Every finding on record at Complete Care at Shrewsbury LLC

Based on observation, interview, record review, and policy review, the facility failed to ensure one resident of three (Resident (R)53) of 33 sampled residents were treated with dignity in toileting. This failure had the potential to negatively impact the quality of life and self-esteem for the affected resident.Findings include: Review of R53's admission Record located in the resident's EMR section titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms. Review of R53's annual MDS with an ARD of 05/10/25 located in the resident's EMR tab titled MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out 15 points which indicated the resident's cognition was intact and able to make his own decisions. The resident was assessed to have an indwelling catheter and was always incontinent of bowel. The resident required substantial assistance with toileting. Review of R53's Care Plan with a revision date of 06/11/15 located in the resident's EMR tab titled Care Plans revealed the resident required one person assistance with toileting and transfers. Observation on 09/22/25 at 11:30 AM revealed R53 was in his wheelchair trying to get into his room to use the bathroom. Certified Nursing Assistant (CNA)1 told the resident that he could not use the bathroom in his room since housekeeping was cleaning his bathroom. CNA1 also stated the resident would have to wait until she finished taking another resident to the shower. The CNA further told the resident that she would put him to bed and clean him up afterwards. During an interview on 09/22/25 at 1:55 PM, R53 revealed he had just returned from an appointment and needed to use the bathroom. R53 stated that he was upset by the CNA response to his need for the bathroom. The resident stated this was not a dignified response and felt humiliated by the CNA's statement that he could use the bathroom in his briefs. R53 stated that he had been trying to toilet himself in a timely manner to avoid having any bowel movement accidents. During an interview on 09/22/25 at 2:30 PM, CNA1revealed that she was getting another resident ready for a shower when R53 was attempting to get to the bathroom in his room. The CNA stated that she did not have time to stop what she was doing to assist R53. CNA1 stated the resident is usually incontinent of bowel and she thought he already had an incontinent episode. CNA1 stated that she did not realize that she had humiliated the resident by her statements. During an interview on 09/25/25 at 3:30 PM, Licensed Practical Nurse (LPN)3 revealed that CNA1 was a good worker but at times she could be a bit brisk with the residents without realizing it. The observation and resident interview was explained to LPN3; LPN3 stated that CNA1's response to the resident's request for assistance was a violation of his dignity. Review of the facility policy titled Promoting/Maintaining Resident Dignity with a revision date of 03/10/25 directs the staff .All staff members are involved in providing care to residents to promote and maintain resident's dignity and respect residents' rights.Respond to resident's for assistance in a timely manner. NJAC 8:39-4.1(a)

Based on observations, interviews, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for five residents (Residents (R)44, R9, R133, R6, and R80 in a total sample of 33 residents. This failure placed residents at risk of unmet care needs.Findings include: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R44 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure with hypoxia (an inadequate oxygen supply to the body). Review of an 06/16/25 Nursing Progress Note located in the Progress Notes tab of the EMR revealed, .Patient received via stretcher from [hospital name withheld] at approximately 11:35 PM. Patient is alert and awake. Noted with moments of forgetfulness. Respirations easy and unlabored on oxygen at 2L [liters] via nasal cannula. Review of a modified quarterly MDS located in the MDS tab of the EMR with an ARD of 08/12/25 revealed R44 was not coded for the use of oxygen. Review of an 08/17/25 Order Summary located in the Orders tab of the EMR after R44 returned from a hospital stay revealed, 'Oxygen at 2L/min via Nasal Cannula, continuously. Review of the 5-day PPS [prospective payment system-a required assessment for Medicare A residents] located in the MDS tab of the EMR with an ARD of 08/24/25. revealed that R44 was not coded for oxygen use. During an observation on 09/22/25 at 11:55 AM, R44 was observed wearing oxygen and was not able to respond to questions due to significant shortness of breath. During an interview on 09/25/25 at 11:23 AM, the MDS Coordinator (MDSC) stated, I did not code her oxygen, and I need to make a correction. 2. Review of the admission Record located in the Profile tab of the EMR revealed R9 was admitted to the facility on [DATE] with diagnoses that included a stroke and diabetes. Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 07/11/25 revealed R9 had a BIMS score of nine out of 15 which indicated R9 was moderately impaired in cognition and had received radiation therapy during the observation period. Review of the EMR including the Assessments tab and Nursing and Provider Progress Notes did not show documentation as to why R9 had received radiation therapy. During an interview on 09/25/25 at 11:27 AM, the MDSC stated, That was coded inaccurately. 3. Review of the admission Record located in the Profile tab of the EMR revealed R133 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of the admission MDS located in the MDS tab of the EMR with an ARD of 01/29/25 revealed R133 had a BIMS score of five out of 15 which indicated R133 was severely impaired in cognition. Review of the discharge return anticipated MDS located in the MDS tab of the EMR with an ARD of 02/17/25 revealed R133 had a weight of 166 pounds and had not sustained weight loss. Review of the weights located in the Weights/Vitals tab of the EMR revealed indicated that on 02/03/25 weight was listed as 177.3 pounds. During an interview on 09/24/25 at 10:37 AM, Registered Dietician (RD)2 was asked if she was responsible for coding the MDS for nutrition. RD 2 stated, Yes. RD2 further stated, She was refusing weights, and the assessment should have reflected the 166 pounds and the weight loss. I am not sure that 177.3 pounds was an accurate weight. 4. Review of R6's admission Record located in the EMR tab titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease. Review of R6's Physicians Orders dated 05/01/25 and located in the EMR tab titled Orders revealed an order for Affinity Hospice to evaluate and treat. Review of R6's Affinity Care Facility Notification of Admission dated 05/05/25 located in the EMR tab titled Miscellaneous revealed the resident was accepted into the hospice program on 05/05/25.Review of R6's quarterly MDS with an ARD 08/20/25 located in the EMR tab titled MDS documented the resident as not receiving hospice services. During an interview on 09/25/25 at 11:13 AM, the MDS Coordinator (MDSC) and the two corporate MDS (CMDS)1 and CMDS2 verified that the quarterly MDS for R6 inaccurately documented that she was not receiving hospice services. 5. Review of R80's admission Record located in the EMR tab titled Profile revealed the resident was admitted to the facility 05/28/25 with diagnoses that included age related osteoporosis with a pathological fracture. Review of R80's admission Fall dated 06/30/25 located in the EMR tab titled Assessments documented that the resident sustained a fall on 06/30/25. The resident was assessed to have a fall risk score of 19 indicating the resident was a high fall risk. Review of R80's quarterly MDS with an ARD 09/04/25 located in the resident's EMR tab titled MDS revealed the resident was assessed as not having any fall since admission to the facility. During an interview on 09/25/25 at 11:13 AM, the MDS Coordinator (MDSC) and the two Corporate MDS coordinators (CMDS)1 and CMDS2 confirmed the quarterly MDS was inaccurate as it did not capture the resident's fall in June. Review of the October 2024 RAI, manual, page 1-5 revealed, .An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations.It is important to note here that information obtained should cover the same observation period as specified by the MDS (minimum data set) items on the assessment, and should be validated for accuracy (what the resident's actual status was during the observation period) by the IDT (interdisciplinary team) completing the assessment. NJAC 8:39-33.2(d)

Based on observations, record review, interviews, and review of facility policy, the facility failed to ensure care plans were developed and/or implemented for five residents (Residents (R) R1, R7, R14, R36, and R104) from a total sample of 33 residents. This failure had the potential that residents would not receive all necessary care and services.Findings include: 1. Review of R1's admission Record located in the electronic medical record (EMR) tab titled Profile revealed the resident was admitted to the facility initially on 03/28/21 and readmitted [DATE] with diagnoses that included Asperger's syndrome (developmental disorder to effectively socialize and communicate. Review of R1's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/11/25 located in the EMR tab titled MDS revealed for Active Diagnosis listed the resident with Asperger's syndrome. Review of R1's Care Plan with a revision date of 09/15/25 located in the EMR tab titled Care Plans revealed the care plan did not address the resident's diagnosis of Asperger's syndrome and the signs and symptoms of this syndrome. During an interview on 09/25/25 at 4:06 PM, Licensed Practical Nurse (LPN)3 stated she was aware of R1's diagnosis of Asperger's syndrome and felt it should have been included in the resident's care plan to make the other care givers aware of the resident's symptoms. 2. Review of R7's admission Record located in the EMR tab titled Profile' revealed the resident was admitted to the facility 07/03/24 with diagnosis that included conversion disorder with seizures or convulsions, a functional neurological symptom disorder, is a psychiatric condition in which psychological stress manifests itself as physical symptoms. Review R7's Care Plan with a revision date 07/15/25 located in the EMR tab titled Care Plans revealed the care plan did not reflect the resident's diagnosis of conversion disorder and what signs and symptoms to observe. During an interview on 09/25/25 at 4:06 PM, LPN3 revealed that she was aware of the R7's diagnosis of conversion disorder related to seizures. LPN3 stated that while talking to the resident she would suddenly blink and say that she's had a seizure. LPN3 stated the resident's diagnosis of conversion disorder should be included in the care plan so the staff would know what to expect and how to react. Interview with the Director of Nursing on 09/24/25 at 11:20 AM revealed the R1 had the diagnosis of Asperger's syndrome and R7's diagnosis of conversion disorder prior to admission to the facility however felt that there was not a need to develop a care plan unless the residents exhibited those signs and symptoms while admitted to the facility. 3. Review of R14's admission Record located in the EMR tab titled Profile revealed the resident was admitted to the facility 04/28/25 with diagnoses that included chronic kidney failure with dependance on renal dialysis. Review of R14's admission MDS with an ARD of 05/05/25 located in the EMR tab titled MDS revealed the resident was assessed to receive dialysis. Review of R14's Physicians Orders dated 06/04/24 located in the EMR tab titled Orders revealed the resident was to receive dialysis on Tuesday, Thursday, and Saturday. Monitor dialysis site left internal jugular permacath for signs / symptoms of infection and/or bleeding. Assess site for any changes in skin condition. Report any noted redness, edema or increased skin temperature to MD. External hemodialysis permacath do not change end caps or dressing. Review of R14's Care Plan with a revision date of 09/23/25 located in the EMR tab titled Care Plans revealed the resident's dialysis care interventions failed to include orders not to change the end caps on the external permacath. During an interview on 09/25/25 at 4:06 PM, LPN3 revealed the physician's orders not to change the end caps on the resident's permacath should have been included on the care plan. 4.Review of the admission Record located in the Profile tab of the EMR revealed R36 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a condition where the brain does not function properly) and a stroke. Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 08/26/25 revealed R36 had a BIMS score of three out of 15 which indicated R36 was severely impaired in cognition and had one non-injury fall during the observation period. Review of an 09/11/25 Fall Investigation Report provided by the DON revealed, .Writer was alerted that resident was on the floor. Resident lying supine [on his back] position on the floor with his head facing the headboard of the bed.Resident stated, I got up to get my food and fell. The intervention for preventions to place mats next to the bed. Review of the revised 09/11/25 Fall Care Plan revealed, R36 had an actual fall with no injury. The 09/11/25 interventions included, Floor mats placed at both sides of the bed. During an observation on 09/23/25 at 3:00 PM, there was a floor mat located on the door side of the bed and there was no fall mat on the wall side of the bed. During an interview on 09/23/25 at 3:04 PM, LPN 6 confirmed that there was only one fall mat next to his bed. During an interview on 09/23/25 at 3:09 PM, LPN/Unit Manager 2 confirmed that there was only one fall mat next to his bed and there should have been two per the Care Plan. 5. Review of the admission Record located in the Profile tab of the EMR revealed R104 was admitted to the facility on [DATE] with a diagnosis of transient cerebral ischemic attacks (TIAs-a temporary disruption of blood flow to the brain) and progressive bulbar palsy (a condition that attacks the nerves). Review of the admission MDS located in the MD tab of the EMR with an ARD of 07/25/25 revealed R104 had a BIMS score of 10 out of 15 which indicated R104 was moderately impaired in cognition and received an anticoagulant (blood thinner) during the observation period. Review of the 08/15/25 Order Summary located in the Orders tab of the EMR revealed, Warfarin [a blood-thinning medication] 6 MG [milligrams]. Give one tablet by mouth in the evening every Monday, Wednesday, Friday, and Sunday for DVT [deep vein thrombosis-a blood clot] prophylaxis May increase risk of bleeding. In addition, Warfarin 6 mgs. Give one tablet by mouth in the evening every Tuesday, Thursday, and Saturday for DVT prophylaxis. Monitor for bleeding, tarry stools. Give with 2.5 mg to 8.5mg in total. Review of the Comprehensive Care Plan did not show a focus/goal or interventions for the use of the Warfarin. During an interview on 09/25/25 at 1:23 PM, LPN/UM 3 was asked who was responsible for developing the care plans. The LPN/UM 3 stated, We do the baseline care plan and then add to it to make the Comprehensive Care Plan. LPN/UM 3 was asked why there was no Care Plan for the use of Warfarin since it was a significant medication. UM verified there was no care plan for Warfarin usage. Review of the facility's policy titled Comprehensive Care Plans with a revision date of 03/01/25 directs the staff as follows: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.The comprehensive care plan will describe at a minimum the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well. NJAC 8:39-11.2(e)thru (i)NJAC 8:39-27.1(a)

Based on record review, interview, and policy review, the facility failed to ensure four of five residents (Resident (R)12, R82, R89, and R129) reviewed for immunizations out of a total sample of 33 residents had been offered and/or provided a pneumococcal immunization This failure increased the risk of residents contracting pneumonia.Findings include: 1. Review of R12's electronic medical record (EMR), located under the Census tab revealed R12 was admitted to the facility on [DATE] with diagnoses found under the Medical Diagnosis tab included encounter for surgical aftercare following surgery of the digestive system, colostomy, and an incisional site infection. Review of R12's paper medical record revealed no documentation that the resident had been offered a pneumococcal immunization. 2. Review of R82's EMR , located under the Census tab of the EMR, revealed R82 was admitted to the facility on [DATE] with diagnoses found under the Medical Diagnosis tab included acute cystitis without hematuria, unspecified injury to the head, muscle weakness, dysphagia, and severe protein calorie malnutrition. Review of R82's paper medical record revealed authorization for the pneumococcal immunization had been signed by his representative on 09/05/25. 3. Review of R89's EMR located under the Census tab of the EMR, revealed R89 was admitted to the facility on [DATE] with diagnoses found under the Medical Diagnosis tab included encounter for aftercare from surgery on the circulatory system. Review of R89's paper medical record revealed she had signed the consent form on 08/23/25 for a pneumococcal immunization but did not indicate whether she had wanted the immunization or not. 4. Review of R129's EMR, located under the Census tab of the EMR, revealed R129 was admitted to the facility on [DATE] with diagnoses found under the Medical Diagnosis tab included enterocolitis, acute kidney failure, and chronic obstructive pulmonary disease. Review of R129's medical record revealed no documented evidence that pneumococcal immunization had been offered. During an interview on 09/23/25 at 2:00 PM, Licensed Practical Nurse (LPN) 2, who was the unit manager for the second floor, stated when a new resident was admitted , the admitting nurse was responsible for providing education to the resident and/or representative on the pneumococcal immunizations. LPN2 stated the nurse would also have the forms signed with the choice made. LPN2 confirmed the immunization forms for the above residents had not been signed and/or no choice had been made. During an interview on 09/23/25 at 3:30 PM, the Director of Nursing (DON) stated the admitting nurse was responsible for offering the pneumococcal vaccine and for completing the consent form. The DON stated the Infection Preventionist(IP) followed up with an audit of the records to ensure the forms had been signed and the residents had chosen whether or not to receive the vaccination. During an interview on 09/24/25 at 1:16 PM, the IP stated her role was to ensure the immunization forms had been filled out completely. The IP confirmed the staff were not ensuring the resident and/or their representatives had been offered the vaccines. Review of the facility's policy titled, Infection Prevention and Control Program, dated 09/01/24, revealed, . Residents will be offered the pneumococcal vaccines recommended by the Centers for Disease Prevention and Control (CDC) upon admission, unless contraindicated or received the vaccines elsewhere . NJAC 8:39-19.4

Based on record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual the facility failed to ensure that a Significant Change Minimum Data Set (MDS) was completed for one resident (Resident (R)6) from a total sample of 33 residents. This failure had the potential for residents not to receive appropriate care in timely manner.Finding include: Review of R6's admission Record located in the electronic medical record (EMR) tab titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease, bipolar disorder, moderate protein calorie malnutrition, and heart failure.Review of R6's Physicians' Orders dated 05/01/25 located in the resident's EMR tab titled Orders revealed Affinity Hospice was to evaluate and treat.Review of R6's Affinity Care Facility Notification of Admission dated 05/05/25 located in the resident's EMR tab titled Miscellaneous revealed the resident was accepted into the hospice program on 05/05/25.Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/20/25 located in the resident's EMR tab titled MDS revealed the resident was assessed as receiving hospice services.Review of R6's quarterly MDS with an ARD of 08/20/25 located in the resident's EMR tab titled MDS revealed the resident was not receiving hospice services.Additional review of R6's MDS section failed to reveal a Significant Change MDS for the resident being placed on hospice services.During an interview on 09/25/25 at 3:00 PM with the Corporate MDS 1 and the MDS Coordinator (MDSC) confirmed a Significant Change MDS should have been completed in the allotted time after the resident was started on hospice services.Review of the RAI Manual revealed a significant change in a resident's status triggers the need for a Significant Change in Status Assessment (SCSA). This assessment, part of the Minimum Data Set (MDS) 3.0, must be completed within 14 calendar days following the determination that a significant change has occurred. A significant change in the context of MDS assessments refers to a major decline or improvement in a resident's condition that impacts multiple areas of health and requires intervention.Definition of Significant Change: According to the Centers for Medicare & Medicaid Services (CMS), a significant change is defined as a major decline or improvement in a resident's physical or mental condition that meets the following criteria.1.Non-Self-Limiting: The change will not typically resolve itself without further intervention by staff or through standard clinical interventions. 2.Impact on Multiple Areas: The change affects more than one area of the resident's health status.3. Interdisciplinary Review Required: The change necessitates a review or revision of the resident's care plan by an interdisciplinary team (IDT). NJAC 8:39-11.2(i)

Based on observations, record review, interviews, and policy review, the facility failed to revise care plans for two residents (Residents (R) 137 and R9) from a total sample of 33 residents. This failure had the potential for residents to have unmet care needs. Findings include: 1.Review of R137's admission Record located in the electronic medical record (EMR) tab titled Profile revealed the resident was admitted initially to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included end stage renal disease with dialysis dependency. Review of R137's Physicians Orders dated 12/17/24 and located in the EMR tab titled Orders revealed the resident was to receive dialysis Tuesday, Thursday, and Saturday. The order included for nursing to Monitor Bruit and Thrill to Left arm fistula every shift. Monitor Hemodialysis site for signs/symptoms of complications (e.g., bleeding, swelling, pain, drainage, odor, hardness, or redness at site). Notify the physician and dialysis center immediately with any urgent problems every shift. No Blood Pressure on Left arm secondary to fistula every shift. Review of R137's Five Day Medicare Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/24 located in the EMR tab titled MDS revealed the resident was coded for dialysis. Review of R137's Nursing Notes dated 01/02/25 located in the EMR tab titled Progress Notes revealed the resident was sent to the emergency room for excessive bleeding from the dialysis fistula caused by the resident picking at the site. Review of R137's Nursing Notes written by the MDS Coordinator located in the EMR tab titled Progress Notes revealed the resident had returned to the facility after hospitalization for a rupture of the fistula caused by the resident's picking at the fistula. The MDS Coordinator documented plans to revise the resident's care plan to monitor the resident for picking at the fistula. Review of R137's Care Plan with a revision date of 01/05/25 located in the EMR tab tilted Care Plans revealed the care plan interventions had not been revised to reflect the resident's behavior of picking the fistula graft site. Interview on 09/24/25 at 1:45PM with LPN3 revealed the nurses can revise the resident's care plan at the time of an incident or change in the condition and thought it had been revised during the care plan meeting Interview on 09/25/25 at 11:15AM with the Director of Nursing revealed the resident's care plans are developed during the resident's care plan meeting with the interdisciplinary team. The floor nurses can revise a resident's at the time of the resident's change in condition. 2. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R9 was admitted to the facility on [DATE] with diagnoses that included a stroke and an acute kidney injury. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 07/11/25 revealed R9 had a Brief Interview of Mental Status (BIMS) score of nine out of 15 which indicated that R9 was moderately impaired in cognition, weighed 129 pounds and had sustained weight loss. Review of the 04/04/25 Nutrition Care Plan located in the Care Plan tab of the EMR revealed, R9 is at risk for malnutrition R/T [related to] ascites [abdominal swelling] which may mask weight loss-need for ONS [oral nutritional supplement]-below UBW [usual body weight]-varied intake R9 has allergy to mushrooms and is on a diuretic, weight may change due to fluid/edema. Significant weight loss unplanned. Revised on 09/23/25. Interventions included:1. Provide diet as ordered liberalized, regular, thin. Dated 04/04/25.2. Provide supplements as ordered Glucerna 1.5. Dated 04/04/25 Revised on 09/23/25. Review of an 09/08/25 Nutrition Note located in the Progress Notes tab of the EMR revealed, .Nutrition follow-up. Current body weight is 114.6 pounds. She had a significant 10 pounds/7% weight loss x one month, unplanned, likely secondary to decreased appetite/intake.She will be evaluated by speech therapy. Recommend health shake 4oz daily, and super mashed potatoes 4 oz daily to help meet needs. Recommend changing Glucerna 1.5 8oz order from PM to AM to ensure she is drinking it. During an interview on 09/24/25 at 10:30 AM, Registered Dietician (RD) 1 was asked if she was responsible for updating and revising the Nutrition Care Plan. RD1 stated, Yes. RD1 was asked about the update to R9's diet per her 09/08/25 to R9's diet and should the Care Plan be updated to reflect her current nutritional requirements. RD1 stated, Yes, I should have changed that. Review of the facility policy titled Care Plan Revisions Upon Status Change with a revision date of 03/01/25 directs staff .The comprehensive care plan will be reviewed, and revised as necessary when a resident experience a status change.The care plan will be updated with new or modified interventions. NJAC 8:39-11.2(e)

Based on interviews and record review, the facility failed to ensure nursing assessments of a surgical incision were provided for one resident (Resident (R)132) in a total sample of 33. This failure placed residents at risk of health complications and hospitalization.Findings include: Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R132 was admitted to the facility on [DATE] with a diagnosis of a right hip fracture with surgical repair. Review of the 09/16/25 admission Comprehensive Nursing Assessment located in the Assessments tab of the EMR revealed under the Skin Assessment section revealed that R132 had a surgical wound. There was no further documentation to show an assessment of the surgical site. Review of the 09/16/25 admission Nursing Progress Note located in the Assessments tab of the EMR revealed, .XXX[AGE] year-old male patient arrived at facility via wheelchair accompanied by one transport from [hospital name withheld] with primary diagnosis of closed right hip fracture.Right hip surgical incision with dressing intact. There was no further documentation of an assessment of the surgical site. Review of the September 2025 Treatment Administration Record (TAR) and the Medication Administration Record (MAR) revealed no documentation of a daily assessment or monitoring of the right hip surgical wound. Review of the 09/18/25 Care Plan located in the Care Plan tab of the EMR revealed, R132 has an actual impairment to skin integrity of his right hip r/t surgical wound. Interventions included:1. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short.2. Educate resident/family/caregivers of causative factors and measures to prevent skin injury.3. Encourage good nutrition and hydration in order to promote healthier skin. Review of an 09/22/25 Provider Note located in the Progress Notes tab of the EMR revealed, Resident seen and examined at nursing request for fever of 102.7. Heart rate 110, respirations 30, blood pressure 101/62. Oxygen sat was 87% placed on oxygen at two liter per nasal cannula came up to 96%. The resident laying [sic] in bed eyes are [sic] open but did not answer any questions, has dementia. The right hip surgical site with staples swollen with warmth noted s/p [status post] right femur fracture surgery repair. Told Licensed Practical Nurse/Unit Manager (LPN/UM) 2 and Director of Nursing (DON) to send the resident to the hospital for possible sepsis [a life-threatening condition that occurs when the body's immune system overreacts to an infection]. Review of a 09/22/25 Sepsis Protocol was completed and documented in the EMR under the Assessments tab. The protocol states, All subacute patients will be screened for the possibility of sepsis at least daily and as needed. There were no other Sepsis Protocols completed prior to 09/22/25. During an interview on 09/24/25 at 11:32 AM, the Director of Nursing (DON) was asked when a resident entered the facility having had surgical repair of the hip with an obvious incision, what is the expectation to assess and monitor that incision site for signs/symptoms of infection. The DON stated, First, there should be an order to monitor the surgical site for signs/symptoms of infection. The DON stated, The staff should be utilizing the Sepsis Protocol. The DON was asked when staff were to implement the Sepsis Protocol. The DON stated, Generally, it should be done on admission for a baseline assessment. In addition, there needs to be a progress note or documentation on the Comprehensive Nursing Assessment. The DON confirmed that assessing and monitoring of the surgical site should have begun for R132 at the time of admission. Review of the 09/22/25 Hospital emergency room Report provided by the Administrator revealed that R132 was admitted with sepsis related to a urinary tract infection and pneumonia. NJAC 8:39-27.1

Based on observations, record review, interviews, and policy review, the facility failed to monitor the effectiveness of wander guards and modify interventions for two of 33 sampled residents (Resident (R)16 and R69). This failure had the potential to interfere with the residents' right to self-determination and their right to make choices about significant aspects of their life in the facility. Findings include: 1. Review of R16's Resident Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed an admission date of 10/21/23 with diagnoses of Parkinson's disease. Review of R16's quarterly Minimum Data Set (MDS), located in the EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 08/01/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R16 was moderately cognitively impaired. This same MDS indicated there were no changes in R16's mental status and there were no wandering behaviors. The MDS indicated a wander guard was in use daily. Review of R16's Care Plan, dated 01/27/25, located in the EMR under the RAI tab, revealed R16 was an elopement risk with a history of attempts to leave the facility. A wander guard was placed on 12/03/24. A review of R16's progress notes located in the EMR under the Progress Notes tab dated 12/02/24 indicated R16 was found by the front door of the facility attempting to stand up from his wheelchair and stating he had a car waiting for him. The Director of Nursing (DON) was notified, and she placed a wander guard on his left ankle. There were no other attempts of elopement documented in R16's EMR. A review of R16's elopement assessments located under the Assessment tab of the EMR revealed an elopement assessment dated [DATE] indicating R16 was a high risk for elopement related to wandering in the past month. A review of R16's behavior tracking dated 09/01/25 to 09/25/25 revealed no documented behaviors of wandering. During an interview on 09/22/25 at 3:29 PM, R16 stated he had the wander guard on to keep him inside because he was not supposed to go out. R16 stated he did not try to go outside because he was not supposed to. A review of R16's EMR revealed no discussion of his wander guard and whether it was effective or if other interventions should be attempted during the care plan meetings on 02/06/25 and 05/02/25. 2. Review of R69's Resident Face Sheet, located in the EMR under the Resident tab, revealed an admission date of 08/15/22 with diagnoses of bi-polar disorder, anxiety disorder, and major depressive disorder. During the initial tour of the facility on 09/22/25, R69 was observed with a wanderguard in place. R69 declined to talk with the surveyor during the investigation. Review of R69's annual MDS, located in the EMR under the RAI tab with an ARD of 06/26/25, revealed the resident had a BIMS score of 13 out of 15, indicating R69 was cognitively intact. This same MDS indicated there were no changes in R69's mental status and there were no wandering behaviors. The MDS indicated a wander guard was not in use. Review of R69's Care Plan, dated 12/25/25, located in the EMR under the RAI tab, revealed R69 was an elopement risk and had attempted to leave out the front door. A wander guard was placed on 03/04/25. A review of R69's progress notes located in the EMR under the Progress Notes tab dated 03/03/25 indicated R69 had a wander guard to the left ankle. There was no documentation as to why the wander guard was placed. Continued review of the EMR revealed a progress note dated 07/22/25 noting R69 with several attempts to get on the elevator. The progress note indicated that R69 became upset and stated she felt trapped and locked on the unit and was treated like an animal. A review of R69's' elopement assessments located under the Assessment tab of the EMR revealed an elopement assessment dated [DATE] indicating R69 was a high risk for elopement with no reported incidents of wandering in the last month. There was no other elopement assessment for R69 located in the EMR indicating why the wander guard was placed. A review of R69's EMR revealed there was no behavior monitoring or intervention report implemented for the behavior of wandering or elopement. A review of R69's EMR revealed no discussion of his wonder guard and whether it was effective or if other interventions should be attempted during the care plan meetings on 06/04/25. During an interview on 09/25/25 at 10:45 AM the DON stated that she will be notified of any attempt to elope and will place the wander guard. The DON stated that assessments are completed for the wander guard and wandering risk but were not completed prior to or when these wander guards were placed. The DON stated wander guards were discussed during the care plan meeting and if the behavior increased or decreased the risk should be re-evaluated to see if the wanderguard was effective. A review of the facility policy titled Elopement and Wandering Residents dated 03/05/25 indicated that all residents will be assessed for elopement upon admission and throughout their stay. Additionally, the facility is responsible to establish a systematic approach to monitoring and managing residents at risk for wandering an assessment of the risks, evaluation of the risks, implementing interventions to reduce the risks and monitoring for the effectiveness of the interventions and modifying the interventions when necessary. NJAC 8:39-5.1(a)NJAC 8:39-27.1(a)

Based on interview, record review, and review of the Social Service Director job description, the facility failed to ensure the Comprehensive Social Services Assessment was completed upon admission for one resident (Resident (R)66) in a total sample of 33 residents. This failure placed residents at risk of unmet psychosocial needs.Findings include: Review of an undated Social Services Director job description revealed, .The Social Services Director (SSD) is responsible for overseeing the development, implementation, supervision and ongoing evaluation of the Social Services.The Social Services Director will complete and/or delegate the completion of the social services component of the comprehensive assessment. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R66 was admitted to the facility on [DATE] with diagnoses that included a recent stroke with left-sided paralysis, major depressive disorder, and adjustment disorder with depression. Review of the Comprehensive Social Services Assessment located in the Assessments tab of the EMR, dated 08/14/25, was documented as incomplete. There was no documentation on the assessment to show the SSD had completed the Comprehensive Assessment. Review of the 08/19/25 Psychiatric Visit Note located in the Progress Notes tab of the EMR revealed, Resident presents as calm and cooperative. He notes a past history of anxiety and severe depression including two past attempts to end his life. He reports having a difficult time coping with having to rely on others after his stroke. He reports sleeping well. The resident denies experiencing any suicidal or homicidal ideation, auditory or visual hallucinations, or side effects from his psychotropic medications. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/20/25 revealed R66 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated R66 was cognitively intact, had no behaviors and was administered an antipsychotic and an antidepressant medication during the observation period. During an interview on 09/22/25 at 9:32 AM, R66 was asked about his psychosocial well-being and if the facility met his needs. R66 stated, I was raped when I was in the army, and I have PTSD [post-traumatic stress disorder]. I can't take showers. R66 was asked if he is seeing a psychiatrist or psychologist helping him deal with his PTSD. R66 stated that he used to see a VA [Veterans Association] psychiatrist. During an interview on 09/24/25 at 8:52 AM, the SSD was asked about her incomplete Comprehensive Assessment and when this assessment should be completed. The SSD stated, 'It should have been done after admission. The SSD confirmed that it was not completed. The SSD was asked if she was aware that R66 had voiced that he had PTSD. The SSD stated, No, I wasn't aware of it. The SSD was asked if she performs, upon admission, a Trauma Informed Care assessment to determine any past trauma. The SSD stated, No, I don't do those unless the resident brings it up. NJAC 8:39-27.1(a)

Based on observation, record review, interview, and policy review, the facility failed to ensure staff wore the proper Personal Protection Equipment (PPE) when caring for two of two residents (Resident (R)6 and R14) identified as requiring Enhanced Barrier Precautions (EBP) out of a total sample of 33 residents. This failure increased the risk of cross-contamination of microorganisms to other residents. Findings include: 1. Review of R6's admission Record located in the EMR tab titled Profile' revealed the resident was admitted to the facility on [DATE] with diagnoses that include moderate protein calorie malnutrition. Review of R6's Weekly Skin Review dated 08/27/25 located in the EMR tab titled Assessment revealed the resident had developed a pressure ulcer to the left buttocks. Review of R6's Physician Orders' dated 09/07/25 located in the EMR tab titled Orders revealed the resident was on Enhanced Barrier Precautions (EBP) related to wounds. Observation on 09/24/25 at 8:20 AM revealed Certified Nursing Assistant (CNA)4 entering R6's room carrying linen supplies without donning a gown and gloves. There was EBP signage posted on the resident's door and a cart that contained face masks, gloves, and gowns. CNA4 reentered the resident's room again without donning gown and gloves. Upon entering the room CNA4 was observed preparing to give R6 a bed bath.During an interview on 09/24/25 at 8:42 AM, CNA4 revealed that she was an agency CNA and had worked with the resident for the past month and was not aware the resident was on EBP and that she should wear personal protective equipment (PPE) when providing resident care. 2. Review of R14's admission Record located in the EMR tab titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included acute/chronic kidney failure with dependance on renal dialysis.Review of R14's Physicians Orders dated 06/05/25 located in the EMR tab titled Orders revealed the resident required EBP related to having a foley catheter, a permacath for dialysis, and history of vancomycin resistant enterococci (VRE) infection.Observation during the initial tour on 09/22/25 at 11:35 AM revealed R14's room did not have EBP signage or a cart containing PPE outside his room. Observation on 09/22/25 at 1:10 PM revealed Licensed Practical Nurse (LPN)8 entering R14's room without donning personal protective equipment to administer medications and to check the resident's permacath dressing. Observation on 09/23/25 at 9:30 AM revealed R14 was in his room preparing for his dialysis appointment.During an interview on 09/23/25 at 9:30 AM, R14 revealed staff did not always wear a gown and gloves when entering the room to provide care such as checking his permacath dressing or emptying his urinary drainage bag.During an interview on 09/23/25 at 1:48 PM, LPN8 stated R14 had been on EBP precautions since admission to the facility for his foley catheter and dialysis permacath. LPN8 was also reminded that she was observed entering the resident's room to provide medications on 09/22/25 without donning PPE. LPN8 stated that she was unaware of that this surveyor was observing her on 09/22/25 Review of the facility's policy titled, Infection Prevention and Control Programs, dated 09/01/24, revealed, . This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy indicated that all staff were responsible for following all policies and procedures related to the program. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 09/01/24, revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug organisms . An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO . PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting . NJAC 8:39-19.4

Based on record review, interview, and policy review, the facility failed to ensure four of five residents (Residents(R) 12, R82, R89, and R129) reviewed for COVID-19 immunizations out of a total sample of 33 were offered a COVID-19 immunization and/or chose to have the immunization but had not received it. Failure to offer and administer could result in the residents acquiring COVID-19.Findings include: 1. Review of R12's electronic medical record (EMR) Census tab revealed R12 was admitted to the facility on [DATE] with diagnoses found under the Medical Diagnosis tab included encounter for surgical aftercare following surgery of the digestive system, colostomy, and an incisional site infection. Review of R12's paper medical record revealed no documentation to show that the COVID-19 vaccine was offered. 2. Review of R82's EMR Census tab of the EMR, revealed R82 was admitted to the facility on [DATE] with diagnoses found under the Medical Diagnosis tab included acute cystitis without hematuria, unspecified injury to the head, muscle weakness, dysphagia, and severe protein calorie malnutrition. Review of R82's paper medical record revealed authorization for a COVID-19 immunization had been signed by his representative on 09/05/25. 3. Review of R89's EMR Census tab of the EMR, revealed R89 was admitted to the facility on [DATE] with diagnoses found under the Medical Diagnosis tab included encounter for aftercare from surgery on the circulatory system, Review of R89's paper medical record revealed she had signed the consent form on 08/23/25 for COVID-19 immunization but did not indicate whether she had wanted the immunization or not. 4. Review of R129's EMR Census tab of the EMR, revealed R129 was admitted to the facility on [DATE] with diagnoses found under the Medical Diagnosis tab included enterocolitis, acute kidney failure, and chronic obstructive pulmonary disease. Review of R129's medical record revealed no documentation to show the COVID-19 vaccine was offered. During an interview on 09/23/25 at 2:00 PM, Licensed Practical Nurse (LPN) 2, who was the unit manager for the second floor, stated when a new resident was admitted , the admitting nurse was responsible for providing education to the resident and/or representative on the immunizations. LPN2 stated the nurse would also have the forms signed with the choice made. She confirmed the immunization forms for the above residents had not been signed or no choice had been made for the COVID-19 immunizations. During an interview on 09/23/25 at 3:30 PM, the Director of Nursing (DON) stated the admitting nurse was responsible for ensuring the immunizations had been offered and the form completed with their choice and signature. The DON stated the Infection Preventionist (IP) followed up with an audit of the records to ensure the forms had been signed and the residents had made a choice related to vaccines. During an interview on 09/24/25 at 1:16 PM, the IP stated her role was to ensure the immunization forms had been filled out completely. She confirmed the staff were not ensuring the resident and/or their representatives had been asked about immunizations. Review of the facility's policy titled, Infection Prevention and Control Program, dated 09/01/24, revealed, . Residents or resident representatives will have the opportunity to accept or refuse a COVID-19 vaccination, and change their decision based on current guidance . NJAC 8:39-5.1(a)

COMPLAINT#: NJ00176055 Based on observation, interview, and review of pertinent facility documentation on 1/16/25, it was determined that the facility failed to: a). serve hot foods at an acceptable temperature for the residents, and b). follow its Test Tray Policy. This deficient practice was identified for a test tray that was placed on the second cart that was delivered to the second floor unit during the lunch meal service. In addition to the test tray, the cart contained meals for 9 residents. This was evidenced by the following: Resident #2 was not at the facility at the time of the survey. On 1/16/25, at 10:32 A.M., during an interview with the Food Service Director (FSD), he stated, If I received a complaint about food temperatures, I would do a test tray. The FSD stated that he could not recall when the last complaint was received, nor when he last completed a test tray. No documentation was provided to the surveyor. On 1/16/25, at 11:43 A.M., the surveyor observed the Food Service Director (FSD) calibrate his thermometer at 32 degrees Fahrenheit (F). On 1/16/25, at 12:41 P.M., the dietary aide exited the kitchen with the meal cart, which included the test tray, accompanied by the surveyor and the FSD. At this time the FSD confirmed that he brought the calibrated thermometer with him. On 1/16/25, at 12:44 P.M., the dietary aide delivered the meal cart, which included the test tray, to the hallway of the second floor. On 1/16/25, at 12:46 P.M., the resident meal pass began. On 1/16/25, at 12:53 P.M., the last resident meal tray was served. On 1/16/25, at 12:54 P.M., in the presence of the surveyor, the FSD took the following food temperatures: -Baked Ham: 117.7 degrees F -Roasted Potatoes: 123.9 degrees F -Broccoli: 121.6 degrees F At that time, the surveyor interviewed the FSD regarding what the appropriate food temperature should be when the food was served. The FSD stated that hot foods should be above 135 degrees when served. On 1/16/25, at 4:31 P.M., during an interview with the Administrator, the Director of Nursing, and the FSD, the FSD stated that the above noted foods did not meet the appropriate temperature. He further restated that test trays were only being conducted when a complaint was reported to him. The surveyor reviewed the facility's undated Food Temperatures and Holding Policy, which indicated that, Hot food should arrive to the resident above 135 degrees F. The surveyor reviewed the facility's undated Test Tray Policy, which indicated that test trays were to be completed weekly at random mealtimes. The policy further revealed that the Test Tray Forms would be kept on file for one year. NJAC 8:39-17.4 (a)

COMPLAINT #: NJ00175673 Based on interview, employee file review, and review of other pertinent documents on 7/23/24, it was determined that the facility failed to obtain and keep a record of an employee certification verification and to implement their Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This deficient practice was identified for 1 of 3 sampled agency employees (Certified Nursing Assistant #1) during the employee file review. The deficient practice was evidenced by the following: Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed on 5/2023, indicated .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to .e. staff from agencies .2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents .4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property . On 7/23/24, the surveyors reviewed 3 sampled agency employees and reviewed their pre-employment file. A review of CNA #1's employee file (EF) revealed that an orientation checklist was done on 5/7/2024 by the facility. The EF further revealed the CNAs Profile compiled on 5/23/24, obtained from the Agency Company. The Profile revealed that CNA #1's credential was created on 4/24/23, the credential indicated that her License Status was Active. The Profile further revealed that the CNAs Background Check was completed on 12/19/23. During an interview conducted by the surveyors on 7/23/24 at 12:53 p.m. with the Human Resources (HR) and the License Nursing Home Administrator (LNHA). The HR and LNHA stated that when a new agency employee comes in the building, the facility verifies the employee's certification through Online Public Registry (OPR). The HR stated that CNA #1's certification was visually check on or after 5/7/24 (unable to recall exact date). On 7/23/24 at 3:04 p.m., the surveyors contacted New Jersey Department of Health Certificate of Need and Licensing, who confirmed that CNA #1's certification was Suspended since 3/7/24 and this would have been noted if it was verified by the facility in May 2024. The facility was unable to provide documentation evidence that CNA #1's certification was verified before providing care to the residents on 5/22/24 and 6/15/24. Review of the job description Human Resource Director, dated 9/28/2022, indicated Purpose of Your Job Position .is to manage the Human Resources department in accordance with current applicable federal, state, and local standards, guidelines, and regulations. To follow all company policies and apply them uniformly to all employees as directed by your Administrator and the Director of Human Resources. To assure that qualified personnel are interviewed, trained and employed. To timely perform all administrative tasks with regards to personnel actions .Duties and Responsibilities .Administrative Functions .Check applications and references of prospective employees and arrange for interview with department managers as required or requested .Also files applications for positions, by positions or alphabetically, to include job applications, resume, reference checks, etc. of that person meeting eligibility requirements for the position to which they applied .Develop, implement and maintain an adequate personnel filing system that meets the needs of the facility and complies with current employment practices . N.J.A.C 8:39-9.3(b)

Based on observation, record review, interviews, and review of facility policy, the facility failed to ensure adequate supervision of residents by specifically failing to prevent Resident (R) #60 from wandering into other residents' rooms leading to physical altercations with other residents. Due to the vulnerable nature of the nursing home population, a potential for serious injury or serious physical or psychosocial impairment from being hit by R #60, or R #60 being hit, existed, and the likeliness of R #60 hitting another resident or being hit by another resident in the facility was high and required immediate action to prevent further events of physical abuse by or to R #60. This deficient practice was identified for one out of two residents (Resident #60) reviewed for resident to resident abuse. The Immediate Jeopardy began on 11/27/23, the date of the first incident of resident abuse by R #60. Review of Nurse Notes located in the EMR under the Progress Notes tab revealed the following entries related to R #60's continuous wandering in residents rooms: a) 11/27/23, Resident entered another resident's room and the resident stated they were hit by R #60. No injuries were noted and R #60 was sent to the hospital for an evaluation. Upon return, R #60 continued to wander into other residents' rooms; b) 04/07/24, Resident wandered into [R #24's] room without anybody knowing it. Then someone was yelling for help and aides went to the room and found R #60 on [his/her] right side on the floor with [his/her] left arm protecting [him/herself]. R #24 admitted that [he/she] was about to punch R #60 as [he/she] is not allowed in [his/her] room. R #60 continued to wander into residents' room daily. The facility's Administrator and Director of Nursing (DON) were informed on 05/24/24 at 6:54 PM that Immediate Jeopardy existed related to the failure to ensure adequate supervision of R #60 to prevent potential abuse to other residents by R #60 and prevent abuse to R #60 by other residents. An acceptable removal plan was received on 05/24/24 at 11: 34 PM and was verified on-site on 05/24/24 at 11:50 PM. Findings include: Review of the Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy last reviewed 05/2023 revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to . physical abuse . the facility will develop and implement policies and protocols to prevent and identify abuse or mistreatment of others. Review of the Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/03/23, revealed R #60 had a Brief Interview for Mental Status (BIMS) score of three 03 out of 15, indicating severe cognitive impairment. Review of the Quarterly MDS with an ARD of 02/29/24, revealed R #60 had a BIMS score of two 02 out of 15 indicating severe cognitive impairment. Review of the Census tab located in the electronic medical record (EMR) revealed R #60 was admitted to the facility on [DATE]. Review of R #60's Med Diag [Medical Diagnoses] tab located in the EMR revealed R #60 was admitted with moderate dementia with behavioral disturbance, and restlessness and agitation. Review of R #60's Care Plan initiated on 07/28/23, revealed the first concern/focus area for R #60 was wandering into other residents' rooms. The Care Plan Interventions included: -Educate me/family/caregivers on successful coping and interaction strategies. -If reasonable, discuss my behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. -Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for my disruptive behaviors by offering tasks which divert attention such as (activities including playing cards, word games, and arts & crafts). Provide a program of activities that is of interest and accommodates residents' status. -Assess for fall risk. -Distract residents from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Monitor location. Document wandering behavior and attempted diversional interventions in progress notes. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, visits with family. -WANDERGUARD in place. Review of R #60's Nurse Note located in the EMR under the Progress Note tab dated 07/29/23, [first documentation of R #60 wandering into rooms] revealed R # 60 was confused and wandering the unit freely. The note stated the staff must frequently assist R #60 from other resident rooms. The note continued to state the other residents were upset and complained. While doing rounds on the unit this writer found R #60 in room [ROOM NUMBER] in bed with another female resident. Attempted to remove [resident] from the bed and [resident] became very combative and verbally abusive to staff. Resident then proceeded to wander in and out of other resident's rooms, very hard to redirect. Will continue to monitor. Review of R #60's Nurse Note located in the EMR under the Progress Note tab dated 07/30/23 revealed, Resident confused, verbally aggressive when staff tries to redirect, combative, wandering in other resident rooms and getting into their beds, even when redirecting to his/her assigned room, resident does not stay inside. Review of the updated Care Plan located in the EMR under the Care Plan tab revealed a focus area related to R #60 being physically aggressive towards staff and a history of harm to others was initiated on 07/30/23, with interventions including for R #60 to be evaluated for more appropriate level of care [dementia unit]. There was a focus related to a behavior problem of entering other rooms, taking things, and lying on beds initiated on 07/28/23, with interventions including intervening as necessary to protect the rights of others. There was no documented evidence of a history of harm to others. Review of R #60's Nurse Note located in the EMR under the Progress Note tab dated 08/01/23, revealed the resident was roaming the hallways and going into several residents rooms on this shift. The note further revealed the resident was evaluated by the physician and recommended to continue Lexapro (for depression) and start a new order for Depakote for dementia with behavioral disturbances. It was also recommended the resident be transferred to a dementia unit in the Assisted Living Facility or another Skilled Nursing Facility. All the recommendations were reviewed with the resident's primary physician and his/her family. The resident remains at the facility and there is no documented evidence any attempts were made to transfer the Resident #60 to a facility with a dementia unit. Review of Nurse Notes located in the EMR under the Progress Notes tab revealed the following entries related to R #60's continuous wandering in residents rooms: - On 08/02/24, Resident still wandering the unit, observed going in other rooms, redirected by staff, sometimes difficult to redirect, not sitting quietly with other residents. - On 08/03/24, Resident was in bed, around 3 AM resident came out of his/her room walking the hallways and going into other resident's room. At 4 AM resident enter (sic) into rm [room] 307, Resident called the CNA [Certified Nursing Assistant} to get [him/her] out. Around 11:30 PM resident from 329 came out screaming to get resident out [his/her] room and [he/she] has wheelchair coming into [his/her] room, this writer redirects [him/her] back to [his/her] room. - On 08/04/24, Resident confused, forgetful, requires constant monitoring, wandering on the unit in/out of other rooms, other residents upset, redirecting this resident is difficult at times and [he/she] can be combative and become verbally angry, ongoing behavior monitoring, frequent checks as to [his/her] whereabouts. - On 08/05/24, Patient [R #60] mood is pleasant but continues to walk in and out of other resident's rooms taking their belongings and lying in their beds. - On 09/05/23, Received resident in [his/her] room, during this shift resident got out of [his/her] bed and was going into other resident's room. Patient was redirect (sic) back to [his/her] room on several occasion. - On 10/29/23, Received pt [R# 60] in [his/her] room . Patient has been going into other resident room and cursing resident. Resident was redirected back to [his/her] room several times. - On 10/30/23, Resident was constantly redirected back to [his/her] room after entering other resident room, Patient has been cursing residents when they asked [him/her] to leave, they room. - On 11/12/23, Received resident in [his/her] room, when awake resident was going into other rooms. Needs constant redirection. Frequently curses at residents and staff. Another resident, [name redacted] in room [ROOM NUMBER] A called police on [R #60]. Stated [R #60] came into [his/her] room while [he/she] was resting in bed and wouldn't leave. Incident was unwitnessed. No physical altercation. The Care Plan was updated for R #60 on 11/28/23, after the 11/27/2023 incident to include that the resident would have frequent monitoring and be kept close to the nursing station. Review of additional Nurse Notes located in the EMR under the Progress Notes tab revealed the following entries related to R #60's continuous wandering in residents rooms: - On 12/14/23, Resident [R #60] went into another resident's room and was asked to leave by the resident. R #60 walked backwards out of the room and lost [his/her] balance and fell to the floor. - On 12/16/23, Resident continues to wander halls and go into patient rooms. Found 2 times sleeping in another resident's bed. continue to redirect back to [his/her] own room. Further review of Resident #60's Care Plan revealed that after the 04/07/24, incident between R #60 and R #24, the following interventions were added: Redirect resident to public areas when [he/she] is noted walking toward other resident's rooms. Review of Nurse Note dated 05/10/24 revealed, Resident alert with confusion using word salad when speaking. Resident continues to go into other resident's rooms. Resident redirected when entering another resident's room. Resident is aggressive at times and yells and using profanity when redirected. Psych [psychiatry] consult pending. MD [medical doctor] and family made aware. Engage resident in conversation, redirect, take her outside, offer tasks that diverts her attention. On 05/21/24 at 2:16 PM, the surveyor observed R #60 wandering in and out of other resident rooms. Staff were not observed redirecting R #60. On 05/24/24 at 2:15 PM, the surveyor interviewed the Certified Nursing Aid (CNA #3) who stated there wasn't a protocol with R #60. The staff redirect R #60 out of other resident's rooms when he/she was seen in the rooms. On 05/24/24 at 7:15 PM, the surveyor interviewed the Director of Nursing (DON) who stated she was new and was not familiar with R #60's behaviors or wandering. An acceptable removal plan was received on 05/24/24 at 11:34 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including placing Resident #60 on 1:1 supervision until appropriate placement was found. The survey team verified the removal plan on-site on 05/24/24 at 11:50 PM. NJAC 8:39-4.1(a) NJAC 8:39-9.4(f) NJAC 8:39-13.4

Based on document review and interview, the facility failed to provide copies of the facility's bed hold policy to four of five residents (Resident (R) 343, R17, R38 and R27) reviewed for hospitalization out of a sample of 21 residents. This failure created the potential for residents and/or responsible parties to not have the information needed to safeguard their return to the facility. Findings include: 1. Review of R343's electronic medical record (EMR), under the Census tab revealed an admitted [DATE], a discharge to the hospital date of 05/02/24, and readmission to the facility on [DATE]. The clinical record lacked evidence that the resident and/or responsible party was given a copy of the facility's bed hold policy when the resident was transferred to the hospital. During an interview on 05/24/24 at 10:14 AM, the Administrator confirmed the facility failed to provide a copy of the bed hold policy to residents and/or the responsible party upon transfer to the hospital. 2. Review of the Progress Notes in the electronic medical record (EMR) revealed, on 04/20/24, R17 was taken to the emergency room (ER) for altered mental status and hypotension. R17 returned to the facility on [DATE]. Review of R17's EMR or hard chart located on the third floor held no documentation bed hold information had been issued to the resident. During an interview on 05/24/24 at 8:28 AM, Licensed Practical Nurse (LPN) 2 stated during a normal transfer to the hospital the nurse assigned to the resident would complete the bed hold/transfer notice and provide to the resident or their responsible party if present or by phone prior to sending the resident out. LPN2 stated a copy would be maintained in the hard chart on the unit and the business office manager would receive a copy of the form. During an interview on 05/24/24 at 2:13 PM, the Business Office Manager (BOM) stated she was responsible for gathering the information from bed hold/transfer notices and entered them into a spreadsheet and sent a copy to the Ombudsman related to the acute care transfers. The BOM was unable to locate copies of the bed hold notices for R17. 3. Review of the Progress Notes in the EMR revealed R38 had a doctor's appointment on 04/02/24 with his primary care provider; during this appointment the physician's office sent the resident to the ER due to tightness in his chest with congestion. R38 was readmitted to the facility on [DATE] with a diagnosis of shortness of breath (SOB.) Review of R38's Miscellaneous tab in the EMR revealed no documentation bed hold information had been issued to the resident. During an interview on 05/24/24 at 2:13 PM, the BOM stated was unable to locate copies of the bed hold notices for R38. 4. Review of the Census tab located in the EMR revealed R27 was admitted to the facility on [DATE]. Review of Progress Notes located in the EMR revealed R27 was transferred to the hospital due to uncontrolled high blood pressure and dizziness on 10/29/23 and readmitted to the facility on [DATE]. Further review revealed R27 was transferred to the hospital due to generalized weakness in both legs on 12/26/23 and readmitted to the facility on [DATE]. Review of the EMR revealed no documentation bed hold information had been issued to the resident. During an interview on 05/24/24 at 12:15 PM, the Regional Nurse supplied a transfer notice and Ombudsman notice for R27's hospital transfers. The Regional Nurse stated R27 did not receive a bed hold notice for the two hospital transfers. Review of the form titled Transfer/Bed Hold notice prior to hospitalization or therapeutic leave dated 12/06/19 revealed the form was to be completed and given to the resident or responsible party at the time of the transfer. The form had spaces for the resident's name, resident responsible party, date of transfer, date notice was being issued, and the location to which the resident was being transferred. Review of the facility policy titled, Bed-Holds and Returns last revised 10/2019 stated, . Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: . rights and limitations of the resident regarding bed-holds; the reserve bed payment policy as indicated by the state plan (Medicaid residents); .the details of the transfer (per the Notice of Transfer) . NJAC 8:39-5.1(a) NJAC 8:39-5.3(b) 21382

Based on record review, interview, and review of facility policy, the facility failed to ensure that seven of eight supplemental residents (R19, R51, R40, R7, R16, R49, and R58) receive adequate assistance obtaining weekly showers. During the group meeting the residents voiced concerns about not getting scheduled showers. This failure has the potential for the residents to experience a decline in their ability to perform their ADLs. Findings include: Review of the facility policy titled ''Activities of Daily Living, Supporting'' updated October 2021 documented as follows ''Residents will be provided with care, treatment and services as appropriate lo maintain or improve their ability to carry out activities of daily living (ADLs) .'' During a group meeting held on 05/23/24 at 2:30 PM, seven (R19, R51, R40, R7, R16, R49, and R58) of the eight residents attending the meeting voiced concerns about not receiving showers according to their wishes. The following comments were made during the group meeting. R19 stated he was told that a staff member must be present to assist with showers and there was not enough staff available to assist the resident with showers. R19 stated it had been several weeks since he had a shower. R51 stated all needed was for the staff setup the shower room for her and she could take the shower alone. R51 stated she was told there were not enough staff to help with her shower. R51 confirmed it had been several weeks since she had a shower. R40 stated he had been told the same thing about not enough staff to assist with showers. R7, R16, R49, and R58 agreed with what R19, R51, and R40 stated. The following residents agreed it had been several weeks since they were offered a shower according to their preference: R7, R16, R19, R40, R49, R51, and R58. 1. Review of R7 annual Minimum Data Set'' (MDS) with an Assessment Reference Date (ARD) of 02/07/24, located in R7's electronic medical records (EMR) ''MDS'' tab, revealed R7 had a Brief Interview for Mental Status (BIMS) score of 15 out 15 points which indicated the resident's cognition was intact. The resident required substantial to maximum assistance with showers. Review of R7's ''Care Plan'' with a revision date of 11/02/23, located in R7's EMR ''Care Plans'' tab, revealed R7 was scheduled for showers on the Tuesday and Fridays on the 3-11 shift with the assistance of one staff person. Review of R7s ''Bath/Shower Sheets'' for the month of May 2024 provided by the facility revealed the resident had only received one shower since 05/01/24. 2. Review of R16's Medicare MDS'' with an ARD of 05/20/24, located in R16's EMR MDS tab revealed R16 had a BIMS score of 15 out of 15 points which indicated R16's cognition was intact. R16 was assessed to require substantial to maximum assistance with showers and toileting. Review of R16's ''Care Plans'' with a revision date of 11/02/23, located in the resident's EMR ''Care Plans'' tab, revealed R16 was scheduled to receive showers on Tuesdays and Fridays on the 3-11 shift with the assistance of one staff person. Review of R16's ''Bath/Shower Sheets for the month of May 2024 provided by the facility revealed R16 had not received any showers since 05/01/24. 3. Review of R19's annual MDS'' with an ARD of 05/07/24, located in the resident's EMR ''MDS'' tab, revealed R19 had a BIMS score of 15 out of 15 points which indicated the resident's cognition was intact. R19 was assessed to require substantial to maximum assistance with showers and toileting. Review R19's ''Care Plan'' with a revision date of 11/21/23, located in the resident's EMR ''Care Plans'' tab, revealed R19 was to receive showers on Wednesday and Saturdays on 7-3 shift with the assistance of one staff member. Review of R19's ''Shower Sheets'' for the month of May 2024 provided by the facility revealed the resident has not received any showers since 05/01/24. 4. Review of R40's Medicare MDS'' with an ARD of 03/31/24, located in R40's EMR ''MDS'' tab revealed R40 had a BIMS score of 10 out of 15 points which indicated R40's cognition was moderately impaired. R40 was assessed to require substantial to maximum assistance with toileting. The resident was not observed for showers during the assessment period. Review of R40's ''Care Plan'' with a revision date of 02/14/24, located in R40's EMR ''Care Plans'' tab, revealed R40 was scheduled for showers on Wednesdays and Saturdays on the 3-11 shift with the assistance of one staff member. Review of R40's ''Shower Sheets'' for the month of May 2024 provided by the facility revealed the resident had not received any showers since 05/01/24. 5. Review of R49's annual MDS'' with an ARD of 02/17/24, located in R49's EMR ''MDS'' tab revealed R49 had a BIMS score of 15 out 15 points which indicated R49's cognition was intact. R49 did not require assistance with showers. Review of R49's ''Care Plan,'' with a revision date of 01/04/24, located in R49's EMR ''Care Plans'' tab, revealed R49 required the assistance one person for showers. The care plan did not identify the resident schedule shower days. Review of R49's ''Shower Sheets'' for the month of May 2024, provided by the facility, revealed R49 had not received any showers since 05/01/24. 6. Review of R51's quarterly MDS'' with an ARD of 02/13/24, located in R51's EMR ''MDS'' tab, revealed R51 had a BIMS score of 13 out 15 points which indicated R51's cognition was intact. R51 was assessed to not require assistance with showers. Review of R51's ''Care Plan'' with a revision date of 02/21/24, located in R51's EMR ''Care Plans'' tab, revealed R51 required the assistance of one staff person for showers. The care plan did not identify R51's scheduled shower days. Review of R51's ''Shower Sheets'' for the month of May 2024, provided by the facility, revealed R51 had not received any showers since 05/01/24. 7. Review of R58's annual MDS'' with an ARD of 02/23/24, located in R58's EMR ''MDS'' tab, revealed R58 had a BIMS score of eight of 15, which indicated R58's cognition was moderately impaired. R58 was assessed as not requiring any assistance with showers. Review of R58's ''Care Plan'' with a revision date of 04/13/23, located in R58's EMR ''Care Plans'' tab, revealed R58 was scheduled for showers on Tuesdays and Fridays on the 3-11 shift with assistance of one staff member. Review of R58's ''Shower Sheets'' for the month of May 2024 provided by the facility revealed R58 had only received two showers since 05/01/24. During an interview on 05/23/24 at 3:54 PM, Certified Nurse Aide (CNA) 1 revealed the residents use the showers in their rooms. The residents are scheduled for showers twice a week on each shift. Those scheduled showers are attached to the CNAs assignment sheets. The CNAs are responsible for assisting those residents that require assistance. An interview with the Director of Nursing (DON) on 05/24/24 at 1:30 PM revealed the residents are scheduled to take showers twice a week in their rooms. The DON reviewed the residents' showers and stated that lacked documentation of the residents receiving the scheduled showers. The DON stated it was the facility's expectation residents would receive showers as they were scheduled. An interview on 05/24/24 at 1:36 PM with the Administer revealed the issue of the residents receiving the showers was discussed with the staff. The Administrator was asked to interpret the shower sheets for the month of May. The Administrator stated that it was possible that the CNAs did give the showers but forgot to document the residents received the showers. The Administrator was reminded that this was a concern voiced by the residents. The Administrator stated this lack of documentation indicates that a performance improvement plan needs to be developed. NJAC 8:39-27.1(a) NJAC 8:39-27.2

Based on interview, record review, and facility policy review, the facility failed to report an injury of unknown origin in a timely manner for one (Resident (R) 13) out of one resident reviewed for injury of unknown origin out 21 sampled residents. The facility further failed to report an allegation of abuse between R60 and R24 in out of two residents reviewed for abuse in a timely manner out of 21 sampled residents. This failure had the potential to place residents at risk of not receiving appropriate care and protection. Findings include: 1. Review of the Census tab located in the electronic medical record (EMR) revealed R13 was readmitted to the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/29/23 revealed R13 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating the resident was severely impaired in cognition. Review of R13's nurse Progress Note dated 04/15/23 and located in the EMR under the Progress Note tab revealed R13 was found to have bruising on the top of her right hand at 8:30 AM by the Certified Nursing Assistant (CNA) and let the nurse know. Review of an Administrative Progress Note located in the EMR under the Progress Note tab dated 04/15/23 at 1:25 PM revealed the previous Administrator was informed by the nurse on duty of the bruises on the hand of R13. The note indicated R13 had pointed to her hand and told the nurse that, she beat the hell out of me. The police were called, and an investigation was initiated. Review of the [NAME] Police Department report provided by the facility dated 04/15/23 revealed the facility called the police at 12:29 PM and officers responded. The report revealed the call was for a welfare check and would be reported to the State Agency (SA). Review of the Reportable Event Record/Report dated 04/16/23 at 12:00 PM provided by the facility revealed the time of event of the unknown injury/bruises was at 5:00 AM on 04/15/23, however was not reported to the SA until the next day on 04/16/23. 2. Review of the admission MDS with an ARD of 06/03/23 located in the EMR revealed R60 had a BIMS) score of three out of 15 indicating severe cognitive impairment. Review of the quarterly MDS with an ARD of 02/29/24 revealed R60 had a BIMS score of two out of 15 indicating severe cognitive impairment. Review of R24's quarterly MDS with and ARD of 03/38/24 revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact. The resident had no behaviors. Review of Progress Note dated 04/07/24 revealed, [R60] wandered to [R24's] room without anybody knowing it. Then someone was yelling for help and aides went to the room and found [R60] on her right side on the floor with her left arm protecting herself. [R24] admitted that she was about to punch [R60] as she is not allowed in her room. This incident was not reported to the SA and R60 continued to wander into residents' room daily. During an interview on 05/24/24 at 7:15 PM the Director of Nursing (DON) stated the facility had questioned the resident [R24] involved with R60 during the 04/07/24 incident, however, the facility did not report the incident to the SA. Review of the Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating policy last reviewed 05/2023 revealed, all reports of resident abuse including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies as required by current regulations. Findings of all investigations are documented and reported. NJAC 8:39-9.4(f)

Based on interview, record review, and facility policy review, the facility failed to thoroughly investigate a resident to resident abuse incident between two (Residents (R) 60 and R24) out of two residents reviewed for abuse out of a sample size of 21. This failure has the potential for further resident-to-resident abuse occurring and not being investigated so interventions can be put in place. Findings include: Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/03/23 and located in the electronic medical record (EMR) revealed R60 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment. Review of the quarterly MDS with an ARD of 02/29/24 revealed R60 had a BIMS score of two out of 15 indicating severe cognitive impairment. Review of R24's quarterly MDS with an ARD of 03/38/24 revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact. The resident had no behaviors. Review of the Progress Note located in the EMR under the Progress Note tab dated 04/07/24 revealed, [R60] wandered to [R24's] room without anybody knowing it. Then someone was yelling for help and aides went to the room and found [R60] on her right side on the floor with her left arm protecting herself. [R24] admitted that she was about to punch [R60] as she is not allowed in her room. The incident was not investigated and R60 continued to wander into residents' room daily. During an interview on 05/24/24 at 7:15 PM the Director of Nursing (DON) stated the facility had questioned the resident [R24] involved with R60 during the 04/07/24 incident, however, confirmed the facility did not complete a thorough investigation. Review of the Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating policy last reviewed 05/2023 revealed, all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. NJAC 8:39-9.4(f)

Based on interview, record review, and review of the facility's transfer form, the facility failed to notify the Ombudsman program of the transfer of two of five residents (Resident (R) 17 and R38) reviewed for hospitalization out of a sample of 21 residents. This failure has the potential for residents to not be aware of their transfer rights. Findings include: 1. Review of the Progress Notes in the electronic medical record (EMR) revealed, on 04/20/24 R17 was taken to the emergency room (ER) for altered mental status and hypotension. R17 returned to the facility on [DATE]. Review of R17's EMR and hard chart located on the third floor held no documentation related to a transfer notice having been issued to the resident. 2. Review of the Progress Notes in the EMR revealed R38 had a doctor's appointment on 04/02/24 with his primary care provider; during this appointment the physician's office sent the resident to the ER due to tightness in his chest with congestion. R38 was readmitted to the facility on [DATE] with a diagnosis of shortness of breath (SOB.) Review of R38's Progress Notes tab in the EMR revealed no documentation of notification into the responsible party or the attending physician. Review of the Miscellaneous tab in the EMR revealed no documentation related to related to transfer rights. During an interview on 05/24/24 at 8:28 AM, Licensed Practical Nurse (LPN) 2 stated during a normal transfer to the hospital the nurse assigned to the resident would complete the Transfer/Bed Hold notice prior to hospitalization or Therapeutic Leave form and provide to the resident, or their responsible party if present, or by phone prior to sending the resident out. LPN2 stated a copy would be maintained in the hard chart on the unit and the business office manager would receive a copy of the form. During an interview on 05/24/24 at 2:13 PM, the Business Office Manager (BOM) stated she was responsible for gathering the information from bed hold/transfer notices and entered them into a spreadsheet and sent a copy of the spreadsheet to the Ombudsman related to the acute care transfers. The BOM was unable to locate copies of the notice of transfer for R17 and R38. Review of the form titled Transfer/Bed Hold notice prior to hospitalization or Therapeutic Leave dated 12/06/19 revealed the form was to be completed and given to the resident or responsible party at the time of the transfer. The form had spaces for the resident's name, resident responsible party, date of transfer, date notice was being issued, and the location to which the resident was being transferred. R17 and R38 did not have a copy of this form in their EMR or hard chart. Review of the facility policy titled, Transfer or Discharge, Emergency last revised 12/01/19 revealed . Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: . prepare a transfer form to send with the resident, notify the representative (sponsor) or other family member . NJAC 8:39-5.1(a) NJAC 8:39-5.3(b)

Based on observation, record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure ''Minimum Data Set (MDS)'' assessments accurately reflected residents' status for one of three residents reviewed for elopement from 21 sampled residents (Resident (R) 29). R29's ''MDS'' did not reflect R29's wandering behaviors. This had the potential for R29 to have unmet care needs. Findings include: Review of R29's ''Admission Record'' located in the electronic medical record (EMR) under the ''Profile'' tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavior disturbances, repeat falls, and unsteadiness on feet. Review of R29's ''Admission Elopement Assessment,'' dated 05/03/24 and located in the EMR under the ''Assessment'' tab, revealed R29 had a history of wandering behaviors in the past month. Review of R29's ''Physician's Orders'' for the month of May 2024, located in the resident's EMR under the ''Orders'' tab, revealed an order dated 05/03/24 for a Wander Guard/Wander Elopement Device due to poor safety awareness every shift check placement and functionality. Review of R29's admission ''MDS'' with an Assessment Reference Date (ARD) of 05/04/24, located in the resident's EMR under the ''MDS'' tab, revealed the resident's wandering behaviors and the physician's order for a wander-guard bracelet were not reflected. During an observation on 05/22/24 at 3:05 PM, R29 was in bed with eyes closed and a wander-guard bracelet on the right ankle. During an interview on 05/24/24 at 9:05 AM, the Unit Manager/Licensed Practical Nurse (UM/LPN) revealed R29 had a history of exhibiting wandering behaviors and had physician orders to wear a wander-guard bracelet. UM/LPN stated the wandering behaviors, and the wander guard bracelet should be documented on the ''MDS.'' During an interview on 05/24/24 at 1:30 PM, the Director of Nursing (DON) revealed that since R29's wandering behaviors were identified in the admission elopement assessment it should have been reflected on the admission ''MDS'' and it was not. Review of the RAI Manual,'' revised October 2023, indicated information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the Interdisciplinary Team completing the assessment. NJAC 8:39-33.2