that she should have placed the pull cord within the resident's reach. On 9/8/25 at 12:28 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, and VP of Clinical Operations to discuss the above observations and concerns. A review of the facility's policy, Call Lights, dated 1/25, revealed:Always position the call light conveniently for use and within the reach of the resident. NJAC 8:39-27.1 (a); 31.8 (c) (9)

Based on record review, interview, and policy review, the facility failed to protect resident's right to be free from resident-to-resident physical abuse four of five residents (R)7, R8, R13, and R14) reviewed for abuse out of 14 sampled residents. This had the potential to cause injuries to the residents. Findings include: 1. Review of R7's Face Sheet, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia, dysphagia, major depressive disorder, adjustment disorder, mood disorder, and anxiety disorder. Review of R7's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R7's Care Plan, dated 10/01/24 and located in the residents' EMR under the Care Plan tab, revealed, Staff were called to the room due to R7 pulling on R8's sweater and R8 swung and hit R7 in the face. Interventions put in place the residents were immediately separated, body assessment, police notified, continue to redirect resident and psychological evaluation. Review of R8's Face Sheet, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder-bipolar type, mood disorder, anxiety disorder, adjustment disorder and depressive disorder. Review of R8's quarterly MDS with an ARD of 10/05/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of R8's Care Plan, dated 10/01/24 and located in the residents' EMR under the Care Plan tab, revealed, The resident was screaming for security, staff observed R7 pulling R8's sweater, R8 swung his/her hand to R7's face. Intervention in place the residents immediately separated, body assessment, notified police, stop sign placed on resident's door. Review of the Self-Report Form provided by the facility, dated 10/01/24 revealed, R7 pulled R8's sweater from his/her back and in response R8 swings his/her hand to R7's face. During an interview on 01/27/24 at 12:20 PM with Registered Nurse/Unit Manager (UM) said during the afternoon on 10/02/24 she heard yelling coming from R8's room and went into the room and observed R7 pulling R8's sweater and in response R8 pushed his/her arm and told him/her to get back. UM could not remember if R8 hit R7 anywhere. Staff immediately separated them and completed a full body assessment. A stop sign was placed outside R8's door to prevent other residents from going into the room. This was the first incident UM was aware of with these two residents. 2. Review of R14's Face Sheet, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, bipolar depression, anxiety, borderline personality disorder, adjustment disorder and mood disorder. Review of R14's quarterly MDS with an ARD of 02/09/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS' score of 8 out of 15, which indicated the resident was moderately cognitively impaired. Review of R14's Care Plan, dated 03/04/24 and located in the residents' EMR under the Care Plan tab, revealed, Resident ran over .resident's (R13) foot with wheelchair and he/she reacted by hitting him/her in the head. Interventions in place, residents separated, body assessment completed, police notified, psychological evaluation, and smoking scheduled adjusted to prevent residents from smoking at the same times. Review of R13's Face Sheet, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included schizophrenia, anxiety disorder, major depressive disorder, unspecified mood disorder, and major depressive disorder. Review of R13's quarterly MDS with an ARD of 02/15/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS score of 5 out of 15, which indicated the resident was severely cognitively impaired. Review of the Self-Report Form provided by the facility, dated 03/04/24 revealed the resident-to-resident altercation was substantiated. The incident was witnessed by other residents and staff. During an interview on 01/28/25 at 9:22 AM Certified Nursing Aide (CNA)2 said on 03/04/24 residents were going to smoke area when R14 got too close to R13 and hit his/her foot and the R13 punched R14 in the head. Residents were separated. She was unable to remember what happened after the incident. During an interview on 01/28/25 at 9:31 AM Licensed Practical Nurse (LPN)2 revealed on 03/04/24 R14 was heading to the smoke area and was in a rush trying to be the first to smoke. R14 stepped on R13's toes and he/she punched him/her in the head. Staff separated them and after that they were assigned to different smoke groups. During an interview on 01/28/25 at 2:36 PM the Director of Nursing (DON) stated the investigation between R7 and R8 revealed R7 pulled the sweater of R8 and R8 turned around and swung at R7's face. She said R7 was a wander, who would accidentally enter other resident rooms. They put up door stops on residents' room including R8 to prevent R7 or other residents who may wander from entering their rooms and there being a confrontation. She said the incident between R13 and R14 was substantiated. There were residents and staff that saw R13 hit R14 in the head after he/she ran over his foot. Review of the Facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 01/2025 revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Complaint #: NJ00178362, NJ00178481 Based on observations, interviews, record reviews and review of pertinent facility documents on [DATE], it was determined that the facility failed to ensure a safe environment for a resident (Resident #1) who had a Physician's Order for a prescribed diet of dysphagia puree, Consistent Carbohydrate Diet (CCD), Thickened Liquid Nectar consistency. On [DATE], Resident #1 who was sitting in a wheelchair, was attending an outdoor activity program with other residents. The Director of Recreation (DOR) had donuts cut into thirds for an afternoon lunch snack. The DOR gave Resident #1 a bite sized soft donut, when the resident reached out for it. The DOR left the resident with 3 other Activity Staff (AS). Resident #1 started coughing and observed choking. The AS immediately wheeled the resident back into the facility and nursing staff performed the Heimlich maneuver (an abdominal thrust maneuver, used to treat upper airway obstructions caused by foreign bodies). Food particles were removed by staff. Resident #1 became unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated by the facility and 911 Emergency Medical Services (EMS) were notified and arrived at the facility. Resident #1 was transferred to an acute care hospital emergency room (ER). Resident #1 was admitted with cardiac arrest, respiratory arrest and choking due to food in the larynx [voice box]. Resident #1 is a [AGE] year-old status post (s/p) Cerebral infarction, with hemiplegia and Hemiparesis, Turner's Syndrome and Type II Diabetes Mellitus without complications and Multiple Sclerosis. The MDS indicated that Cognitive Skills for daily Decision Making at a 3, which is severe cognitive impairment. This deficient practice created an Immediate Jeopardy (IJ) to the health and well-being of Resident #1, who was provided food that was not the prescribed consistency by a non-nursing staff. The staff member had been previously in-serviced about resident diets and verification with nursing staff on [DATE] and [DATE]. This had the likelihood to impact all residents who are prescribed pureed diets and other consistencies. This deficient practice was identified for 1 of 6 residents (Resident #1). The facility provided documented evidence of a Plan of Correction (POC) that was initiated at the time of the incident and prior to the survey on [DATE] to the Surveyor. - On [DATE] post the incident, the staff member was suspended pending investigation and subsequently terminated. - All residents on puree diets were identified and verified that plan of care was in place and being followed. - On [DATE] - [DATE] staff was immediately educated on identification of resident diets and ensured only food consistent with the diet is provided. - Residents on altered diets identification procedure updated to include utilization of a colored dot on the resident door tag as well as on the resident bracelet. All staff were educated on the new process. Resident diet list will be printed by reception daily and provided to all nursing units and the recreation program. The procedure will be audited by the Director of Nursing/Designee daily x 2 weeks, then weekly x 4 weeks then monthly x 3 months. - On [DATE] - [DATE] staff was immediately educated on resident diet consistencies. Understanding will be audited by Director of Nursing/Designee daily x 2 weeks, then weekly x 4 weeks, then monthly x 3 months. - On [DATE] - [DATE] staff was immediately educated on how to identify residents' diet. Understanding will be audited by Director of Nursing/Designee daily x 2 weeks, then weekly x 4 weeks then monthly x 3 months. There was sufficient evidence that the facility corrected the non-compliance and is in substantial compliance at the time of the current survey on [DATE] for the specific regulatory requirements for F689. The Immediate Jeopardy Past Non-Compliance started on [DATE] and ended on [DATE] when all nursing and non-nursing staff was educated and trained on identification of residents' altered diets and consistency policies and procedures. On [DATE] at 11:08 am [morning], the surveyor made a tour of the Unit in the presence of Licensed Practical Nurse (LPN)#1 Unit Manager and observed the following: - 11:13 am, Resident #5 had a feeding tube and was on dysphagia puree - had a yellow dot on his/her door name and yellow dot on his/her bracelet. - 11:25 am, Resident #3 was on dysphagia puree - had a yellow dot on his/her door name and yellow dot on his/her bracelet. - 11:37 am, Resident #4 was on dysphagia puree - had a yellow dot on his/her door name and yellow dot on his/her bracelet. - 11:41 am, Resident #2 was on dysphagia puree - had a yellow dot on his/her door name and yellow dot on his/her bracelet. - 11:46 am, Resident #6 was on dysphagia puree - had a yellow dot on his/her door name and yellow dot on his/her bracelet. On [DATE] at 11:54 am, the surveyor observed Recreation Assistant (RA) #1 in the unit's dining room assisting in putting away lunch trays. RA #1 stated Residents on modified diets had yellow dots on their bracelets. RA #1 further stated she had an updated list printed out daily by the receptionist and that if she saw residents on the list without yellow dots on their bracelets, she would check and confirm with the nurse prior to meal service. At this point, the RA #1 showed the surveyor the yellow binder she was holding which contained the updated list of the residents on modified diets on that day. The deficient practice was evidenced by the following: Review of the Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of each resident's functional capabilities, dated [DATE], Resident #1's Cognitive Skills for Daily Decision Making was coded 3 indicating that the resident's cognition was severely impaired. Resident #1 MDS further revealed in Section GG Functional Abilities and Goals that the resident was dependent on staff for the completion of her/his Activities of Daily Living (ADL). Review of the Resident #1's Order Summary Report (OSR), a list of physician orders, dated [DATE], revealed Resident #1 had a Dietary-Diet Order Summary of Consistent Carbohydrate Diet (CCD) [diabetic] diet of Dysphagia Puree texture [food is blended into smooth texture], Thickened Liquid Nectar consistency with an order and start date of [DATE]. Review of Resident #1's Care Plan (CP) initiated on [DATE] reflected a CP Focus [health problem] Resident #1 [name] is at risk for malnutrition R/T [related to] varied intake on altered texture diet; Goal: Resident #1 [name] will follow puree diet as ordered and demonstrate adequate oral intake .Interventions: .Follow Puree diet. Review of the Facility Reportable Event (FRE) submitted to NJDOH (New Jersey Department of Health) for Resident #1, dated [DATE], showed Date and Time of Event: Oct-,d+[DATE] 01:45 PM [afternoon] under Narrative: Resident #1 [name] .is alert and staff anticipate [him/her] needs .Resident #1 [name] on puree diet and nectar thick liquids. On [DATE] Resident #1 [name] was in a recreation program the director of recreation was passing out pieces of donuts cut into thirds. Resident #1 [name] reached out for a piece, and it was handed to [him/her]. [She/He] was then noted to be coughing ., nursing called, Heimlich maneuver performed, and food particles removed by staff. Resident #1 [name] was not responsive, and CPR initiated EMS arrived and continued interventions. Transferred to ER and admitted with cardiac arrest, respiratory arrest, and choking due to food in larynx [voice box]. Additionally, a review of the facility's Incident Report (IR) #2126 titled Choking indicated under Incident Description: Nursing Description: Resident was outside in front of building with recreation with activities staff. [She/He] was noted to be coughing on the donut. Brought into the facility to [her/his] room and nursing staff called . Review of a document titled, Incident Note, dated [DATE] and signed by Staff #1 [name], revealed Resident #1 [name] was brought outside with other residents for fresh air. Soft donuts cut into thirds were available to residents for an after-lunch snack. I gave Resident #1 [name] a bite sized soft donut as she reached out for it .A few minutes later she /he was noted to be choking and was brought back in immediately by activity staff . Review of a facility's document titled In-service Record/Meetings, dated [DATE] with Licensed Practical Nurse (LPN) #1 Unit Manager as the presenter and Topic: Resident's Diet, indicated DOR was in-serviced [educated] on .Any special diet will be listed in the paper located in the Binder with a staff and staff should review the list prior to start of their shift. In an interview with the surveyor on [DATE] at 11:48 am [morning], LPN #1 Unit Manager stated there is a yellow binder of residents' list on modified or altered diets with their pictures by the nursing station. LPN #1 UM further stated during the verbal endorsements between nurses and Certified Nursing Assistants (CNA)s between shifts or change of shifts, changes in the modified list are being discussed, and CNAs signed in the assignment sheets indicating they received the endorsement. In an interview with the surveyor on [DATE] at 11:54 am, RA#1 stated they had in-services on residents with altered diets and a list was always provided to them every day by the nursing staff where they kept it in a yellow binder. RA #1 further stated the list is updated daily from the nurse and if there were any questions, RA #1 would ask the nurse. Furthermore, in an interview with the surveyor on [DATE] at 12:09 pm [afternoon], RA #2 stated an updated list of modified diets is being provided to them [Recreation/Activity Department] every day. RA #2 further stated she would confirm with nurse of the updated list before she starts coffee/snack rounds with RA #1 in the dayroom/ dining room (DR) during the Activity Day Program. RA #2 stated she had received education in-services regarding altered diets by the nurses or dietitian often especially when there were changes. Review of the facility's policy, titled Mechanically Altered/Therapeutic Diet Policy, reviewed/revised on [DATE], included under Policy Explanation and Compliance Guidelines: .4.All diet orders are to be communicated to the dietary department and recreation department in accordance with facility procedures. N.J.A.C. 8:,d+[DATE].4(a)(2)

Based on interview, and record review, it was determined that the facility failed to ensure that the responsible physician supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 1 of 25 residents, Resident #45 was reviewed for physician visits and was evidenced by the following: On 6/23/24 at 10:59 AM, the surveyor observed Resident #45 lying in bed who was noted to be alert and responsive. On 6/24/24 at 9:33 AM, the surveyor reviewed the Admission Record for Resident #45 which revealed the resident was admitted to the facility with diagnoses that included but were not limited to end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant); dependence on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly); and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/31/24, reflected that Resident #45 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. A review of the physician's progress notes reflected there was no documented evidence that the physician visited and examined Resident #45 at least every 60 days from March 2024 through May of 2024. On 6/26/24 at 11:10 AM, the surveyor interviewed the Unit Manager (UM) on the first floor, License Practical Nurse (LPN), who has been working in the facility for [AGE] years. The UM stated, The last progress note from the primary doctor was February 20, 2024. Notes were done for December 2023 and January 2024, but March, April, and May of 2024, I didn't see any notes from the doctor in the computer or the chart. The Nurse Practitioner (NP) does not see this patient. On 6/26/24 at 11:30 AM, the surveyor interviewed the Director of Nursing (DON), Registered Nurse (RN), regarding physician visits, she stated, The doctor comes in and visits his patients frequently and he just started documenting in the computer. The surveyor requested to provide documentation of any notes from the doctor from March-May of 2024. On 6/26/24 at 12:50 PM, the DON acknowledged in the presence of the survey team that Resident's #45 physician did not complete progress notes for three months. The facility did not provide any additional documentation. On 6/26/24 at 1:15 PM, the survey team discussed the above concern with the facility's Licensed Nursing Home Administration (LNHA), DON, [NAME] President of Regional Operations, and two Regional of Clinical Services. On 6/27/24 at 9:25 AM, the surveyor reviewed the most current facility policy and procedure titled, Physician Visits which revealed, The Attending Physician must make visits in accordance with applicable state and federal regulations. NJAC 8:39-23.2 (d)

C#: NJ00170690 Based on interviews and record review, as well as review of pertinent facility documents on 1/30/24, the facility failed to use a two-person assistance interventions for 1 of 4 residents (Resident #2), as determined necessary by the Resident's comprehensive Care Plan (CP). The failure to follow this intervention during morning care on 01/20/24 for Resident#2,.who was combative towards the one staff member present at that time, resulted in the resident groaning in pain and his/her right upper arm swollen and requiring immediate transfer to an acute care hospital emergency room for further evaluation. The deficient practice was evidenced by the following: According to the ADMISSION RECORD Resident #2 was admitted with diagnoses which included, but were not limited to, Cerebral Palsy, Muscle Wasting and Atrophy, Scoliosis, Major Depression, Adjustment Disorder, Insomnia, Pain in Unspecified Shoulder, Anxiety Disorder, Muscle Weakness. The Minimum Data Set (MDS) an assessment tool dated 12/23/23, revealed that Resident #2's cognition was moderately impaired and required total of 2-person assistance from staff with Activities of Daily Living (ADL). The MDS further revealed that the Resident's upper and lower extremities were impaired. Review of Resident #2's progress notes (PN), dated 1/16/24 at 3:44 p.m., documented by Licensed Practical Nurse (LPN #1), revealed that the Resident was alert and oriented to person, place, and time. Review of Resident #2's CP included but were not limited to: A CP initiated on 3/29/23, the CP and revised on 5/24/23, indicated that Resident #2 had physical functioning deficit related to (r/t) mobility, self-care impairment. Interventions included but were not limited to, bed mobility, dressing, and personal hygiene assistance of 2 persons. A C/P initiated on 10/26/23 indicated Resident #2 had potential episodes to be verbally aggressive toward staff r/t anger. Interventions included but were not limited to, assess and anticipate resident's needs such as food, thirst and have two staff at all times, toileting needs, comfort level, body positioning, pain etc. Give the resident as many choices as possible about care and activities. Review of Resident #2's form Special Instructions (SI), dated, printed, and provided by the facility via email on 2/1/24, the SI indicated that Resident required 2 persons assist during Bed Mobility, Toileting, Dressing. The Certified Nursing Assistant (CNA) failed to use a two-person assist when CNA #2 started providing care to Resident #2 with 1 person assist which was not in accordance with the Resident's CP. This resulted in the Resident's immediate transfer to an Acute Care Hospital (ACH) due to right arm pain and swelling. During an interview with the Unit Manager/Licensed Practical Nurse (UM/LPN) on 01/30/24 at 9:29 a.m., the UM/LPN revealed that Resident #2 was transferred to an ACH on Saturday morning of 1/20/24 because of an incident that happened (unable to say exact date) between Resident #2 and the CNA. A review of Resident #2's PN, dated 1/20/24 at 7:41 a.m., documented by LPN #2, documented Nursing observations, and recommendations are: during AM [morning] care [CNA #2] on duty call nurse to check resident that [he/she] was groaning in pain, nurse went in to assess, found the R [right] upper arm with slight swelling, resident c/o [complaint] pain with movement, As per MD [resident's physician], resident [Resident #2] was sent out to [ACH] for further evaluation. During the surveyors' telephone interview with LPN #2 on 2/01/24 at 3:11 p.m. she stated that on 1/20/24 at around 5:30 am she was passing medications in the hallway when CNA #2 requested she see Resident #2 in her/his room. According to LPN #2 when she arrived in Resident #2's room, there was no other staff inside the room. LPN #2 observed Resident #2 in bed lying on his back, naked, did not have diaper on, and the bed sheets had not been changed. According to LPN #2, Resident #2 reported that CNA #2 pulled [her/his] arm down and [she/he] heard a clicking sound and was in pain after she/he refused care. LPN #2 added that the CNA reported that Resident #2 was refusing care, she started changing the fitted sheet on resident's bed when the Resident started yelling, screaming, and cursing at her, CNA #2 tried to turn the Resident and heard a cracking sound. LPN #2 stated that Resident #2 was a two person assist, the CNA provided care by herself because the CNA stated that she was trying to start the process and will get help later because everybody was busy. During the surveyors' telephone interview with CNA #2 on 01/30/24 at 4:06 pm, CNA #2 stated that on 1/20/24 around 5:00 a.m., Resident #2 was refusing care and had asked her to leave the room. The CNA stated, because the Resident was soaked and wet, I decided to just change the linen, [Resident #2] was cursing, [she/he] said I don't like, I don't want to be bothered, so I continued to fix the bed. According to CNA #2, Resident #2 started hitting and cursing her, she continued fixing the bed and she heard the clicking sound and called the nurse. The CNA stated that she did not call for help because she was just changing the linen and she was trying to make it easier for my co-worker and she had to leave early. Review of Resident #2's PN, dated 01/21/2024 at 7:54 a.m., documented by LPN #2, revealed, as per [ACH], patient (Resident #2) get admitted for Fracture. Review of the Resident #2's hospital record (HR), dated 1/20/24 at 7:48am, revealed that Resident #2 had Shoulder Pain. The HR further revealed that Resident #2 reported that someone pulled [his/her] R [right] arm while being cleaned and change x [at 5:30 a.m.]. The HR also indicated under Physical Exam: .Right shoulder: Moderate swelling anterior tenderness, limited range of motion due to pain .FINAL DIAGNOSIS .Right humeral fracture . The Facility's Reportable Event Record/Report (FRE) dated 1/20/24 at 10:00 a.m., indicated that at around 6:00 a.m. CNA #2 called LPN #2 to check on Resident #2. The FRE further indicated CNA also added that while she was doing early morning care, she heard resident's right arm pop while repositioning [her/him] during care. When assessed, resident was noted with right upper arm swelling and resident was not able to move [her/his] or her arm while instructed. When [Resident #2] was interviewed, [she/he] reported that [she/he] heard a 'crack' coming from [her/his] arm when CNA repositioned [her/him] during care. [She/he] was medicated with Tylenol as ordered with relief .the Center received a call from [Acute Care Hospital] at 10:00 a.m. that the resident was admitted for [diagnosis] of Fractured Right arm .[Town] PD [Police Department] came and informed the staff that the hospital and the resident's sister/brother reported to [the] incident and took statements from the staff. [CNA #2] is suspended pending completion of investigation. Attached with the FRE was the Summary of Reportable Even Record/Report (SRERR), dated 1/23/24. The SRERR confirmed the abovementioned FRE. The SRERR indicated Conclusion: While [CNA #2] was repositioning [Resident #2 she/he] sustained a fracture of right upper extremity. CNA will be terminated for not following the plan of care of the resident . Attached with the FRE, a statement of RN #2 (assisted LPN #2) dated 1/20/24 indicated I was asked to check the resident [Resident #2] downstairs by nurse [LPN #2] who reported that patient was complaining of pain and was noted with a swollen right arm. I came and assessed resident and noted [right] upper arm swelling. When I spoke to the resident [she/he] stated that the CNA 'pushed me down' (my arm) and felt pain in my arm . During an interview with the Director of Nursing (DON) on 1/30/24 at 3:03 pm, the DON stated that staff behavior caused the injury when she turned the resident by herself; resident was a two person assist; CNA did not follow the CP, Kardex [special instructions]. DON stated CNA was turning the Resident when CNA heard the sound. The facility's policy titled Care Plans, Comprehensive Person-Centered, updated on 10/2023 indicated under Policy Interpretation and Implementation .#2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .#8. The comprehensive, person-centered care plan will .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .g. Incorporate identified problem areas, h. Incorporate risk factors associated with identified problems .#10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident .#11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes .a. When possible, interventions address the underlying source(s) of the problem area(s) . N.J.A.C. 8:39-11.2 (f)

Based on interview, document review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of facility policy, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. The failure to have a system in place that monitors antibiotic use in accordance with established protocols had the potential to affect all 106 residents of the facility. Findings include: Review of a CDC document undated titled, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority.Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use'. CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Below are examples of antibiotic use and outcome measures.Process measures: Tracking how and why antibiotics are prescribed.Antibiotic use measures.Tracking how often and how many antibiotics are prescribed.Antibiotic outcome measures.Tracking the adverse outcomes. Review of documents provided by the facility titled, Monthly Infection Control Report, for the months of 02/2022 through 06/2022 (there was no document available for 07/2022), 08/2022,09/2022 (there were no documents for 10/2022 and 11/2022), and 12/2022 through 03/2023 and then one for 04/2023 failed to identify who the residents were with infections, failed to identify which room the residents were in, failed to identify the date of onset of the infection(s), if the criteria was met or not by Loeb (a set of criteria if a resident had an infection or not and if an antibiotic might be indicated to treat), and if there were cultures, laboratory blood work taken or an x-ray completed to determine a true infection and the need for antibiotics. The documents provided by the facility had several columns which were titled community or hospital acquired infections. There was no method to determine potential clusters nor was there information which would identify how each infection was treated. Review of a document provided by the facility titled, Infection Log, for the month of 03/2023 revealed resident names, room numbers, date of onset of an infection, site of the infection, if the criteria was met or not, if there were cultures, laboratory blood work taken or an x-ray completed, who the prescriber was, the antibiotic name and the prescription duration, and the date of the resolution of the infection. During an interview on 05/26/23 at 11:35 AM, the Regional Nurse stated the Infection Control Preventionist (ICP) was able to communicate the tracking and trending of infections identified in the facility but did not have it documented appropriately. During an interview on 05/26/23 at 1:33 PM, the Medical Director confirmed he attended Quality Assurance (QA) meetings on a quarterly basis. The Medical Director stated each resident was clinically assessed, such as urine and blood work, for the need of antibiotics and stated the facility had an ICP. Review of a policy provided by the facility titled Antibiotic Stewardship, dated 03/21, indicated .The facility will educate and train staff and practitioners about the facility Antibiotic Stewardship, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes. NJAC 8:39-19.4(d)

Based on observation, interview, record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility. As part of this failure, the facility did not have an effective antibiotic stewardship program, which had the potential to affect all residents of the facility. (Cross Reference F881) Findings include: Review of a document titled, Centers for Disease Control (CDC) . National Healthcare Safety Network (NHSN) . Long Term Care Facility Component Tracking Infections in Long-Term Care Facilities, dated 01/2020, indicated, Surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data. A facility infection prevention and control (IPC) program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents, staff, and visitors. Information collected during surveillance activities can be used to develop and track prevention priorities for the facility. When conducting surveillance, facilities should use clearly defined surveillance definitions that are collected in a consistent way. This method ensures accurate and comparable data regardless of who is performing surveillance. A review of documents provided by the facility and referenced at the facility's infection control logs, failed to include evidence the facility tracked, trended, identified the potential for clusters of infections, and failed to include any corrective action taken by the facility to address the potential clusters of infections. During an interview on 05/26/23 at 1:40 PM, the Director of Nursing (DON) and the [NAME] President (VP) of Operations were present. The DON stated there was no tracking and trending and it was the Assistant Director of Nursing (ADON) who was the Infection Control Preventionist (ICP) and the current ICP began a few months ago. The DON confirmed the facility used to track and trend infections but currently did not based on what she saw in the infection control logs. Review of a policy provided by the facility titled Infection Prevention and Control Program, dated 11/2019, indicated .The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.The elements of the infection prevention and control program consists of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection.surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics.detecting unusual pathogens with infection control implications.Standard criteria are used to distinguish community-acquired from facility-acquired infections.Data gathered during surveillance is used to oversee infections and spot trends. NJAC 8:39-19.1(a)1 NJAC 8:39-19.4(f)

Based on interview, record review, and policy review, the facility failed to ensure allegations of abuse / neglect and/or the investigations were submitted to the New Jersey Department of Health (NJDOH) within the time limits of the policy and federal regulation for five of eight residents (Resident (R)14, R25, R91, R38, and R28) reviewed for abuse in a total sample of 28 residents. Findings include: 1. Review of R14's Admission Record from the facility electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with medical diagnoses that included schizophrenia (hallucinations and delusions). During an interview on 05/23/23 at 2:52 PM, R14 stated that 15 staff jumped on him and sprayed [NAME] in his eyes. The Administrator was advised of R14's allegation on 05/23/23 at 4:30 PM and stated they (facility staff) were unaware of the allegation previously. On 05/25/23 at 9:15 AM the Administrator was asked for any documentation related to the allegation. On 05/25/23 at 11:00 AM, the Administrator provided two printed Progress Notes (from the EMR) and stated, This is my investigation. Review of the Progress Notes revealed a note dated 05/23/23 at 8:40 PM by a Registered Nurse (RN) that stated R14's allegation, that a body assessment was completed, and the psychiatric Nurse Practitioner (NP) was advised; the second note was dated 05/25/23 at 10:35 AM by Social Services that stated she met with R14 regarding the allegation (re-stated in note) and that the resident stated it happened at a hospital where he was told to leave it alone. On 05/25/23 at 1:35 PM the Administrator was asked if R14's statement had been considered an allegation of abuse and responded Asked [named the Director of Nursing (DON)] and she reports everything. She [DON] felt very strongly that this was a behavior. When clarified about the investigation, the Administrator stated, We did an investigation, well, we asked psych to eval him and the social worker talked to him [R14] and found out it happened at [hospital name]. We didn't feel it was an allegation of abuse. During an interview on 05/25/23 at 3:15 PM regarding the decision not to report R14's statement as an allegation of abuse, the DON stated, It's because the history and the story itself. He [R14] said 15 people maced him, we checked him and no evidence, and we interviewed him later and he said it happened elsewhere. Basing [sic] on the report itself 15 people jumped on him, I'm not saying - I'm being honest because if he says 15 people how he didn't even tell us, he wasn't able to tell us how and where. We did call the psychiatrist though and he did follow up. Once again, based on the story - we have to investigate first because the policy says okay so, if there is an allegation of abuse - you investigate first you don't just jump [clarified jump was to call in to the State Agency] you have to get the whole story. When asked if anyone had interviewed R14 on 05/23/23, the DON responded, He was actually interviewed but the nurse did not document. They did interview, they did not document, I'm just being honest. On 05/26/23 at 8:50 AM, the DON advised that she did call R14's allegation into the State Agency, It's late but it's called in. Review of the file regarding the report to the NJDOH provided by the DON showed handwritten notes that the police department was notified on 05/25/23 at 4:30 PM, and the NJDOH was notified on 05/25/23 at 4:40 PM. 2. Review of R25's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included dementia, glaucoma, heart failure, hypertension, and legal blindness. Review of R25's Progress Notes from the EMR tab of the same revealed: Effective Date: 02/16/2023 18:44 [6:44 PM] Type: . Change of Condition Situation: Found resident sitting down on the floor on morning shift . Assessment: Vital signs stable, complain of back pain . Effective Date: 02/20/2023 09:59 Type: General Note Note Text: @ [at] 7:00 am . Resident c/o [complained of] pain to L [left] hip 9/10 scale with slight movement during morning care, screaming of pain while turning to the side. . ordered to send resident to ER [emergency room of named hospital] for further evaluation. @8:30 resident was picked up by stretcher x 2 person assist . Effective Date: 02/20/2023 13:14 [1:14 PM] Type: General Note Note Text : @1:15PM received a phone call from [NP name] . resident will be admitted with multiple fractures on the pelvic area. Review of facility NJDOH incident report showed the incident happened 02/16/23, one x ray report on 02/16/23 showed a negative acute examination except for right pubic bone fracture, and an x ray on 02/17/23 showed an old fracture of the right pubic ring; the resident was sent to the hospital on 02/20/23 and the report to the NJDOH was dated 02/21/23. The five-day investigation summary was dated 03/01/23 but the fax to the NJDOH was dated and sent on 03/03/23. During an interview on 05/24/23 at 4:23 PM regarding the reporting timeline, the DON stated the state agency and state Ombudsman were notified on 02/21/23 after the hospital admission. When asked about the 03/01/23 date on the summary, and the fax receipt date of the investigation summary being faxed to the NJDOH, the DON responded, Well the fax machine dates were off. Upon reviewing the handwritten date on the fax face page of 03/03/23, the DON stated, Oh, well, I guess I sent it in on that date. When asked if that was within the five-day investigation timeline, the DON responded, Well I sent it on 3/3 so not five days. 30260 3. Review of R91's Face Sheet in the Profile tab, located in EMR revealed R91 was admitted to the facility on [DATE]. Review of R91's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 05/15/23, revealed R91 had a Brief Interview for Mental Status (BIMS) of 99, indicating severe cognitive impairment. A review of the facility reported incident (FRI), dated 05/10/23 and completed by the Administrator revealed on 05/09/23 at 5:30 PM, the head of security (SG2) observed the following: security Guard (SG)4 assigned to R91 was in R91's room. R91 was in a wheelchair and the shirt R91 was wearing was draped over the back of the wheelchair. SG4 informed SG 2 that R91 kept getting out of his wheelchair so SG4 placed R91's shirt over the wheelchair. The report further revealed SG4 was removed from R91's room and sent home and was suspended pending the completion of the investigation. Cross Reference: F604 Right to be free from Physical Restraint. Review of the facility's investigation in the incident revealed the summary of reportable event was faxed to the state survey agency on 05/19/23, 10 days after the incident occurred. During an interview on 05/25/2023 at 1:07 PM, the DON admitted the facility failed to send the summary of the reportable event within 5 working days of the incident. The DON stated she was waiting for the police report. 25232 4. Review of R38's Face Sheet in the Electronic Medical Record (EMR) revealed that R38 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder, psychosis and vascular dementia with behavioral disturbances. 5. Review of R28's Face Sheet in the EMR revealed that R28 was admitted to the facility on [DATE] with a diagnosis of schizophrenia and anxiety. Review of the Reportable Event Record/Report, (initial report) dated 03/21/23, revealed R38 overheard another resident [R28] curse (B---h) and thought it was meant for him. He got upset and punched the other resident [R28] in the face. The residents were separated by staff immediately. Staff noted redness on the cheek of resident [R28] during assessment and ice compress was applied to right cheek as first aid. [R38] refused body assessment. Administrator, Director of Nursing (DON), social worker (SW), primary care provider (PCP), Psych nurse NP and families were made aware of the incident. [name of city] police department (PD) and police officers (PO) [name of officers] came and interviewed the staff and the residents. Interventions: 1. Residents were separated right away. 2. Body assessment was done on [R28], and no injuries were noted. [R38] refused to be assessed. 3. Police department was called, and two police officers (PO) came and interviewed the staff. 4. Administrator, DON, SW, PCP, psych NP, and families were notified of the event. 5. [R28] was moved to another room, and 6. Psychological and psychiatric follow-up were ordered for both residents. Review of Summary of Reportable Event Record/Report, (final report) dated 03/29/23, revealed [R38] was [NAME] himself toward his room when he overheard [R28] who was sitting in his wheelchair outside his door, curse (B---h) and thought it was meant for him. R38 got upset and punched [R28] in the face. Staff separated the residents immediately. [R28] was noted with redness on the right cheek during assessment. Ice compress was applied as first aid. [R38] refused to be assessed. Conclusion: [R38 punched R28] in the face upon overhearing [R28], curse (B---h) thinking it was meant for him. Interventions: 1. Residents were separated right away 2. Body assessment was done on [R28], and redness was noted on the right cheek and ice compress was applied with relief. [R38] refused to be assessed. 3. [name of city] PD was called, and two POs came to interview the staff and the residents 4. Administrator, DON, SW, PCP, Psych NP and families were notified of the event 5. Resident was moved to another room 6. Psychological and psychiatric follow up ordered for both residents 7. Provide 1:1 interaction during episodes of increased anxiety and redirect him away from noisy environment. Review of the Fax sheet, dated 03/29/23, revealed Attached please find summary of reportable. Review of the Email, dated 03/29/23, revealed Summary of Reportable Event Record/Report for event dated 03/21/23 was submitted on 03/29/23. Interview on 05/25/23 at 12:38 PM, the DON said that she notifies the State Survey Agency (SSA) As soon as possible (ASAP). She gets the whole story first then reports, usually on the day of the incident. Said that the initial report is within 24 hours. Said that the summary is completed by five days. Said that sometimes it takes longer than five days to complete the summary and send into the SSA due to waiting on police reports, and/or witness statements. Confirmed that the summary report was greater than five days when it was sent to the SSA. Review of undated facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure, revealed, To facilitate efforts to prevent, detect, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation. Alleged violations under 42 CFR 483.12 (c) immediately (for alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) but not later than: i. Two hours if the alleged violation involves abuse or results in serious bodily injury. ii. 24 hours-if the alleged violation does not involve abuse and does not result in serious bodily injury. iii. Results of all investigations of alleged violations-within five working days of the incident. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: a. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported in the proper timeframe pursuant to this policy. b. Have evidence that all alleged violations are thoroughly investigated. c. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. d. Report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with state law, including to the State Survey Agency, within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. NJAC 8:39-9.4(f)

Based on record review, interview, and policy review, the facility failed to ensure three of three residents and their representatives (Resident (R) 25, R28, and R161) reviewed for facility initiated emergent hospital transfer, from a total sample of 28 residents, were provided with written transfer/discharge notice. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: 1. Review of R14's Admission Record from the facility electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with medical diagnoses that included schizophrenia, hepatic encephalopathy, and chronic obstructive pulmonary disease (COPD). Review of R14's EMR Progress Notes tab showed on 02/20/23 at 9:59 AM .Resident c/o [complained of] pain to L [left] hip 9/10 scale with slight movement during morning care, screaming of pain while turning to the side. PCP [Primary Care Physician].made aware and ordered to send resident to ER [emergency room ] . for further evaluation. @ [at] 8:30 [AM] resident was picked up by stretcher x 2 person assist and left awake, alert and verbally responsive. and at 1:39 PM a Progress Note that the daughter was called and updated that R14 had been admitted to the hospital. Further review of the EMR Progress Notes, Assessments, and Misc [Miscellaneous] tabs did not show evidence R14 and his RR was provided with a written notice of transfer with all the required information. A request for the documentation of written transfer notice was made on 05/23/23 at 12:30 PM with the RNC. During an interview on 05/24/23 at 2:50 PM regarding the process for emergent transfers, Licensed Practical Nurse (LPN) 4 stated, We call the MD and update, get an order to send to hospital. We do a New Jersey Transfer Form [clarified and showed tab in EMR] then get all the papers [clarified to be legal paperwork, POLST [physician's order for life sustaining treatment], studies like lab / x ray, MAR/TAR [Medication Administration Record/Treatment Administration Record], physician orders and face sheet]. Then we call the hospital to give report, then call the ambulance or 911, and alert the family by telephone. When asked if anything written was given to the resident regarding the transfer, LPN4 responded If they are alert, we will tell them. On 05/24/23 at 2:55 PM, LPN4 was asked what happened to all the paperwork and responded, It all goes into the yellow envelope and goes to the hospital with them. This was clarified by asking if the envelope was for the resident or for the hospital, LPN 4 stated, It is for the hospital. In a telephone interview on 05/24/23 at 3:44 PM regarding receipt of a written notice of transfer with the required information, R14's RR stated, No, I got called. I never got anything written. I never got an incident report either. When an explanation that incident reports are often used for quality improvement in a facility, R14's RR stated, Oh, I used to get them from the other facility all the time. When clarified as to what was on the incident report, such as where the resident was being transferred to, the reason for transfer, and the Ombudsman contact information, R14's RR responded, Yeah - that is what I got. When queried if she had ever received a form like that for R14's transfer on 02/20/23, the RR stated, No, I've never received anything. Verified bed hold policy - No, not received that either. A request for the documentation of written transfer notice was made on 05/23/23 at 12:30 PM with the RNC. A form was provided Notice of Emergency Transfer on 05/25/23 at 8:45 AM that contained the date of transfer, resident name, the facility transferred from and to, and the reason for transfer; and the Ombudsman information for an appeal. In a follow-up interview on 05/25/23 at 1:30 PM with LPN4 and LPN1, they reviewed the Notice of Emergency Transfer form and LPN4 stated she was not familiar with the form. LPN1 stated, We fill that out and one goes to the social worker and one to the chart. When asked if the resident or RR received a copy, LPN1 stated, No, nothing to resident or family. 2. Review of R28's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included schizophrenia, acute and chronic respiratory failure with hypoxia (low oxygen levels), convulsions, , major depressive disorder, anxiety, glaucoma, and dysphagia. Review of R28's EMR Progress Note tab showed on 02/21/23 at 11:26 PM that .4:50 PM Resident, [sic] difficult to arouse and not able to take his medications. MD [physician] notified and he ordered to transfer to . hospital for evaluation. 11:05 PM .Hospital ER was called and was told resident admitted with Dx: [diagnosis] hypoxia. Further review of R28's EMR Progress Notes, Assessments, and Misc tabs did not showed evidence of a written notice of transfer or discharge was provided to the resident or RR. A request for the documentation of written transfer notice was made on 05/23/23 at 12:30 PM with the RNC. A form was provided Notice of Emergency Transfer on 05/25/23 at 8:45 AM that contained the date of transfer, resident name, the facility transferred from and to, and the reason for transfer; and the Ombudsman information for an appeal. 3. Review of R161's Admission Record from the EMR Profile tab showed a facility admitted [DATE], a discharge date of [DATE], with diagnoses that included pneumonia, encephalopathy, hypotension, schizoaffective disorder - bipolar type, liver disease, and spondylosis. Review of R161's EMR Progress Notes tab showed on 12/17/22 at 9:17 AM Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs . Pulse: P 115 - 12/17/2022 09:18 Pulse Type: Irregular - new onset . Recommendations: Primary MD made aware and orders to send resident for further evaluation. Review of R161's EMR Census tab showed R161 status was discharged to the hospital on 12/17/22. A request for the documentation of written transfer notice was made on 05/23/23 at 12:30 PM with the RNC. A form was provided Notice of Emergency Transfer on 05/25/23 at 8:45 AM that contained the date of transfer, resident name, the facility transferred from and to, and the reason for transfer; and the Ombudsman information for an appeal. An attempt to contact R161's RR failed. R161 and the RR passed away within weeks of each other. During an interview on 05/26/23 at 2:05 PM with the Director of Nursing (DON) and [NAME] President of Operations (VPO) the query of 'Had anyone identified that written transfer and discharge notices are not being sent to the RR? The DON responded that that would fall to social services or admissions. When asked about an expectation of the form being provided to the resident and RR, the DON responded, Expectation is that everybody who goes out [to the hospital] should be completed the notification should be given to the resident or family member. Review of the facility policy titled Transfer or Discharge Notice, reviewed 02/2023, showed: . 3. The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge; b .The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. A statement of the resident's rights to appeal the transfer or discharge, including: (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; d. The facility bed-hold policy; e. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; . NJAC 8:39-4.1(a)31 NJAC 8:39-5.3(b)

Based on record review, interview, and review of facility policy, the facility failed to ensure three of three residents (Resident (R) 25, R28 and R161) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information from a sample of 28 residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: 1. Review of R14's Admission Record from the facility electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with medical diagnoses that included schizophrenia, hepatic encephalopathy, and chronic obstructive pulmonary disease (COPD). Review of R14's EMR Progress Notes tab showed on 02/20/23 at 9:59 AM .Resident c/o [complained of] pain to L [left] hip 9/10 scale with slight movement during morning care, screaming of pain while turning to the side. PCP [Primary Care Physician].made aware and ordered to send resident to ER [emergency room ] . for further evaluation. @ [at] 8:30 [AM] resident was picked up by stretcher x 2 person assist and left awake, alert and verbally responsive. and at 1:39 PM a Progress Note that the daughter was called and updated that R14 had been admitted to the hospital. Further review of the EMR Progress Notes, Assessments, and Misc [Miscellaneous] tabs did not show evidence R14 and his RR was provided with a written bed hold notice upon transfer. During an interview on 05/24/23 at 2:50 PM regarding the process for emergent transfers, Licensed Practical Nurse (LPN) 4 stated, We call the MD and update, get an order to send to hospital. We do a New Jersey Transfer Form [clarified and showed tab in EMR] then get all the papers [clarified to be legal paperwork, POLST [physician's order for life sustaining treatment], studies like lab / x ray, MAR/TAR [Medication Administration Record/Treatment Administration Record], physician orders and face sheet]. Then we call the hospital to give report, then call the ambulance or 911, and alert the family by telephone. In a telephone interview on 05/24/23 at 3:44 PM R14's RR stated she had never received a written notice regarding a bed hold. In an interview on 05/25/23 11:45 AM, the resident stated he did not remember getting anything in writing. During a follow-up interview on 05/25/23 at 1:30 PM, LPN1 was shown a bed hold form provided by the facility and stated, first time I've seen this form. Bed holds are usually done when they get admitted and it will say in [EMR] if they want a bed hold. I've never seen these (form). Clarified if LPN4 was providing the form to the resident upon transfer, LPN4 stated, No, we're not providing it. 2. Review of R28's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included schizophrenia, acute and chronic respiratory failure with hypoxia, convulsions, major depressive disorder, anxiety, glaucoma, and dysphagia. Review of R28's EMR Progress Note tab showed on 02/21/23 at 11:26 PM that .4:50 PM Resident, [sic] difficult to arouse and not able to take his medications. MD [physician] notified and he ordered to transfer to . hospital for evaluation. 11:05 PM .Hospital ER was called and was told resident admitted with Dx: [diagnosis] hypoxia. Further review of R28's EMR Progress Notes, Assessments, and Misc tabs did not showed evidence of a written bed hold notice was provided to the resident or RR. A request for the documentation of written bed hold notice was made on 05/23/23 at 12:30 PM with the RNC. A form was provided Notice of Emergency Transfer on 05/25/23 at 8:45 AM that contained bed hold policy but not the daily charge for an informed consent. 3. Review of R161's Admission Record from the EMR Profile tab showed a facility admitted [DATE], a discharge date of [DATE], with diagnoses that included pneumonia, encephalopathy, hypotension, schizoaffective disorder - bipolar type, liver disease, and spondylosis. Review of R161's EMR Progress Notes tab showed on 12/17/22 at 9:17 AM Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs . Pulse: P 115 - 12/17/2022 09:18 Pulse Type: Irregular - new onset . Recommendations: Primary MD made aware and orders to send resident for further evaluation. Review of R161's EMR Census tab showed R161 status was discharged to the hospital on 12/17/22. A request for the documentation of written bed hold notice was made on 05/23/23 at 12:30 PM with the RNC. A form was provided Notice of Emergency Transfer on 05/25/23 at 8:45 AM that contained a written bed hold notice but did not contain a daily rate for an informed consent or declination. An attempt to contact R161's RR failed. R161 and the RR passed away within weeks of each other. During an interview on 05/26/23 at 2:05 PM with the Director of Nursing (DON) and [NAME] President of Operations (VPO) , the DON was asked her expectation regarding the provision of a written bed hold notice to the resident and RR upon emergent transfer, stated, Expectation is that everybody who goes out [to hospital] should have the notification completed and should be given to the resident or family member. Review of the facility policy titled Bed-Holds and Returns, reviewed 12/2022, showed: . 3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed- hold period (Medicaid residents); and d. The details of the transfer (per the Notice of Transfer). NJAC 8:39-5.1(a) NJAC 8:39-5.4(c)

Based on record review, interviews, review of the Food and Drug Administration (FDA) warning (www.fda.gov), and policy review, the facility failed to ensure two (Resident (R) 33 and R14) of five residents reviewed for unnecessary medications out of a total sample of 28 residents, had adequate indications, behavior monitoring, and/or a Gradual Dose Reduction (GDR) while on psychotropic medications. Findings include: Review of an FDA document indicated .Olanzapine is an atypical antipsychotic medicine used to treat schizophrenia and bipolar disorder (manic or mixed episodes). For bipolar disorder, olanzapine can be used alone or in combination with other drugs.Olanzapine can decrease hallucinations, in which people hear or see things that do not exist, and other psychotic symptoms such as disorganized thinking. Olanzapine can also decrease the mania of bipolar I disorder.ZYPREXA (Olanzapine) may cause serious side effects, including: 1. Increased risk of death in elderly people who are confused, have memory loss and have lost touch with reality (dementia-related psychosis) . 1. Review of R33's electronic medical record (EMR) Admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of a document provided by the facility titled Physician Report, dated 11/14/22, revealed the consultant pharmacist indicated R33's use of Olanzapine would trigger inappropriate use on the quality indicator report and to review the diagnosis and usage in considering a gradual dose reduction (GDR). The report revealed the Nurse Practitioner (NP) directed that there would be no GDR and signed the document. The NP failed to provide clinical indications for the continued use of Zyprexa. Review of R33's EMR titled Clinical Physician Orders, located under the Orders tab and dated 11/16/22, indicated the resident was ordered Olanzapine 5 milligrams (mg) to be administered by mouth at bedtime for psychosis (out of touch with reality). Review of a document provided by the facility titled, Progress Notes, written by a NP and dated 12/19/22, indicated R33 was being given Olanzapine 5 mg at bedtime for psychosis. The progress notes revealed there were no associated behaviors by the resident for the past two months. Review of a document provided by the facility titled Progress Notes, written by a NP and dated 05/24/23, indicated R33 was on Olanzapine for major depressive disorder and was having hallucinations about getting kids ready for school at 2:00 AM and no GDR at this time. Review of R33's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/23 indicated a Brief Interview for Mental Status (BIMS) score of eight out of 15 which revealed R33 was moderately impaired cognitively. The assessment indicated R33 had no hallucinations or delusions and was not a threat to himself or to others. The assessment indicated R33 took an antipsychotic and had no GDR and the GDR .has not been documented by a physician as clinically contraindicated. Review of R33's EMR Care Plan, located under the Care Plan tab and dated 03/18/23, indicated the resident was on Olanzapine and there was potential for drug related complications. A review was conducted of R33's EMR and paper chart and there was no indication the resident was actively hallucinating or had behaviors which would be a threat to self or to others. Review of documents provided by the facility referred to as behavior logs, dated 01/2022 through 04/2023, failed to indicate R33 had any behaviors. During an interview on 05/24/23 at 1:56 PM, Licensed Practical Nurse (LPN) 2 who was also the Unit Manager on the first floor, stated the behavior notes were under a General Note heading of the EMR. During this interview LPN 2 stated there were no behavior notes in the EMR and would need to follow up. During a subsequent interview on 05/25/23 at 11:38 AM, LPN 2 confirmed there were no behaviors associated with R33 in the EMR and stated behavior monitoring was to be done by the staff. During an interview on 05/25/23 at 2:57 AM, Certified Nurse Aide (CNA) 1 stated R33 was not dangerous to himself or to others. CNA 1 stated she was not afraid of the resident, and he did not yell out constantly. During an interview on 05/26/23 at 1:40 PM, the Director of Nursing (DON) and the [NAME] President (VP) of Operations were present. The DON stated the staff do monitor the behavior of residents who were on psychotropic medications and if there was a negative response in the behavior log, this prompts the EMR to direct the clinical staff to make a note of the specific behavior. The DON confirmed there were no target behaviors for the resident while he was taking Olanzapine. During an interview on 05/26/23 at 2:41 PM, the Consultant Pharmacist stated she bases her GDR recommendations on the behaviors documented in the clinical record. The Consultant Pharmacist stated if there were no associated behaviors with the use of psychotropic medication, she would request a GDR. 28154 2. Review of R14's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included schizophrenia, hypertension, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and hepatic encephalopathy. Review of R14's EMR Orders tab showed physician orders for: -Anti-Anxiety Medication Use - Observe resident closely for significant side effects: Sedation, Drowsiness, Ataxia(drunk walk), Dizziness, Nausea, Vomiting, Confusion, Headache, Blurred Vision, Skin Rash. - Special Attention: If given with other sedatives, hypnotics or alcohol -Anti-Psychotic Medication Use - Observe resident closely for significant side effects: Common - Sedation, Drowsiness, Dry Mouth, Constipation, Blurred Vision, Extra Pyramidal Reaction, Weight Gain, Edema, Postural Hypotension, Sweating, Loss of Appetite, Urinary Retention.- Special Attention For: Tardive Dyskinesia, Seizure Disorder, Chronic Constipation, Glaucoma, Diabetes, Skin Pigmentation, Jaundice. -Ativan (an anxiolytic medication) 2 MG (Milligrams) tablet (generic name lorazepam) three times a day for anxiety Clozaril (an atypical antipsychotic) 200 MG tablet (brand name Clozapine) two times a day for Schizophrenia -Haloperidol 5 MG - three tablets (15 MG) (brand name Haldol, a conventional antipsychotic) three times a day for schizophrenia -Zyprexa 10 MG tablet (generic name Olanzapine) two times a day for Schizophrenia Review of R14's care plan showed focus (F), goals (G) and interventions (I) of: 1.F: Potential for drug related complications associated with use of psychotropic medications related to: Anti-psychotic medication G: Will be free of psychotropic drug related complications I: Will receive lowest therapeutic dose for control of symptoms by/through review date Medication last attempted for reduction within next review -Monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention -Monitor for target behaviors/symptoms of H/O assaultive behavior, property destruction and document. Report behavior changes to physician . -Provide Medications as ordered by physician and evaluate for effectiveness -Refer to psychologist/psychiatrist for medication and behavior intervention recommendations 2.F I sometimes have behaviors which include H/O Hitting during care, H/O Tearing things up G I will calm down with staff intervention I My behavior will stop with staff intervention -Attempt interventions before my behaviors begin -Give me my medications as my doctor has ordered -Help me maintain my favorite place to sit -Let my physician know if my behaviors are interfering with my daily living . During an interview on 05/26/23 at 2:05 PM with the Director of Nursing (DON) and [NAME] President of Operations (VPO), the DON was asked where target behaviors are identified to monitor for each psychoactive medication's efficacy and responded, Our process is, like before we opened our behavior unit - we have behavior monitors for specific medication. Now, we did some changes so now nurses chart every time behavior on each shift. So, if you observe specific behavior you will answer the section yes, if you answer yes, you have to do a chart now. When asked where the behavior that each medication is being used to manage was identified and monitored, the DON replied, We just monitor all behaviors and that is by the nurses. When the question was clarified, At this time, do you have a way to monitor each psychoactive medication for efficacy related to an identified target behavior? the DON stated at 2:18 PM In the summaries we document if observed for all behaviors. If an increase in behaviors observed we refer to psych and they manage the medications. At 2:19 PM the VPO stated, No, no target behaviors are identified to monitor for efficacy [for each medication]. Review of a policy provided by the facility titled Tapering Medications and Gradual Drug Dose Reduction, dated 02/2023, indicated .Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.The resident's target symptoms returned or worsened after the most recent attempt at tapering the dose within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. NJAC 8:39-29.3(a)1 NJAC 8:39-33.2(c)2

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one (Resident (R) 36) of five residents reviewed for flu/pneumonia vaccinations and/or their representatives out of a total sample of 28 residents, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to re-offer R36 the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) in accordance with nationally recognized standards. The facility failed to re-offer R36 the opportunity to be vaccinated with Pneumococcal conjugate vaccine (PCV13) and/or Pneumovax [Pneumococcal Polysaccharide Vaccine (PPSV23)] prior to 10/21/21 and/or offer one dose of Prevnar 20 (PCV20) after 10/21/21. The facility failed to update their most current policies to reflect current standards on pneumococcal vaccinations. This practice had the potential to increase the risk for residents to contract pneumonia. Findings include: Per CDC, For those who have never received any pneumococcal conjugate vaccine, CDC recommends PCV15 or PCV20 for adults [AGE] years or older .Adults [AGE] years or older have the option to get PCV20 if they have already received.PCV13 (but not PCV15 or PCV20) at any age and.PPSV23 at or after the age of [AGE] years old.These adults can talk with their doctor and decide, together, whether to get PCV20. Review of R36's electronic medical record (EMR) titled Admission Record, located under the Profile tab, indicated the resident was initially admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. The resident was not [AGE] years of age after his initial admission. The resident turned [AGE] years of age while a resident at the facility. Review of a document provided by the facility titled, Clinical Immunizations indicated R36 refused the PPSV23 undated entry. There was no other entry on this document which would reflect the facility offered the resident additional opportunities for vaccination. During an interview on 05/25/23 at 9:23 AM, the Infection Control Preventionist (ICP) and Regional Nurse were both present. The ICP stated she only offers residents the PVC13. During an interview on 05/25/23 at 9:54 AM, the ICP confirmed R36 was not offered another opportunity to be vaccinated with PVC20. During an interview on 05/25/23 at 10:25 AM, the Director of Nursing (DON) stated she could not obtain the clinical records for R36 to see if the resident was offered additional opportunities for pneumococcal vaccinations. The DON stated the previous nursing homeowners took all of the resident's clinical records. The DON stated she was not aware the pneumococcal policies were not updated. Review of a policy provided by the facility titled Pneumococcal Vaccine, dated 03/21, indicated .All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.Administration of the pneumococcal vaccines or revaccination will be made in accordance with current Centers for Disease Control Prevention (CDC) recommendations at the time of the vaccinations. NJAC 8:39-19.4(h)(i)

Based on interview, record review, and review of facility policy, the facility failed to ensure 1.Code Status and Advance Directives were in place for one (Resident (R) 54) and 2. the physician completed documentation on the POLST for one resident (Resident (R) 7) of eight residents reviewed for Advance Directives and Code Status out of a total sample of 28 residents. This failure increased the risk the residents' wishes would not be followed. Findings include: 1. Review of R54's electronic medical record (EMR) Admission Record, located under the Profile tab, indicated the resident was initially admitted to the facility on [DATE] and recently readmitted on [DATE]. Review of R54's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/23 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed R54 was cognitively intact. R54 refused to be interviewed by this surveyor. Review of R54's EMR Care Plan, located under the Care Plan tab, failed to address the resident's code status. Review of R54's paper chart failed to indicate the facility provided the resident with information on Advance Directives, nor did the clinical record contain Code Status documentation. During an interview on 05/25/23 at 8:42 AM, the Director of Nursing (DON) stated the Advance Directives would be placed by Social Services in the resident's clinical record. A request was made for the Advance Directive information provided to R54's and/or the resident's representative. During an interview on 05/25/23 at 8:54 AM, Director of Social Services (DSS) 1 stated she meets with the resident and explains the Advance Directive form and the POLST (Physician Orders for Life Sustaining Treatment) which was on the same form. DSS 1 stated the resident's POLST was then discussed/updated during their care conference. During an interview on 05/25/23 at 12:40 PM, the DON confirmed R54 did not have a POLST on his chart, either electronically or in his paper chart. During an interview on 05/26/23 at 12:25 PM, Licensed Practical Nurse (LPN) 1 and LPN 4 confirmed if a resident did not have a code status posted in the EMR or in the hard paper chart, the resident would be considered a full code status. Review of a policy provided by the facility titled Advanced Directives dated 12/22 indicated . Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 30260 2. Review of R7's profile, located in the Profile tab of the EMR revealed R7 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, type 2 diabetes, and dysphagia. Review of R7's POLST, located under the Miscellaneous tab of the EMR, revealed under the signatures section revealed a physician's stamp denoting the physician's printed name, signature, license number, and DEA (Drug Enforcement Administration), but failed to reveal the physician's phone number, date, and time. During an interview with the SSD1 on 05/23/23 at 3:59 PM, SSD1 acknowledged there was no date and time with the physician's stamp and the document lacked a date indicating when it was signed by the physician. Review of the facility's policy titled Advance Directives:(Revised December 2016), Updated 01/2019, reviewed 12/2022, failed to reveal the facility's policy on completing the POLST. Review of a policy provided by the facility titled Advanced Directives dated 12/22 indicated . Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. NJAC 8:39-9.6(a)(e)

Based on interviews, record review, review of facility reported incidents (FRI), and review of the facility policy, the facility failed to protect the rights of two of eight residents reviewed for abuse (Resident (R) 28 and R63) to be free from physical abuse by R38 out of a total sample of 28 residents. Findings include: 1. Review of R38's Face Sheet in the electronic medical record (EMR) revealed that R38 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (hallucinations and delusions [firmly held beliefs not based on reality]), psychosis (out of touch with reality) and vascular dementia with behavioral disturbances. Review of the EMR medical record revealed that R38 had a history of physical aggressiveness with other residents. Interview on 05/26/23 at 9:40 AM with R38, he denied having any concerns with other residents. 2. Review of R28's Face Sheet in the EMR revealed that R28 was admitted to the facility on [DATE] with a diagnosis of schizophrenia and anxiety. Review of the Progress Note, dated 03/21/23 and located in the EMR, revealed At 12:50 PM, writer was called by CNA [Certified Nursing Assistant] into R28's bedroom. Upon arrival observed R28 sitting in his wheelchair holding the right side of his face. Upon assessment of R28 noted redness to the right side of his face with no swelling or bleeding. R38 was [NAME] himself towards his room, stopped by R28. R28 called R38 a Bitch. R38 got up and hit R28 on the right side of his face. R28 denied any pain or distress. Ice pack applied, R28 was educated about not using offensive or abusive language towards his peers and staff. R28's mother, physician, and psych nurse practitioner (NP) made aware. Review of the Reportable Event Record/Report, (initial report) dated 03/21/23, revealed R38 overheard another resident [R28] curse (B---h) and thought it was meant for him. He got upset and punched the other resident [R28] in the face. The residents were separated by staff immediately. Staff noted redness on the cheek of resident [R28] during assessment and ice compress was applied to right cheek as first aid. R38 refused body assessment. Administrator, Director of Nursing (DON), social worker (SW), primary care provider (PCP), Psych nurse NP and families were made aware of the incident. [name of city] police department (PD) and police officers (PO) [name of officers] came and interviewed the staff and the residents. Interventions: 1. Residents were separated right away. 2. Body assessment was done on R28, and no injuries were noted. R38 refused to be assessed. 3. Police department was called, and two police officers (PO) came and interviewed the staff. 4. Administrator, DON, SW, PCP, psych NP, and families were notified of the event. 5. R28 was moved to another room, and 6. Psychological and psychiatric follow-up were ordered for both residents. Review of [name of city] Police Department Investigation Report, dated 03/21/23, revealed On 03/21/23 at approximately 1:23 hour PM, officer [name of officer] was dispatched to [address of the facility] on reports of a dispute. Upon arrival, met with disputing parties R28 and R38. The two male parties had a physical altercation regarding R28 using profanity. While speaking with both parties I did not observe any physical signs of injury. Both parties agreed to respect each other's boundaries. No further police action taken. Review of the Witness Interview Record for R28, dated 03/21/23, revealed R38 hit me. I just want to go to [name of hospital]. Review of the Witness Interview Record for R38, dated 03/21/23, revealed R28 called me a b---h, that is why I hit him. Review of the Witness Interview Record for Registered Nurse (RN) 1, dated 03/21/23, revealed Was in the nursing station and saw security get up from his post and ran towards the male hallway. Then he came back and told me about the incident. I went to room [number] right away and saw [R28] being assessed and left the room to check on the other resident [R38] across the hall. [R38] was in his room sitting on his bed and stated that he got upset when resident [R28] called him a B---h and punched him in the face. Review of the Witness Interview Record for security guard (SG) 2 dated 03/21/23 revealed I was in my post in the hallway near the elevator monitoring the activities on both hallways and the elevator area. I saw [R38] get up from his wheelchair and approach [R28] who was sitting in his wheelchair near the doorway of his room. I ran towards them, but the event happened before I could reach them. [R38] struck [R28] on the face. Review of the Witness Interview Record for Certified Nursing Assistant (CNA) 6, dated 03/21/23, revealed Saw [R38] in wheelchair toward his room. [R38] got up from his wheelchair and punched [R28] in the face when he heard [R28] say b---h. The incident happened very fast and was unable to redirect them before the incident could happen. [R38] hit [R28] on the face. Another CNA was close by and took [R28] inside his room. Review of the Witness Interview Record for CNA 5, dated 03/21/23, revealed Was in the hallway handing another resident a cup of water and saw [R38] get up from his wheelchair when [R28] said something. I ran towards them, but the event occurred before I could reach them. I moved [R28] away from [R38] and took him inside his room. I called the nurse to the room to check on [R28]. Review of the Witness Interview Record for RN 2, dated 03/21/23, revealed I was called to room [number] by CNA to check on [R28] in the room. [R28] was seen in his wheelchair holding the right side of his face. Assessment noted redness on the right side of face. Per CNA, [R38] was [NAME] toward his room and overheard [R28] who was sitting by his doorway curse b---h and [R38] got upset. [R38] got up from his wheelchair, punched [R28] in the face. CNA took [R28] inside his room and then called me to the room. Review of Summary of Reportable Event Record/Report, (final report) dated 03/29/23, revealed [R38] was [NAME] himself toward his room when he overheard [R28] who was sitting in his wheelchair outside his door, curse (B---h) and thought it was meant for him. [R38] got upset and punched [R28] in the face. Staff separated the residents immediately. [R28] was noted with redness on the right cheek during assessment. Ice compress was applied as first aid. [R38] refused to be assessed. Conclusion: [R38] punched [R28] in the face upon overhearing [R28], curse (B---h) thinking it was meant for him. Interventions: 1. Residents were separated right away 2. Body assessment was done on [R28], and redness was noted on the right cheek and ice compress was applied with relief. [R38] refused to be assessed. 3. [name of city] PD was called, and two POs came to interview the staff and the residents 4. Administrator, DON, SW, PCP, Psych NP and families were notified of the event 5. Resident was moved to another room 6. Psychological and psychiatric follow up ordered for both residents 7. Provide 1:1 interaction during episodes of increased anxiety and redirect him away from noisy environment. Interview on 05/25/23 at 11:23 AM, RN 1, said that R38 is high temper, low tolerance. Went on to state that hitting is his baseline behavior. Unsure that she could recall any details about this specific incident. Interview on 05/25/23 at 12:05 PM, SG 2, said that there were many incidents involving R38. Said that R38 gets easily agitated and tends to focus on his money. Said that he does not recall the incident between R38 and R28 since there is so many incidents with R38. Interview on 05/25/23 at 12:38 PM, the DON said that a behavioral facility in another city was transferred here when that facility closed. R38, along with other residents, were transferred here after that facility was closed. Said that the second floor was turned into a behavior unit, back in August 2022. Said that R38 is usually okay until someone invades his space. Said that R38 is focused on money, and soda. Said that R38 gets irritated when people are talking loudly. Indicated that there has been different interventions put into place for R38 such as room change, psych follow ups right away, psychological follow ups, seating in the dining room far away from the other residents that R38 has gotten into an altercation with, sat a monitor by the elevator to ensure that both halls could be seen at all times, and the monitor could call for help if an incident would occur, and behavioral training with initial training and refreshment courses. Said that something triggers R38, but he was not a continuous threat to self and/or others. Said that the facility staff uses a reward system by using soda, and redirection especially when the events happened in the hallway R38 is redirected back to his room. Confirmed that the facility has not considered placing R38 on a 1:1. Said that psych will either recommend a 1:1 or sometimes the facility staff will place the residents on 1:1. Interview on 05/26/23 at 9:25 AM, R28 was confused and unable to answer questions. Said he was going to the group home today. On 05/26/23 at 10:46 AM, an attempted interview with CNA 5, with a voice mail left; however, by the end of the survey process, no return phone calls. Interview on 05/26/23 at 10:54 AM, RN 2, said that she did not see the actual incident, but wrote a statement due to working that shift. Said that R38 is always focused on money, looking for the bank lady all the time. When you tell R38 something that he does not understand, he gets flustered and goes off. R38 has a bad temper. Interview on 05/26/23 at 11:02 AM, CNA 6, she said that she was sitting in the hallway with R28 at the time of the incident when R38 came rolling down the hallway and jumped up and hit R28 when R38 thought R28 said something to him. The residents were separated. R38 only hit R28 once, and there were no injuries to either resident. This incident was reported to the nurse as well as the supervisors. 3. Review of R63's Face Sheet in the EMR revealed that R63 was admitted to the facility on [DATE] with a diagnosis of dementia, depression, and legal blindness. Review of the Progress Note dated 04/27/23 in the EMR revealed Security staff heard somebody calling for help from room[number], when security went to the room, found [R63] sitting on [R38's] bed bleeding from the left lip. [R38] was standing near the bathroom door. Security called for help and residents were separated. Head to toe assessment was done on [R63] who was bleeding from the lip. [R63's] lip was cleaned with normal saline (NS) and bacitracin applied. There was a cut to the left side of [R63's] lip. Pressure was applied until bleeding stopped and no swelling was noted at this time. [R63] was transferred to another room. When [R63] was interviewed, [R63] reported that [R38] hit him with no reason. [R38] reported that [R63] touch his -ss and hit him on the back and [NAME], that is why he hit him. [R63] stated that [R63] did not do anything. [name of city] PD was called, came out and interviewed residents of the altercation. The PCP, psych NP, Administrator, DON, SW, and families were informed of the incident. Review of the Reportable Event Record/Report, (initial report) dated 04/27/23, revealed Security staff heard somebody calling for help from room [number], when he went to the room, he found [R63] sitting on resident's bed bleeding from the left lip and resident standing near the bathroom door. Security staff called for help and staff responded right away. When [R63] was interviewed. He reported that resident [R38] hit him for no apparent reason but unable to tell why he was sitting on roommate's bed. [R38 ]reported that [R63] touched his -ss and hit him on the back and [NAME] that is why he hit his roommate. Both residents are from the second-floor behavior unit. Residents were separated right away. Body assessment was completed on both residents and no injuries noted on [R38]. [R63] was noted bleeding from the lip further assessment revealed a cut on the lower lip. Pressure applied till bleeding stopped. No swelling was noted at this time. [R63] was transferred to another room right away. [name of city] PD was called and police officer [name of officer] responded to the center and interviewed the staff and [R38]. PCP, psych NP, Administrator, DON, SW, and families were notified of the event. Seen and evaluated by psych NP, no new recommendations given. Review of [name of city] Police Department, dated 04/27/23, revealed On 04/27/23, dispatched to [facility address] second floor on a report of a simple assault fight between two patients. Upon arrival, met with the caller/nurse [name of nurse] who stated the two patients/residents [R63 and R38] got involved in a fist fight. [R38] advised [name of staff] that he punched[R63] in his face because [R63] hit him first on his back. [R63] was bleeding from his mouth due to the fight. [staff member name] stated [R63 and R38] are mentally ill, and they both were given medical attention after this incident which occurred at 07:30 AM this morning. [R63 and R38] are fine. No further police action was needed. Review of the Witness Interview Record, dated 04/27/23, for R38 revealed He touched my -ss then hit me on the back and [NAME]. Review of Witness Interview Record, dated 04/27/23, for R63 revealed He hit me on the face, I did not do anything. Review of Witness Interview Record, dated 04/27/23, CNA 3, revealed Responded to the room when security called for help with other staff members and found [R63[]sitting on roommates [R38's] bed bleeding from the lip and reported that he was hit by roommate. Roommate [R38] was found standing near the bathroom door. [R38] was assisted out of the room by security right away. Review of Witness Interview Record, dated 04/27/23, for Licensed Practical Nurse (LPN) 3, revealed Responded to the room with other staff members and found [R63] sitting on [R38's] bed bleeding from the lip and reported that [R38] hit him on the face. [R38] was redirected out of the room by security. Body assessment was done on [R63] and noted a cut on lower lip left side with bleeding. Pressure applied. No other injuries noted at this time. Review of Witness Interview Record, dated 04/27/23, for SC 1, revealed Heard somebody calling for help, responding to room and found [R63] sitting on the bed of [R38] bleeding from the lower lip and reported that [R38] hit time on the face. [R38] who was found standing by the bathroom door reported that he was hit first by [R63]. Called for help right away. Residents were separated right away. Review of the Summary of Reportable Event Record/Report, (final report) dated 04/28/23, revealed Security staff heard somebody calling for help from room[number], when he went to the room, he found [R63] sitting on [R38's] bed bleeding from the left lip and [R38] standing near the bathroom door. Security staff called for help and staff responded right away. When [R63] was interviewed, he reported that [R38] reported that roommate [R63] touched his -ss and hit him on the back and the [NAME] that is why he hit his roommate. Both residents are from the second-floor behavior unit. Conclusion: [R38 hit R63] on the face. As a result, [R63] sustained a cut on the left side area of the lower lip. Interventions: 1. Residents were separated right away. 2. Body assessment completed on both residents and no injuries noted on [R38]. [R63] was noted bleeding from the lip further assessment revealed a cut on the lower lip. Pressure applied till bleeding stopped. No swelling was noted at this time. 3. [R63] was transferred to another room right away. 4. [name of city] PD was called and police officer [name of officer] responded to the center and interviewed the staff and [R38]. 5. PCP, psych NP, Administrator, DON, SW, and families were notified of the event. 6. Seen and evaluated by psych NP, no new recommendations given. Interview on 05/25/23 at 11:48 AM, CNA 3, revealed that R38 is focused on money to buy sodas with. She remembers the incident, and residents were separated. Said that this incident (04/27/23) was the only incident that she calls involving R38. Said that R38 said that R63 hit him. Interview on 05/25/23 at 11:41 AM, LPN 3, revealed that this incident, there was a cut observed on R63's lip, residents were separated and R63's room changed. Said that this was over an argument in their room. Said that different interventions have been used for R38 such as medication changes, comfort room, and using sodas as a reward. Interview on 05/25/23 at 11:35 AM, SG 1, said that he was assisting another resident in their room, when he heard R63 screaming. When he went into the room of R63 and noticed that there was blood on the floor, and bed. Said that R63 was sitting on the bed of R38. Both residents were separated. R38 was standing next to the bathroom. Removed R63 from the room and R63 said that he was trying to use the bathroom, and R38 punched him. R38 said that he punched R63. Said that R38 is mostly independent but does focus on his money. Said that the comfort room has been used with R38; however, does get agitated with that. R38 is short tempered. Interview on 05/26/23 at 9:30 AM, R63 was confused and unable to answer questions. Review of undated facility policy titled Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revealed To ensure the proper management of conduct between residents and the staff of [name of facility] to facilitate the resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation. It is the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Responding to allegations of abuse, neglect, exploitation, or mistreatment the reports of all investigations to the Administrator or his or her designated representative and to other officials in accordance with state law, within five working days of the incident. The facility must have evidence that all alleged violations are thoroughly investigated. NJAC 8:39-4.1(a)5

Based on, staff interviews, record review, and policy review, the facility failed to ensure the right of one resident (Resident (R) 91) one resident to be free from physical restraints imposed for the purposes of convenience out of a total sample of 28 residents. Findings include: Review of R91's Face Sheet in the Profile tab, located in R91's electronic medical record (EMR), revealed R91 was admitted to the facility on [DATE]. Review of R91's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 05/15/23, revealed R91 had a Brief Interview for Mental Status(BIMS) score of 99, indicating severe cognitive impairment. A review of the facility reported incident (FRI), dated 05/10/23 and completed by the Administrator, revealed on 05/09/23 at 5:30 PM, the head of security (SG)2 observed the following: security Guard (SG) 4 assigned to R91 was in R91's room. R91 was in a wheelchair and the shirt R91 was wearing was draped over the back of the wheelchair. SG4 informed SG2 that R91 kept getting out of his wheelchair so SG4 placed R91's shirt over the wheelchair. The report further revealed SG2 was removed from R91's room and sent home and was suspended pending the completion of the investigation. During an interview on 05/25/23 at 1:07 PM, the Director of Nursing (DON) stated the SG2 was making rounds on 05/09/23 when he went into R91's room and observed SG4 in R91's room sitting. SG4 was assigned to watch R91 1:1 (staff was performing continuous observation of resident to prevent resident from self-harm). R91 was wearing a shirt that was tucked over the back of his wheelchair. SG4 stated he restrained R91 because R91 kept getting out of his wheelchair. The DON further stated SG4 had since been terminated. The DON admitted SG4 was using R91's shirt as a restraint. During an interview on 05/25/23 at 11:59 AM, SG2 stated he was doing his rounds on 05/09/23 at about 5:50 PM when he observed SG4 in R91's room. SG4 was on his phone and was sitting with his foot on another chair, and R91 was in his wheelchair, not moving, with the shirt he was wearing tucked over the back of the wheelchair. SG4 stated R91 kept trying to get out of his wheelchair and had to be restrained. SG2 stated he immediately removed SG4 from the situation, sent him home pending investigation. SG4 was later terminated. SG2 stated he and all his security staff had abuse prevention training. Observation of R91 on 05/23/23 at 12:46 PM revealed resident was confused, agitated, and moved constantly. R91 had a continuous 1:1 security monitor. Observation on 05/24/23 at 1:47 PM revealed R91 during activities with 1:1 monitor. Review of facility's policy titled Abuse Prevention Program revealed .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy further provided, .the facility will ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. NJAC 8:39-4.1(a)6

Based on record review, interview, review of Facility Reported Incidents (FRI), and policy review, the facility failed to ensure that a thorough investigation was documented regarding two resident-to-resident altercations involving one resident (Resident (R) 38), out of a sample of 28 residents. There was no evidence that the facility interviewed other current residents regarding the allegations. Findings include: 1. Review of the Reportable Event Record/Report (initial report) dated 03/21/23 revealed R38 overheard another resident [R28] curse (B---h) and thought it was meant for him. He got upset and punched the other resident [R28] in the face. The residents were separated by staff immediately. Staff noted redness on the cheek of resident [R28] during assessment and ice compress was applied to right cheek as first aid. [R38] refused body assessment. Administrator, Director of Nursing (DON), social worker (SW), primary care provider (PCP), Psych nurse, nurse practitioner (NP) and families were made aware of the incident. [name of city] police department (PD) and police officers (PO) [name of officers] came and interviewed the staff and the residents. Interventions: 1. Residents were separated right away. 2. Body assessment was done on [R28], and no injuries were noted. [R38] refused to be assessed. 3. Police department was called, and two police officers (PO) came and interviewed the staff. 4. Administrator, DON, SW, PCP, psych NP, and families were notified of the event. 5. [R28] was moved to another room, and 6. Psychological and psychiatric follow-up were ordered for both residents. Review of the Witness Interview Record for R28 dated 03/21/23 revealed [R38] hit me. I just want to go to [name of hospital]. Review of the Witness Interview Record for R38 dated 03/21/23 revealed [R28] called me a b---h, that is why I hit him. During further review of the FRI, there was no evidence of other residents being interviewed regarding the abuse allegation. 2. Review of the Reportable Event Record/Report, (initial report) dated 04/27/23, revealed Security staff heard somebody calling for help from room[number], when he went to the room, he found [R63] sitting on resident's bed bleeding from the left lip and resident standing near the bathroom door. Security staff called for help and staff responded right away. When [R63] was interviewed. He reported that resident [R38] hit him for no apparent reason but unable to tell why he was sitting on roommate's bed. [R38] reported that [R63] touched his -ss and hit him on the back and [NAME] that is why he hit his roommate. Both residents are from the second-floor behavior unit. Residents were separated right away. Body assessment was completed on both residents and no injuries noted on [R38]. [R63] was noted bleeding from the lip further assessment revealed a cut on the lower lip. Pressure applied till bleeding stopped. No swelling was noted at this time. [R63] was transferred to another room right away. [name of city] PD was called and police officer [name of officer] responded to the center and interviewed the staff and [R38]. PCP, psych NP, Administrator, DON, SW, and families were notified of the event. Seen and evaluated by psych NP, no new recommendations given. Review of the Witness Interview Record dated 04/27/23 for R38 revealed He touched my -ss then hit me on the back and [NAME]. Review of Witness Interview Record dated 04/27/23 for R63 revealed He hit me on the face, I did not do anything. Interview with the Director of Nursing (DON) on 05/25/23 at 12:38 PM, said that other residents would only be interviewed if they were witness to the event. Does not recall in either incident if other residents were interviewed; however, confirmed no evidence in the report that other residents were interviewed. Cross Reference: F600-Free from abuse Review of undated facility policy titled Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revealed To ensure the proper management of conduct between residents and the staff of [name of facility] to facilitate the resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation. It is the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Responding to allegations of abuse, neglect, exploitation, or mistreatment the reports of all investigations to the Administrator or his or her designated representative and to other officials in accordance with state law, within five working days of the incident. The facility must have evidence that all alleged violations are thoroughly investigated. NJAC 8:39-4.1(a)5

Based on observation, interview and record review, it was determined that the facility failed to provide appropriate assistance to avoid an accident to Resident #10, which resulted in a fractured hip and failed to provide appropriate assistance to avoid an accident for Resident # 7, 2 of 6 residents reviewed for falls. The deficient practice was evidenced by the following: 1. On 6/13/16 at 7:05 p.m. the surveyor toured the unit with a staff nurse who said that Resident #10 was alert and oriented, had a fall in the facility and sustained a fracture as a result of the fall. The resident was in the bed watching television and pleasant upon greeting. On 6/14/16 at 9:15 a.m. the surveyor interviewed the resident who was in the wheelchair in the resident's room. The surveyor asked the resident about the fall that occurred in the facility. The resident said that on Easter morning, 1 certified nursing assistant (CNA) was in the resident's room assisting the resident to the wheelchair from the bed. The resident said that the wheelchair was not locked and as the CNA helped the resident into the wheelchair, the wheelchair slid back and the resident fell to the floor and the CNA fell on top of the resident. This fall caused a fracture to Resident #10's left hip. The resident told the surveyor that there should have been 2 CNA's during the transfer but that morning there was only 1 CNA. According to the resident, the resident told the staff what had happened that day. At 11 a.m. the surveyor reviewed the resident's records. The resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Both the Annual Minimum Data Set (MDS) of 1/18/16 and the Quarterly MDS of 4/12/16 stated that Resident #10 had a BIMS of 14, indicating the resident was cognitively intact. According to the Risk Management System fall investigation dated 3/26/16 at 7:30 a.m., the circumstances of the event stated aide assisted patient to sit on the wheelchair, missed to sit lost balance then fell . The root cause/conclusion summary of the investigation stated loose lock on the wheelchair and an addendum stated April 7, 2016: Anti-roll back was ordered on the wheelchair of the resident and applied by the maintenance department. There was no resident statement on the fall investigation. The surveyor reviewed the Interdisciplinary Progress Notes (IDPN) dated 3/26/16 at 7:30 a.m., which stated as per CNA resident fell . CNA was transferring resident into w/c when pt slid and was eased on the floor. The IDPN from 3/26/16 at 8 a.m. stated No c/o pain. There was no resident statement regarding the fall. The IDPN dated 3/27/16 at 7 a.m. stated routine pain management and X-ray ordered for left hip pain. At 9 p.m. the IDPN stated received X-ray result to left hip (fracture). The resident was then transferred to the emergency room . The Witness Interview Record dated 3/26/16 at 8 a.m. indicated that the CNA was transferring the resident and the record stated Who else was present? Just the CNA and What did you do? The resident slid on the floor during transfer immediately called the nurse. On 6/15/16 at 8:45 a.m., the surveyor reviewed the resident's Annual Minimum Data Set ((MDS) dated [DATE]. Under section G- Activities of Daily Living (ADL) Assistance, the facility assessed the resident as needing extensive assistance and two persons physical assist with transfer in and out of bed. The surveyor reviewed the resident's care plan which was updated after the fall dated 4/1/2016 which indicated Pt with decreased functional mobility due to recent fracture to the pelvis. Pt needs max assist x 2 with transfers. At 8:45 a.m., the Director of Nursing (DON) provided the surveyor with the resident's Radiology Report dated 3/27/16 which stated There is a subcapital fracture with no significant displacement. Left hip fracture as described above. The DON also provided the surveyor with the CNA's Individual Performance Improvement Plan which indicated that on 3/26/16 the CNA transferred pt by self who required 2 person assist and it also indicated Above mentioned employee transferred a resident by herself- resulted to resident fall incident with + fx of pubic ramis. Resident required 2 person assist. On 6/16/15 at 9:15 a.m., the surveyor interviewed the CNA via telephone and asked the CNA to explain what happened on 3/26/16 while transferring this resident. The CNA said she went into the room to get the resident from the bed to the wheelchair in the morning and was alone during this transfer. The CNA said that she locked the resident's wheelchair and lifted the resident by herself when the wheelchair moved backward and both the resident and the CNA fell to the floor. The CNA said she does not recall falling onto the resident during this transfer. The CNA said once they fell , she discovered that the locks were not working and reported the fall and failed locks to the nurse. The CNA said that she did not test the wheelchair locks prior to transferring the resident and the CNA said she should have had 2 people in the room during this resident's transfer. At 9:35 a.m., the surveyor interviewed the Maintenance Supervisor (MS) regarding the facility's procedure for checking resident equipment. The MS said the wheelchairs were checked every day when there were complaints, and once a month, all the facility's wheelchairs were checked. The MS provided the surveyor with a record that indicated the last time this resident's wheelchair was serviced was on 12/4/2014 when the breaks were fixed. The next documented service on this resident's wheelchair was on 3/27/16 which stated inspection on w/c nothing wrong. Refer to F226. 2. On 6/13/16 at 6:38 p.m. the Nurse Supervisor (NS) toured with the surveyor. The NS informed the surveyor that Resident #7 was only oriented to self (responds to name only), not place or time (alert, disoriented). The surveyor was informed that Resident #7 had a seat belt that the resident could not open, a physical restraint) when sitting in a wheel chair, to assist in preventing falls. On 6/14/16 at 9:30 a.m. the surveyor reviewed the resident's records. The resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the Minimum Data Set (MDS) assessment tool dated 4/12/16 which noted in the Activities of Daily Living (ADL) Assistance that the resident was Total Dependence and should be transferred with Two+persons physical assist. On 6/17/16 at 10:35 a.m. the surveyor reviewed an incident report from 7/27/15 for Resident #7. The Incident Description documented under Nursing Description: Resident was eased slowly and sat on the floor by certified nursing assistant (CNA). No fall was indicated. Further review of the Incident Description documented, Resident Description: Resident is confused and unable to describe what happened. The Employee Statement included in the incident report dated 7/27/15 and signed by the CNA who was assigned to Resident #7 during the incident documented, I was transferring the resident and could not handle resident by myself so I eased resident slowly to the floor then went to ask for help. NJAC 8:39-27.1(a)