Every finding on record at Cranbury Center

Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 05/28/2026, it was determined that the facility failed to maintain an environment free from the use of physical restraint for Resident #2.This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed for restraint.During the survey, a tour was conducted by the surveyor, there was no restrictive device noted for any resident.On 05/23/2026, during the 7:00 AM-3:00 PM shift, the Registered Nurse (RN#1) who was assigned to Resident #2 stated the resident was experiencing respiratory distress. RN#1 administered a respiratory treatment by nebulizer mask. RN#1 stated during the treatment Resident #2 became combative and pulled off the mask from their face. RN#1 stated she then used a pillowcase, wrapped it around Resident #2's left hand and tied it to their side rail to ensure Resident #2 received their respiratory treatment. At approximately 10:20AM, Resident #2 was found by their Hospice Nurse with a restraint to left hand. The hospice nurse called and requested the Manager on Duty (MOD) to immediately come to the facility. The MOD arrived at the facility at approximately 11:00AM and went to Resident #2's room. The MOD untied Resident #2's left hand from their side rail and assessed for injury and bruises with none documented.RN#1 who was assigned to Resident #2 on 05/23/2026, restrained the resident during a respiratory treatment and failed to follow the facility Use of Restraint policy, which led to an Immediate Jeopardy situation.The IJ began on 05/23/2026, and ended on 05/25/2026 when the facility self-corrected the deficient practice. The Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON) were informed of the F604 IJ and were provided with the IJ template on 05/28/2026 5:02 P.MThe facility self-corrected and put themselves back in compliance to prevent serious harm from occurring or reoccurring by immediately completing the following:On 05/23/2026, the MOD (Manager on Duty) immediately removed the restricting device from Resident #2. A full body assessment was completed with no injuries noted. The Medical Doctor and Legal Guardian were notified. The Police were called and were onsite for a report. Both nurses working on the unit were immediately suspended pending an investigation.On 05/23/2026, the MOD conducted an audit on all residents living on the unit to ensure no restrictive devices were in place.On 05/23/2026, an In-service initiated with all staff by the DON/LNHA on abuse, restraints and reporting.On 05/24/2026, the DON/ Designee started unannounced rounding on all residents to ensure residents are free of any restrictive devices daily on off shifts.The IJ is Past Non-Compliance. The surveyor verified the implementation of the facility's Removal Plan (RP) while onsite on 5/28/26, and determined that there is sufficient evidence that the facility corrected the noncompliance on 05/25/2026, and is in substantial compliance at the time of the current survey for the specific regulatory requirements for F604. The evidence was as follow.A review of the facility's policy titled Use of Restraint, with a review and revision date of 09/15/2025, under Policy revealed: Patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the patient's medical symptoms. Under definitions revealed: Physical Restraint refers to any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the patient's body, cannot be removed easily by the patient, and restricts the patient's freedom of movement or normal access to their body.A review of the Facility Reportable Event (FRE) dated 05/24/2026, submitted to the New Jersey Department of Health (NJDOH) included the following:On 05/23/2026, Resident #2's left upper extremity was observed secured to the enabler (side rail) by a pillowcase. An assessment was performed on the resident, and no injuries were noted. Staff involved were suspended immediately pending investigation.The facility provided a summary of the investigation related to the FRE, which stated that RN#1 who was assigned to Resident #2 admitted to looping Resident #2's left hand to the enabler (side rail) using a pillowcase while attempting to administer a nebulizer treatment.According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia (significant, progressive decline in memory), major depression (a serious mood disorder characterized by persistent feeling of sadness), respiratory failure ( a critical life threatening condition that occurs when respiratory system cannot adequately perform its essential gas exchange functions), and functional quadriplegia (the complete inability to move due to severe physical disability or frailty).According to the Minimum Data Set (MDS), an assessment tool dated 03/17/2026, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that the resident's cognition was severely impaired.Resident #2's CP included the following:Under Focus, date initiated 10/17/2024: I [Resident #2] am resistive /combative with care related to: Cognitive Loss/Dementia. Under Goal: I [Resident #2] will have no more than 30 episodes of (i.e. (that is) resisting care/being combative with care) by the review date. Under Interventions: If resident/patient becomes combative or resistive, postpone care/activity and allow time for the resident to regain composure.A review of Resident #2's 05/2026 Order Summary Report (OSR) revealed the following physician's orders (PO): Ipratropium-Albuterol 3 milliliter orally every 6 hours as needed for shortness of breath or wheezing.On 05/28/2026 at 10:44 A.M., a telephone interview was conducted with RN#1 who was assigned to Resident #2. She stated that on 05/23/2026, Resident #2 was experiencing respiratory distress. RN#1 attempted to administer Resident #2's respiratory treatment by mask. Resident #2 was combative and removed their mask. RN#1 then used a pillowcase, wrapped it around Resident #2's left hand and tied it to their side rail. RN#1 stated she should have called the resident's Medical Doctor for refusal and document the refusal. On 05/28/2026 at 12:31 P.M., an interview was conducted with the DON in the presence of the LNHA. The [NAME] stated the nurse did not follow the facility's policy for restraint. The facility self-corrected and put themselves back in compliance to prevent serious harm from occurring or reoccurring by immediately completing the following:On 05/23/2026, the MOD (Manager on Duty) immediately removed the restricting device from Resident #2. A full body assessment was completed with no injuries noted. The Medical Doctor and Legal Guardian were notified. The Police were called and were onsite for a report. Both nurses working on the unit were immediately suspended pending an investigation.On 05/23/2026, the MOD conducted an audit on all residents living on the unit to ensure no restrictive devices were in place.On 05/23/2026, an In-service initiated with all staff by the DON/LNHA on abuse, restraints and reporting.On 05/24/2026, the DON/ Designee started unannounced rounding on all residents to ensure residents are free of any restrictive devices daily on off shifts.The IJ is Past Non-Compliance. The surveyor verified the implementation of the facility's Removal Plan (RP) while onsite on 5/28/26, and determined that there is sufficient evidence that the facility corrected the noncompliance on 05/25/2026, and is in substantial compliance at the time of the current survey for the specific regulatory requirements for F604. N.J.A.C:8:39-4.1 (6)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure the code status for a resident (Resident # 61) was accurately documented in the electronic medical record (EMR) that correctly identified their wishes in the event of a medical emergency. This deficient practice was identified for 1 out of 37 residents (Resident # 61). Resident # 61 wished to be a Do Not Resuscitate (DNR; do not perform cardiopulmonary resuscitation (CPR) if a person's heart stops or they cease breathing). A review of the resident's EMR revealed that Resident # 61's code status was documented as DNR/Full Code (all resuscitation procedures will be provided when a person stops breathing or their heart stops beating). An interview with staff on [DATE], revealed that during an emergency response, staff would initiate CPR while another staff member called the resident's family to verify their wishes. The facility's failure to ensure Resident # 61's code status was correct during an emergency response to ensure their wishes were followed, posed the likelihood of serious harm or death for the resident by receiving an incorrect emergency response. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on [DATE], when a second Physician's Order (PO) was written for a DNR code status and the first PO dated [DATE], for a full code was not discontinued in the resident's EMR. This led to two contradicting code status' in the resident's EMR. The facility Administration was notified of the IJ on [DATE] at 7:25 PM. The facility submitted an acceptable Removal Plan (RP) on [DATE] at 8:27 AM. The survey team verified the implementation of the RP during the continuation of the on-site survey on [DATE] at 6:59 PM. Findings include:A review of the facility's policy titled OPS422 Code Status Orders, revised [DATE], included code status communicates to the clinical staff whether the patient desires cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. Patient identification mechanisms and information about each patient's code status will be easily accessible to the clinical staff for all patients. Code status orders include Full Code and Do Not Resuscitate (DNR). All patients require a code status order as soon as possible upon admission/re-admission, a change in patient preference, or a significant change in patient condition. If the patient's wishes are different from the admission orders, immediately document the patient's wishes in the medical record, notify the physician and obtain the correct order. A review of Resident # 61's Face Sheet, located in resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE], and was listed as a Full Code/DNR status. A review of Resident # 61's banner in the [name redacted] in the EMR revealed the resident was listed as a Full Code/DNR status. A review of Resident # 61's Physician Orders located in the resident's EMR under the Orders tab, revealed two active orders; one dated [DATE], for full code and the second order dated [DATE], for DNR. The full code order was not discontinued on [DATE], when the new order was entered. Which led to two contradicting code statuses in the EMR. A review of Resident # 61's paper chart located on the second-floor nurses station revealed a Physician Order for Life-Sustaining Treatment (POLST; a form that enable residents to indicate their preferences regarding life-sustaining treatment) dated [DATE], for DNR.During an interview on [DATE] at 4:16 PM, the Registered Nurse (RN#1) and the Licensed Practical Nurse (LPN#4) stated that when a resident coded, they looked in the EMR [name redacted] at the dashboard where the advanced directives were listed or the physician's orders. During an interview on [DATE] at 4:25 PM, LPN#2 stated that she used the EMR [name redacted] dashboard to identify the code status of a resident. During an interview on [DATE] at 4:27 PM, LPN#1 confirmed that upon admission, the advance directives were listed on the dashboard in the EMR, and that the document was in the resident's chart. LPN#1 stated in addition, there was a physician's order for either a DNR or Full Code, and if there was a change, the order needed to change as well. During an interview on [DATE] at 4:30 PM, LPN#3 stated she would use the EMR [name redacted] dashboard to identify the code status of a resident. During an interview on [DATE] at 4:30 PM, RN#2 stated if there was not a code status listed or if there were two code statuses listed, she would initiate CPR while someone attempted to contact the family.During an interview on [DATE] at 9:49 AM, the Infection Preventionist/Licensed Practical Nurse (IP/LPN) stated that he was the nurse who verified the physician's order for Resident #61. The IP/LPN stated he put in the DNR order on [DATE], and that the order for Full Code was not discontinued by the physician at that time. The IP/LPN stated it was his responsibility to request an order to discontinue the Full Code status from the physician, but he was unsure if he did that. The IP/LPN stated if he did make that request, it would have been documented in progress notes in the EMR, but there was no documentation related to it. The IP/LPN stated it was the responsibility of every staff who reviewed the resident's chart to notice the discrepancy in the code status and alert management and the physician to correct it. During an interview on [DATE] at 11:44 AM, the Director of Nursing (DON) stated she expected when a resident was admitted to the facility, that staff verified the resident's code status and ensured the physician's order was correct and reflected the correct code status. The DON stated if there was a change in code status, she expected the old order to be discontinued when the new order was put in. An acceptable Removal Plan (RP) was received on [DATE] at 8:27 AM, 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 immediacy including; the conflicting orders for Resident #6l were immediately clarified with the attending physician and responsible party on [DATE]. The correct code status of DNR was verified for Resident #61, the previous Full Code order was discontinued leaving a single active order in the EMR. The banner bar on the EMR reflected only one active code status of DNR for Resident #61. An audit of all active residents was completed on [DATE], by the DON, the Assistant Director of Nursing (ADON), and the unit manager. Chart reviews were completed to ensure there were no conflicting code status orders and that documentation matched the care plan and the POLST, Advanced Directive, and or provider notes. No other mismatches were identified during the initial audit. All findings from the initial audit were documented on an audit tracking tool spreadsheet. The DON and ADON were educated and trained by the Market Clinical Advisor on all areas listed below on [DATE]. All licensed nurses, the Admissions Director, the Medical Records, therapy staff and social services were educated by the ADON between [DATE] and [DATE], either in person or via telephone if not present in the facility, on how to verify code status during admissions and readmissions. All licensed nurses were also educated by the ADON between [DATE] and [DATE], on new physician's orders stop and verify protocol: nurses must confirm that whenever a new Code Status order is entered, no contradicting orders remain to confirm accuracy of code status on the shift-to-shift report daily. The survey team verified the implementation of the Removal Plan on-site on [DATE] at 6:59 PM, and determined the immediacy was removed.NJAC 8:39-4.1(a)(2)NJAC 9.6

Based on observation, interviews, and facility policy review, the facility failed to ensure areas in the kitchen remained sanitary including sanitation buckets remaining at the correct Parts Per Million (PPM) level, the outside of the ice machine was cleaned, dry storage was properly labeled and dated, broken equipment was not used and covers for the steam table were clean when in use. This failure had the potential to affect the spread of food borne illness for 100 of 101 total sampled residents. Findings include:During the initial kitchen tour on 12/01/25 at 10:30 AM with the Dietary Manager (DM), the following observations were made: 1. The sanitary bucket used for wiping cloths, located on the shelf near the floor, was tested and revealed 0 PPM of sanitizer. 2. The lower front of the ice machine was covered in splattered food and water stains. 3. Four ingredient bins, located in the dry storage room, were not labeled or dated. There was one bin with flour, one with breadcrumbs, one with sugar and one with rice. 4. Two plastic containers that held cups and small desert bowls with lids. The lids on both containers had a dirty film and sticky crumbs. Inside the container was a bowl that had dried pudding inside. 5. There was a large coffee urn that had approximately six inches of packing tape at the bottom. The DM stated it had broke but they were continuing to use it until the new coffee urn arrived.6. The cover for one of the steam table pans had hard gravy drippings approximately 4 inches long and 1/2 inches wide. During an interview on 12/01/25 at 10:30 AM, the DM stated she had a cleaning schedule, but it was not in writing. She stated that the containers that held flour, breadcrumbs, sugar and rice, should be labeled and dated. She stated the red buckets that hold the sanitizer wash should be changed every two hours and should always have the required PPM to be effective. The DM stated only clean dishes should be stored and containers that hold dishes should also be clean. She stated that broken equipment should be thrown away and replaced.During an interview on 12/04/25 at 3:07 PM, the Administrator stated that kitchen sanitation policies should be followed. She stated if something is broken it should be thrown away and replaced. Review of the facility's policy titled, Environment, revised 06/2025, revealed All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Dining Services Directory will ensure that the kitchen is maintained in a clean and sanitary manner . All food contact surfaces will be cleaned and sanitized after each use . The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. NJAC 8:39-17.2(g)

Based on record review and interview, the facility failed to ensure that four residents (R70, R11, R77, and R20) out of 37 residents sampled had a Minimum Data Set (MDS) that accurately reflected their Preadmission Screening and Resident Review (PASRR) Level II status. This had the potential to affect all residents who qualified for a PASRR Level II. Findings include:1.Review of R70's admission Record located in the Profile tab of the electronic medical record (EMR) revealed a re-admission to the facility on [DATE]. Review of R70's annual MDS under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 06/29/25, revealed no indication of a Mental Illness or Level II services. Review of R70's PASARR I located under the Resident Documents tab in the EMR dated 04/03/18 revealed the resident was referred for a level II. During an interview on 12/04/25 at 9:17 AM the Minimum Data Set (MDSC) nurse stated that all the MDS assessments in section A of the Level II PASARR Conditions were done incorrectly per the Resident Assessment Instrument (RAI) manual, and she would need to modify them. She stated all the residents should have had PASRR level II indicated on section A of their comprehensive assessments. During an interview on 12/04/25 at 11:44 AM the Director of Nursing (DON) said she expected MDS assessments to be completed accurately. 2. Review of the admission Record, located in the profile tab of the EMR indicated that R11 was admitted to the facility on [DATE] with a diagnosis of bipolar and major depressive disorder. Review of Level 2 PASRR, dated 03/12/25, located under the tab document in the EMR, indicated.has a mental health treatment needs that can be met in a nursing facility. The following recommendations are being made for the client: psychiatric consultation upon admit to the nursing facility, routine follow up visits with primary and psychiatrist, medication monitoring, supportive counseling, routine lab testing, formulate and implement a behavioral modification plan to address any behavioral disturbances, provide education on medication to client and family on mental illness and medication, and develop a crisis intervention/safety plan with the client.Review of R11's annual MDS with and ARD of 03/31/25 revealed there was no level 2 PASSR noted on the MDS. 3. Review of the admission Record, located in the profile tab of the EMR indicated that R77 was re-admitted to the facility on [DATE] with a diagnosis of schizophrenia. Review of Level 2 PASRR, dated 05/26/21, located under the tab document in the EMR, indicated .has a mental health treatment needs that can be met in a nursing facility. The following recommendations are being made for the client: psychiatric consultation upon admit to the nursing facility, routine follow up visits with primary and psychiatrist, medication monitoring, supportive counseling, routine lab testing, formulate and implement a behavioral modification plan to address any behavioral disturbances, provide education on medication to client and family on mental illness and medication, and develop a crisis intervention/safety plan with the client.Review of R77's significant change MDS assessment with ARD 02/23/25 revealed there was no level 2 PASRR noted.During an interview on 12/04/25 at 10:35 AM, the MDSC confirmed that both of the MDSsfor R11 and R77 were coded incorrectly. 4. Review of R20's Face Sheet located in the EMR under the Profile tab revealed an admission date of 01/19/25 with medical diagnosis of bipolar disorder.Review of R20's annual MDS located in the EMR under the MDS tab with an ARD of 01/24/25 revealed the resident was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Review of R20's Care Plan located in the EMR under the Care Plan tab, with a revised date of 10/15/25, revealed the focus was [R20] meets PASRR II Level of Determination secondary to: dx (diagnosis) of Serious Mental Illness. The goal was for R20 to Be appropriately evaluated and re-evaluated for specialized services as needed and per state requirements. Interventions included Arrange for PASRR re-evaluation if there is a significant change in status that results in new evidence of possible mental disorder, intellectual disability and/orrelated condition.During an interview on 12/04/25 the MDSC stated R20's MDS was inaccurate and she would be submitting a correction. During an interview on 12/04/25 at 3:07 PM, the Administrator stated that all MDSs should be accurate upon submission. NJAC 8:39-33.2(d)

Based on interview, record review, review of facility reported incident (FRI), and review of the facility policy, the facility failed to ensure one (Resident (R) 46) of four residents reviewed for abuse out of a total sample of 37 residents was free from abuse. This had the potential for an injury to the resident. Findings include:1.Review of R85's admission Record, located in the profile tab of the electronic medical record (EMR) indicated the resident was re-admitted to the facility on [DATE] with severe dementia with agitation. An attempt was made to interview R85 however he did not respond to questions. 2. Review of R46's admission Record, located in the profile tab of the EMR indicated that R46 was re-admitted to the facility on [DATE] with bipolar and adjustment disorder with mixed anxiety and depressed mood. Review of R46's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/24/25 revealed that R46 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating she was moderately impaired cognitive function. During an interview on 12/03/25 at 5:40 PM, R46 revealed R85 got upset when he told him to go away and R85 hit him on the chin. R46 denied that R85 had ever hit him prior to this. Review of the unlabeled, undated Facility Reported Incident (FRI) summary (5-day) revealed that on 11/26/25, a staff member witnessed R85 approach R46. R46, told him [meaning R85] to go away and R85 hit R46 on his [meaning R46] chin. Both residents were immediately separated. Skin assessments were performed on both residents, and no apparent injuries were noted to either resident. R85 did not recall the incident; however, R46 stated that R85 hit him on his chin because he told him to go away. The team feels that when R46 told R85 to go away, he [R85] became agitated and retaliated due to his declining cognitive status. R46 was offered and accepted a room change on the opposite side of the unit. However, later in the shift, he requested to return to his old room. R46 revealed they felt safe in the facility. During an interview on 12/03/25 at 1:15 PM, the Director of Nursing (DON) stated this was an isolated occurrence. During an interview on 12/04/25 at 3:15 PM, the Administrator indicated that this was an isolated occurrence and there had not been another occurrence since then. Review of a policy document titled Abuse Prohibition, revised 11/14/25 indicated Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients.This includes, but is not limited to, freedom from.and any physical. NJAC 8:39-4.1(a)

Based on record reviews, interviews, and facility policy review, the facility failed to identify targeted behaviors, conduct behavior tracking and monitor the side effects of antipsychotic medications for two of five sampled residents (Resident (R) 80 and R6) reviewed for unnecessary medications out of a total sample of 37 residents. These failures placed the residents at risk for not obtaining the intended therapeutic goal of the antipsychotic medication and the potential for serious adverse effects from the antipsychotic medications.Findings include: 1.Review of R80's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Profile tab, indicated the resident was re-admitted to the facility on [DATE] with diagnoses including schizophrenia. Review of R80's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/25 and located in the EMR indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R5 was cognitively intact. The assessment indicated the resident exhibited verbal behaviors one to three days, but no other behaviors were indicated. Review of R80's Physician Order Report dated 09/16/25 and found in the EMR under the Orders tab, indicated R80 was to receive Zyprexa 10 milligrams (mg), one tablet by mouth in the evening for schizophrenia. Review of R80's Medication Administration Record (MAR), dated October, November and December 2025 and found in the EMR under the Orders tab, revealed no documented evidence to show which specific behaviors or side effects were associated with the administration of the resident's antipsychotic medications and required routine monitoring. Review of R80's ''Nurse's Notes'' located in the EMR under the ''Notes'' tab for October, November and December 2025 revealed no documented behaviors related to a diagnosis of schizophrenia. During an interview on 12/03/25 at 3:25 PM Licensed Practical Nurse (LPN)4 stated they do not have a does not list specific side effects or behaviors to look forDuring an interview on 12/03/25 at 4:00 PM Registered Nurse (RN)1 stated if they see any behaviors they will document that. But they have never been instructed to look for specific behaviors for each medication or been told which specific side effects for each medication to look for. She was unable to state which specific side effects to look for related to R80's medication. During an interview on 12/04/25 at 11:44 AM the Director of Nursing (DON) said she was unaware that nursing staff were not monitoring target behaviors or side effects and she expected them to. 2.Review of R6's undated Face Sheet, located in the EMR under the Profile tab, revealed R6 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia. Review of R6's annual MDS with an ARD of 10/13/25, located in the EMR under the MDS tab, revealed R6 had a BIMS score of 15 out of 15, which indicated R6 was cognitively intact. R6 did not exhibit any behaviors within the review period. R6 received an antipsychotic medication routinely during the lookback review period of Risperidone 1mg (milligrams) twice dailyReview of R6's comprehensive Care Plan, updated 09/13/25, located in the EMR under the Care Plan tab, documented [R6] is at risk for complications related to the use of psychotropic drugs . Resident has a hx (history) of paranoia, screaming and curing at others, hallucinations and punching others, racial slur toward staff.Review of R6's Physician's Orders, dated 01/2023, located in the EMR under the Orders tab, revealed R6 received Risperidone (an antipsychotic) 1mg twice daily, with a start date of 05/08/23. Further review failed to reveal orders for behavior tracking and to monitor the side effects of antipsychotic medications. Review of R6's Medication Administration Records (MAR) and Treatment Administration Records (TAR), dated 11/2025 and 12/2025, located in the EMR under the Orders tab, revealed Chart behaviors every shift. The MARS failed to reveal the specific behaviors staff should track. orders for tracking specific behaviors and tracking medication side effects when monitoring antipsychotic medications.During an interview on 12/03/25 at 11:01 AM, the Director of Nursing (DON) stated even though the behaviors are on the care plan, there are no orders for the specific behaviors. She stated risks of taking an antipsychotic should also be in the MAR for monitoring.During an interview on 12/03/25 at 1:45 PM, Licensed Practical Nurse (LPN) 1 stated that R6 did not have targeted behaviors documented in his physician orders on the MAR but should be.During an interview on 12/04/25 at 3:07 PM, the Administrator stated she expected staff to ensure targeted behaviors and risks of medications were identified and monitored. Review of a facility document titled, Psychotropic Drug Use, dated 10/31/18, documented Each customer [resident] receiving an antipsychotic medication for organic mental disorders .is observed for 1. Episodes of the behavioral symptoms being treated and/or manifestations (s) of the disordered thought process. 2. Adverse reactions and side effects. 3. Appropriateness of drug selection and dosage. NJAC 8:39-27.1(a)

Based on record review, interview, and policy review, the facility failed to report an allegation of verbal abuse within two hours for two of three residents (Resident (R) 80 and R46) reviewed for abuse out of a total of 37 residents. his had the potential for continued abuse of the residents.Findings include:1. Review of R80's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Profile tab, indicated the resident was re-admitted to the facility on [DATE] with diagnoses including schizophrenia. 2. Review of R46's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and bipolar disorder. Review of the Nurse's Note dated 08/23/25 and located under Progress Notes tab in the EMR revealed During the 3-11 shift, R80 had reportedly threatened R46 in stating he was going to blow his head off, if he doesn't give him a cigarette while cursing and causing a disturbance in the hallway. That episode had been managed at the time.During an interview on 12/03/25 at 9:43 Registered Nurse (RN)4 stated that earlier in the day after that last smoking break during the 3-11 shift R46 came upstairs and told her that R80 threatened to shoot him because he would not give him a cigarette. She stated that she did not witness this interaction and that R80 denied saying it. She said R46 stated he was not afraid and that R80 had verbal outburts at times. She stated she did not talk to any of the staff who supervised smoking or any other residents, and she did not report it, but she should have. During an interview on 12/04/25 at 11:44 AM, the Director of Nursing (DON) was not made aware of the incident that occurred on 08/22/25, until the next morning on 08/23/25. She stated she did not feel the need to report it since she spoke with R46, and he denied anything occurred and he felt safe. Review of the Facility's policy titled OPS300 Abuse Prohibition revised 11/14/25, revealed Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following: Report allegations involving abuse (physical. verbal. sexual. mental) not later than two hours after the allegation is made. NJAC 8:39-9.4(f)

Based on record review, interview, and policy review, the facility failed to thoroughly investigate allegations of verbal and physical abuse for two residents (Resident (R) 46 and R85) out of five residents reviewed for abuse out of a total sample of 37 residents. This had the potential for continued abuse of the residents.Findings include:1. Review of R80's undated Resident Face Sheet found in the electronic medical record (EMR) under the Profile tab, indicated the resident was re-admitted to the facility on [DATE] with a diagnosis of schizophrenia. Review of R46's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and bipolar disorder. Review of the Nurse's Note dated 08/23/25 and located under Progress Notes in the EMR revealed During the 3-11 shift, R80 had reportedly threatened R46, stating he was going to blow his head off, if he doesn't give him a cigarette while cursing and causing a disturbance in the hallway. That episode had been managed at the time.Review of Soft File undated revealed the Director of Nursing (DON) was made aware of the incident that occurred on 08/22/25 on 08/23/25. Further review revealed no staff who supervised smoking were interviewed or other staff other than Registered Nurse (RN)4 and no residents were interviewed including R46 and R80. During an interview on 12/03/25 at 9:43 RN4 stated that earlier in the day after that last smoking break during the 3-11 shift R46 came upstairs and told her that R80 threatened to shoot him because he would not give him a cigarette. She stated that she did not witness this interaction and that R80 denied saying it. She said R46 stated he was not afraid and that R80 had verbal outburts at times. She stated she did not talk to any of the staff who supervised smoking or any other residents and she did not report it but she should have. During an interview on 12/04/25 at 11:44 AM the Director of Nursing (DON) said she spoke with R46 who stated nothing occurred and he was not fearful and therefor she did not feel the need to interview other residents or staff. She stated since R46 felt safe they were satisfied that there was no concern. 2.Review of R85's admission Record, located in the profile tab of the electronic medical record (EMR) indicated the resident was re-admitted to the facility on [DATE] with severe dementia with agitation. An attempt was made to interview R85 however he did not respond to questions. Review of the undocumented, undated summary (5-day) revealed that On 11/26/25, a staff member witnessed R85 approach R46. R46, told him [meaning R85] to go away and R85 hit R46 on his [meaning R46] chin. Review of the Facility Reported Incident (FRI), there was evidence of only one staff being interviewed and no residents being interviewed regarding the abuse allegation. During an interview on 12/02/25 at 3:00 PM, the DON stated that there was only one staff member that had direct knowledge of the incident, so that is the only staff interview that was obtained. Confirming that there were no resident interviews obtained. The DON said that there were no residents involved. Review of the Facility's policy titled OPS300 Abuse Prohibition revised 11/14/25 revealed, initiate an investigation within 24 hours of an allegation of abuse that focuses on: whether abuse or neglect occurred and to what extent; clinical examination for signs of injuries. if indicated, causative factors; and interventions to prevent further injury. The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews is included. NJAC 8:39-4.1(a)NJAC 8:39-9.4(f)NJAC 8:39-27.1(a)

Based on interview, record review, and policy review, the facility failed to ensure one resident (Resident (R) 5) of 37 residents reviewed was invited to their care plan conference. The facility further failed to hold a care plan conference for R119. This had to potential to cause the residents to be not informed regarding their care. Findings include:1.Review of R5's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed an admission date of 08/18/23 with medical diagnosis of chronic kidney disease.Review of R5's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an assessment reference date (ARD) of 09/07/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R5 was cognitively intact. Review of the Care Conference Notification Letter dated 06/04/25 located in the EMR under the Documents tab revealed, Care plan conference for (R5) on Thursday June 12th at 1:00 PM. The letter was addressed to R5's family members. There was no documentation to support that R5 received notification. Review of the Progress Note dated 06/12/25 located in the EMR under the Progress Notes tab revealed the care plan meeting was held and the resident or family did not attend. Review of the Care Conference Notification Letter dated 08/25/25 located in the EMR under the Documents tab revealed, Care plan conference for (R5) on Thursday, September 4th at 1:00 PM. The letter was addressed to R5's family members. There was no documentation to support that R5 received notification.Review of the Post admission Patient-Family Conference located in the EMR under the Assessments tab, dated 09/08/25 revealed attendees included resident's family, Social Services, Nurse Unit Manager, and Director of Rehab. There was no documentation indicating why R5 did not attend.During an interview on 12/01/25 at 1:35 PM, R5 stated she was not aware of any care conference, nor had she attended a care conference. She stated she would like to attend.During an interview on 12/04/25 at 11:40 AM, the Medical Records Specialist (MRS) stated if a resident did not have family or a responsible party she would give the care conference notice to the resident. If the resident did have family she would give the notice to the family member. She stated she thought the family would then notify the resident. During an interview on 12/04/25 at 11:01 AM, the Director of Nursing (DON) stated residents should always be invited to their care plan meeting. During an interview on 12/04/25 at 3:07 PM, the Administrator stated the resident should always be invited to the care conference and encouraged to attend.2. Review of the admission Record, located in the profile tab of the EMR indicated that R119 was admitted to the facility on [DATE] with diagnoses of anxiety, chronic pain syndrome, cerebrovascular accident (CVA), depression, epilepsy, muscle spasms, and polyneuropathy. Review of the Progress Notes located it the Progress Notes tab of the EMR revealed no evidence of care planning meeting being held quarterly for R119. During an interview on 12/04/25 at 1:50 PM, the MDS Coordinator (MDSC) indicated that prior to January 2025 there was no process in place to determine who gets invited to the care plan meetings and when they were scheduled. The MDSC confirmed that R119 had one in-progress for 06/18/24, otherwise no record for care conferences were found in the medical record for R119. Review of the facility's policy titled Person Centered Care Plan dated 09/15/25 revealed, Care plan meetings: The center has the responsibility to assist patients to participate by extending invitation to pertinent and representatives sent in advance; holing care planning meetings at the time of day when the patient is functioning best, facilitating the inclusion of the patient/representative(s) to attend; and incorporating the patient's personal and cultural preferences in developing goals of care. NJAC 8:39-11.2(e)(f)(h)

Based on observations, interviews, and facility policy review, the facility failed to ensure a homelike environment when staff delivered the lunch meal on a tray from the cart to the table and did not remove the food from the tray in the dining room for 16 of 55 residents that resided on Unit C (Residents (R) 16, R23, R39, R47, R49, R54, R56, R69, R70, R75, R80, R86, R90, R110, R113 and R123. This failure had the potential to result in an institutional dining experience. Findings include: During an observation on 06/11/24 at 12:01 PM, two staff members delivered the lunch meal trays and sat them on the tables in front of R16, R23, R39, R47, R49, R54, R56, R69, R70, R75, R80, R86, R90, R110, R113 and R123. Continued observation revealed nursing staff in the dining room did not remove the food from the tray and place it on the table after the trays were delivered. During an interview on 06/11/24 at 12:13 PM, Certified Nursing Assistant (CNA) 5 verified she had worked at the facility since 2014 and the food was not removed from the tray after it was placed on the table in the dining room on Unit C. During an interview on 06/11/24 at 12:15 PM, CNA6 confirmed she had worked at the facility less than one month and resident's food was always served on trays and not removed from the tray after placed on the table in front of the residents in the dining room. During an interview on 06/11/24 at 12:16 PM, Licensed Practical Nurse (LPN) 3 acknowledged she had worked at the facility over three years, and she had observed staff removing the meal trays from the cart, placing it on the table in front of the residents without removing the plates, bowls, drinks, and utensils from the tray. During an interview on 06/14/24 at 8:53 AM, the Director of Nursing (DON) and Administrator stated leaving food on the trays after being served in the dining room was a cafeteria setting and not a homelike environment. Review of the facility's policy titled, Resident Rights Under Federal Law, revised on 02/01/23 and provided by the facility, revealed . 9. Safe Environment. The resident has the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety NJAC 8:39-31.4(a)

Based upon observation, interview, and facility policy review the facility failed to allow cooking vessels to completely air dry before being placed for storage in one of one kitchen. This failure has the potential to create an environment that would enable bacteria growth between the vessels which could cause illness among 127 of 128 residents. Findings include: During an observation and interview on 06/11/24 at 10:10 AM with the Chef Manager (CM), buffet pans and other pans were stacked to be stored without reaching complete dryness. The CM was shown the multiple stacked pans, and the CM stated all the washed items should have been completely dried before stacking and storing. The CM then proceeded to take the stacks of wet items to the dishwasher room. During an observation and interview on 06/12/24 at 2:34 PM, with the CM and Food Services Director (FSD), buffet pans and other pans were stacked to be stored without reaching complete dryness. The CM and FSD were shown the multiple stacks, and the CM stated all the washed items should have been completely dried before stacking and storing, and that the staff were educated on 06/11/24, the day before. The CM then proceeded to take the stacks of wet items to the dishwasher room to be recleaned. During an interview on 06/14/24 at 11:20 AM, the Administrator verified nesting pans stored for future use in the kitchen should have been completely dried before being stacked together. Review of the facility's policy titled, Warewashing, revised 02/23 and provided by the facility, revealed all dishware, service ware, and utensils will be cleaned and sanitized after each use. The policy continued to indicate, all dishware will be air dried and properly stored. NJAC 8:39-17.2(g)

Based on observation, interviews, record review, and facility policy review, the facility failed to follow a physician's order for a right-hand splint device for one of one resident (Resident (R) 74) reviewed for range of motion of 34 sample residents. This failure could potentially cause worsening contractures and a decline in range of motion. Findings include: Review of R74's Admission Record tab located in the electronic medical record (EMR), indicated R74 was admitted to the facility on [DATE] with diagnoses to include but not limited to, hypertension, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and unspecified lack of coordination. Review of R74's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R74 had moderately impaired cognition. Review of R74's Care Plan, dated 05/12/24 and located in the EMR under the Care Plan tab, revealed [R74] to use RUE (Right Upper Extremity) hand splint during daytime for 6-8 hours . Review of the Physician Orders, dated 05/10/24 and located in the EMR under the Orders tab, revealed R74 to wear a RUE resting hand splint daily for 6-8 hours (hrs.) during daytime .Assistance for application/removal was required every day and evening shift. During an observation and interview on 06/11/24 at 2:29 PM, R74 had a right-hand splint device, which was light and dark blue, lying on his dresser across the room. an interview, R74 was asked about the hand splint observation. R74 stated he was to wear the splint every day and proceeded to remove his right hand from under his bed sheets and showed me his right hand, which was contracted. R74 was asked why he was not wearing his hand splint and R74 stated, No one has put it on me. During an observation on 06/12/24 at 9:12 AM, R74 was lying in his bed resting and observation of the light and dark blue hand splint was still lying on the dresser in the same position as observed on the previous day on 06/11/23. During an interview on 06/12/24 at 9:12 AM, Licensed Practical Nurse (LPN) 2 stated R74 RUE splint should have been worn daily, she placed the splint on R74's right hand. LPN2 was asked the importance of wearing a hand splint and the LPN2 stated, Splints should be worn as ordered and if not worn regularly R74 could lose what range of motion he has. LPN2 further stated that R74 was not able to apply the splint on his own. During an interview on 06/12/24 at 2:19 PM, the Director of Nursing (DON) revealed her expectation of staff was that all physician orders were followed. During an interview on 06/12/24 at 3:17 PM, the facility Administrator revealed her expectation of staff was that physician orders were followed. Review of the facility's policy titled, Activities of Daily Living (ADL), dated 05/01/23, revealed Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) abilities are maintained or improved and do not diminish unless circumstances of the patient's clinical condition demonstrate that a change was unavoidable .assistive devices and adaptive equipment are provided as needed. NJAC 8:39-27.1(a)

Based on observations, interviews, record review, and facility policy review, the facility failed to maintain the residents' dignity when staff stood while assisting residents to eat in the dining room for one of 17 residents (Resident (R) 16) reviewed for meal assistance of 34 sampled residents. This failure had the potential to result in an undignified dining experience. Findings include: Review of R16's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses to include unspecified dementia with agitation and dysphagia. Review of R16's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/29/24 located in R16's EMR under the MDS tab, revealed R16 had a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated the resident was severely cognitively impaired. The MDS revealed R16 required a mechanically altered diet. During an observation on 06/11/24 at 12:02 PM, the meal trays were delivered to 17 residents seated at four tables in the Unit C dining room. During an observation on 06/11/24 at 12:06 PM, R16 was sitting in a wheelchair at the second table in the dining room with the lunch meal placed on the tray in front of her. Continued observation revealed Licensed Practical Nurse (LPN) 3 walked over to R16, picked up a fork then fed her small bites of food from the plate, while standing next to her. During an interview on 06/11/24 at 12:16 PM, LPN3 confirmed she was standing over R16 while assisting her to eat the lunch meal in the dining room. LPN3 stated that by standing while feeding R16 she didn't maintain her dignity. LPN3 also stated she could not find a chair to sit in, so she fed her standing up because she wanted to feed R16 while the meal was warm. During an interview on 06/14/24 at 8:53 AM, the Director of Nursing (DON) and interim Administrator stated they expected nursing staff to sit down next to the resident while feeding them to maintain their dignity. Review of the facility's policy titled, Resident Rights Under Federal Law, revised on 02/01/23 and provided by the facility, revealed . Purpose To treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and selfworth . 5. Respect and Dignity. The resident has a right to be treated with respect and dignity, including (refer lo Center Operations Policies and Procedures, Treatment: Considerate and Respectful) NJAC 8:39-4.1(a)(12)

Based on observation, interview, record review, and facility policy review, the facility failed to follow infection control and prevention guidelines to prevent cross-contamination when they did not follow Enhanced Barrier Precautions (EBP) while performing catheter care for one of one resident (Resident (R) 103) reviewed for catheters of 34 sampled residents. This failure had the potential to spread multidrug resistant organisms (MDROs) to the residents. Findings include: Review of R103's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R103 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, C5-C7 incomplete, colostomy status, pressure ulcer of sacral region stage three, and suprapubic catheter status. Review of R103's comprehensive Care Plan located in the EMR under the Care Plan tab, revealed the following focus areas: I, [R103] have a PICC [peripherally inserted central catheter] line measuring 36cm [centimeters] in my RUE [right upper extremity] r/t [related to] use of ABX [antibiotic] therapy secondary to Multi-Organism Wound Infection [a germ that is resistant to treatment with many antibiotics] , dated 03/01/24, with no EBP interventions; I, [R103] have actual skin breakdown present on admission r/t impaired gait and mobility, deconditioning s/p [status post] hospitalization Wounds Present on Admission: actual pressure ulcer, sacrum, Rt [right] buttock, Lt [left] hip: B/L [bilateral] heels, Rt foot, dated 09/20/23, with no EBP interventions; and I, [R103] have a supra-pubic catheter placed d/t [due to] neurogenic bladder, dated 09/20/23, with no EBP interventions. Review of R103's Physician's Orders, dated 06/01/24, located in the EMR under the Orders tab, revealed orders as follows: Perform Indwelling Catheter Care (Suprapubic catheter 18F [French] with 10 ml [milliliters] balloon) every day and evening shift, Observe right arm double lumen PICC every shift and Dakins (1/4 strength) External Solution (Sodium Hypochlorite) Apply to coccyx topically every day and evening shift for wound***Cleanse wound with Dakin's Solution, apply Silvadene Cream to wound bed, apply wet to dry packing and cover with Silicone bordered foam and apply to coccyx topically as needed for Wound ***Change dressing if loose or soiled. Observation on 06/11/24 at 10:18 AM revealed R103 lying in bed with the indwelling urinary catheter tubing not kinked, the catheter bag was not covered, and was attached to the bottom bed rail. There was no EBP sign on the resident's door and no cart with personal protective equipment (PPE) near or outside of the resident's room. Interview with R103 at this time revealed staff were not wearing a gown when performing catheter or wound care. Observations on 06/11/24 at 10:39 AM, 12:32 PM, and 2:50 PM, revealed there was no EBP sign on R103's door and no PPE cart outside of the room. During an interview and observation on 06/11/24 at 12:34 PM, Licensed Practical Nurse (LPN) 2 confirmed R103 did not have an EBP sign on the door and there was no PPE cart outside of the room or in the hallway. During an interview on 06/11/24 at 12:34 PM, LPN3 verified R103 did not have an EBP sign on the door and there was no PPE cart outside of R103's room. LPN3 stated nursing staff were trained by the former Infection Preventionist (IP) on EBP a few months ago and the EBP was used for residents with open wounds, indwelling urinary catheters, PICC lines, and MDROs (multidrug resistant organisms). LPN3 stated EBP were extra precautions that you took when providing wound and catheter care and should wear a gown and gloves when performing wound and catheter care. During an interview on 06/11/24 at 12:40 PM, Certified Nursing Assistant (CNA) 4 stated she was trained by the former IP on EBP a few months ago and should wear a gown and gloves when providing care to residents but she didn't know which residents should be on EBP. CNA4 also stated residents on EBP would have an EBP sign on the outside of the door and a PPE cart would be placed outside of the door. CNA4 verified R103 did not have an EBP sign on the door or PPE cart in the hallway. CNA4 also stated she was assigned to R103 and had provided catheter care using gloves but not a gown. During an interview on 06/12/24 at 8:31 AM, the Nurse Manager stated the IP would place an EBP sign on the door and PPE cart outside of the room if the resident had an open wound, indwelling catheter, PICC line, and MDRO. The Nurse Manager also stated R103 should have been placed on EBP when he was readmitted on [DATE] but someone missed it. The Nurse Manager indicated a gown, and gloves should be worn when the nursing staff were providing high touch activities for residents on EBP and that these precautions were implemented to protect residents and staff from spreading MDROs. During an interview on 06/12/24 at 4:22 PM, CNA7 acknowledged R103 was not on EBP on 06/11/24 and did not know why the resident was on the precautions today because he had not received report yet. During an interview on 06/14/24 at 12:32 PM, the Administrator stated the former IP resigned two months ago and trained the staff on EBP prior to her departure. The Administrator also stated the interim IP was at the facility most days of the week but not on the weekends and expected the admitting nurse to implement EBP and update the care plan when R103 was readmitted to the facility from the hospital on 06/01/24. During an interview on 06/14/24 at 1:16 PM, the interim IP acknowledged EBP was not implemented for R103 until 06/12/24 and she expected the admitting nurse to implement EBP and document EBP on the care plan after his readmission to the facility on [DATE] per the EBP policy. The interim IP stated the EBP signs were available on the floor at the nurses' station and nursing staff had access to the PPE carts during the week and on weekends. The interim IP also stated that the facility must implement EBP for residents with MDROs but could use their discretion for residents with devices such as PICC lines, indwelling urinary catheters, and open wounds. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), revised 04/01/24 and provided by the facility, revealed . l. Prompt recognition of need: . c. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. 2. Initiation of Enhanced Barrier Precautions: a. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by Center for Disease Control (CDC). b. 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) even if the resident is not known to be infected or colonized with a Multi- Drug Resistant Organisms MDRO) . 4. High-contact resident care activities include: . g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes . Review of the facility's policy titled, Enhanced Barrier Precautions, revised 01/08/24 and provided by the facility, revealed Policy In addition to Standard Precautions, Enhanced Barrier Precautions (EBP) will be used for novel or targeted multi-drug resistant organisms (MDROs) . Purpose to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. Refer to: Enhanced Barrier Precautions procedure Review of the facility's document titled, Procedure: Enhanced Barrier Precautions, revised 05/01/24 and provided by the facility, revealed 1. Post the appropriate Enhanced Barrier Precautions (EBP) sign on the patient's room door . 1.1 Enhanced Barrier Precautions (EBP) are to be utilized for the duration of the patient's stay . 3. Follow the CDC [Centers for Disease Prevention and Control] guidance per table below . Enhanced barrier applies to chronic wounds and/or indwelling medical devices (e.g., central line, urinary catheter, enteral feeding tube, tracheostomy, ventilator) regardless of MDRO colonization status. PPE used for these situations during high contact patient care activities: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, enteral feeding tube, tracheostomy, ventilator, wound care, any skin opening requiring a dressing . Required PPE gown, gloves prior to high contact care activity (change PPE before caring for another patient) . 4. PPE should be accessible and located outside of the patient's room . 12. document: 12.1 type of precautions in care plan Review of the facility's staff in-service titled New EBP Policy, dated 03/20/24 and provided by the facility, revealed nursing staff were trained on the new EBP guidelines. NJAC 8:39-19.4

C#: NJ158046 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 9/21/2022, 9/26/2022, and 9/29/2022, it was determined that the facility failed to supervise and monitor a moderately cognitively impaired resident (Resident #2) appropriately, with a known diagnosis of Anoxic Brain Damage, Cognitive Communication Deficit, Unspecified Dementia with Behavioral Disturbance, Generalized Muscle Weakness, and Unspecified Altered Mental Status, from eloping on 8/20/2022. Resident #2 eloped from the facility, unknowing to the facility staff. According to the Certified Nursing Assistant (CNA), she first saw Resident #2 on 8/20/2022 at 7:45 a.m., when delivering breakfast, and left the Resident sitting in his/her wheelchair with the meal tray in front of the Resident. According to the Occupational Therapist (OT), she went to Resident #2's room to take the Resident to therapy in the morning at approximately 9:20 to 9:30 a.m. The OT stated she took Resident #2 in a wheelchair. However, the OT said she did not recall seeing or hearing Resident #2's Wander Guard (WG) beep when the Resident got on the elevator. The OT explained while taking Resident #2 to rehab, the Resident refused and stated that he/she wanted to wait for his/her spouse. The OT left Resident #2 in the lobby where the Receptionist, other residents, and their family members were. The OT did not notify any facility staff that she left the resident unattended in the lobby. According to the Receptionist, she observed Resident #2 in the lobby with the OT and sitting in front of the front window. However, she did not see Resident #2 go out of the door, and she did not hear the alarm sound. At approximately 10:45 a.m., during the CNA's morning break, she saw a wheelchair in front of the facility, and through the trees in the adjoining parking lot, she noticed someone hanging onto tree branches. The CNA went to see who it was and then realized it was Resident #2. After realizing it was Resident #2, she told the Resident to sit on the ground. The CNA returned to the building to notify the nurse. The CNA and the nurse returned to the parking lot with the Resident's wheelchair, which was still in front of the facility, and brought the Resident back to the facility. Upon returning to the facility, Resident #2 was assessed by the nurse. The Resident had abrasions to the right knee and left forearm, treatment was applied, and an X-ray was ordered. The X-ray was negative for fracture. The facility also failed to follow its policies titled Accidents and Incidents, Person-Centered Care Plan, and Elopement of Patient. The facility's failure to prevent Resident #2, who was an elopement risk from eloping on 8/20/2022, placed Resident #2 and all other residents with wandering behaviors at risk for elopement in an Immediate Jeopardy (IJ) situation. This IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Assistant, Director of Nursing (ADON) on 9/26/2022 at 5:45 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ began on 8/20/2022 and continued through 9/29/2022 when the facility started an elopement in-service, and Resident #2 was placed on continuous one-to-one monitoring with a designated staff assigned. On 9/29/2022, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating staff on the Elopement Policy with specific reference to Resident #2 for exit seeking, frequent removal of wander guards, and providing continuous one-to-one monitoring for Resident #2. So, the noncompliance remained on 09/29/2022 as a level D for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice was identified for 1 of 5 residents ( Resident #2) and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by the healthcare facilities to report incidents on 8/24/2022, with an event date of 8/20/2022 and a time of event of 10:00 a.m., revealed the following: On 8/20/2022, at approximately 10:00 a.m., Resident #2 was observed by the CNA in the Residents' wheelchair in the parking lot of the building next door. Upon bringing the Resident back to the facility, Resident #2 stated he/she was going to check on his/her spouse. The Resident was immediately brought back to the facility by a nurse and the CNA. A physical assessment was done with no injuries, but the Resident complained of knee and right ankle pain. The on-call Physician was notified, and an X-ray was ordered. Findings were negative for fractures and dislocation. According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Anoxic Brain Damage, Cognitive Communication Deficit, Unspecified Dementia with Behavioral Disturbance, Generalized Muscle Weakness and Unspecified Altered Mental Status. According to the Minimum Data Set (MDS), an assessment tool dated 09/19/2022, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 12/15, which indicated the Resident had moderate cognition. The MDS also showed Resident #2 was independent with most Activities of Daily Living (ADLs) and needed supervision and set up with Dressing. A review of the Resident's Care Plan (CP) initiated on 06/24/2022 revealed under Focus: that Resident #2 is at risk for elopement related to Hypoxic brain injury, Dementia. Under Goal, indicated Resident/Patient will not attempt to leave the facility without an escort by next review. Under Interventions included: Med (Medication) Review PRN (as needed) with a date initiated 08/13/2022, Observe risk factors/triggers for exit seeking behavior and adjust care delivery, Monitor the nature and the circumstances (i.e. [for example] triggers) of attempted elopement: during specific activities, involvement of others with resident/patient, patterned etc. and adjust care delivery, Monitor the residents/patients location with visual checks at least every 30 minutes, as needed, date initiated 08/20/2022; Encourage resident/patient participation in activity preferences date initiated 08/16/2022, Allow time for expression of feelings; provide empathy, encouragement, and reassurance, 1:1 monitoring throughout the weekend, date initiated 08/20/2022; STP (Stop): Coach and encourage resident/patient to communicate the desire to leave the program in an appropriate manner, date initiated 08/13/2022, Divert resident/patient by giving alternative objects or activities, date initiated 08/16/2022, Listen to resident/patient try to calm, As appropriate redirect Resident/Patient if near exits or doorways, Wander guard with staff to check frequently as he/she removes it him/her self, date initiated 08/16/2022. Further review of Resident #2's CP initiated 06/14/2022, included under Focus: Resident #2 is at risk for falls: cognitive loss, lack of safety awareness, Hypoxic Brain Injury, Cardiac Hx (history). The CP showed under Goal: Resident #2 will have no falls with injury x 90 days. Under Interventions: included . Encourage resident to notify staff if he/she fall (s), date initiated 6/30/2022, Observe for changes in medical status, pain status, mental status and medication side effects that may contribute to cognitive loss/dementia/delirium and can lead to increase fall risk, report MD (Physician) as indicated, .Encourage resident to utilize w/c (wheelchair) as instructed by therapy, date initiated 7/18/2022. A review of Resident #2's Order Summary Report (OSR)Active Orders as of 09/21/2022 revealed the following Physician Orders (POs): Wander Guard/Wander Elopement Device due to poor safety awareness Expiration date:_August 2024 (update order with new date when the bracelet is changed). Every night shift check function, dated 08/05/2022. Wander Guard/Wander Elopement Device due to poor safety awareness Expiration date:_August 2024 (update order with new date when the bracelet is changed). Every night shift for safety check placement, dated 08/05/2022. A review of Resident #2's Medication Administration Record dated 08/1/2022-08/31/2022 reflected the above POs to check the function and check the placement of the WG for 8/1/2022-8/31/2022 was signed to reflect the WG were checked on the night shift on 8/19/2022 by LPN #4. A review of Resident #2's Progress Notes (PNs) revealed the following: On 8/15/2022 at 1:56 p.m., the PNs written by the Licensed Practice Nurse (LPN #1) revealed Resident #2 had no wander guard on Resident nor on (his/her) w/c. Administrator wait [was] aware the Resident removed wander guard once it's placed. On 08/17/2022 at 9:28 p.m., the PNs written by LPN #2 revealed that Resident #2 still did not have the Wander guard in place. On 8/18/2022 at 11:24 a.m., the PNs written by LPN #1 revealed that Resident #2 had No wander guard. Director of Nursing (DON)/Administrator (Adm) both aware. On 8/18/2022 at 9:14 p.m., the PNs written by LPN #3 revealed Resident #2 .has no wander guard. DON aware. On 8/19/2022 at 10:35 a.m., the PNs written by the Registered Nurse (RN) revealed that Resident #2 removed all wander guard from the wheelchair and on his/her BLE (bi-lateral extremity). On 8/19/2022 at 10:01 p.m., the PNs written by LPN #3 revealed Resident #2 refused (the) wander guard. On 8/20/2022 at 12:47 p.m., the Physician Progress Notes (PPNs) written by the Physician revealed Resident #2 eloped from the facility, found on the parking lot of the next building. According to the PPNs, Resident #2 reports that he/she saw his/her spouse's car pull up next door and went to help him/her and direct him/her to the correct building as he/she has problems with his/her eyes. The PPNs also revealed that the Resident fell while going up the hill. Resident #2 now has pain and a small abrasion to the right knee and ankle discomfort. The PPN further showed that since Thursday, Resident #2 has had problems in the right foot and now appears to be slightly worse. No LOC (loss of consciousness) or head trauma . On 8/20/2022 at 10:00 p.m., the PNs written by LPN #6 revealed Q (every) shift note and or CIC (Change in Condition) follow-up-reason for stay/documentation: Elopement. Additional details about this note: Day 1, 2nd shift. Alert & aware. Able to make simple needs known. Received in room awake. Went down to smoke at 4:15 p.m. Followed (the) Resident down. Was back up in 10 minutes. Stayed up in room the rest of the evening. Consumed most of supper. Refused Depakote. Denied having pain. Sleeping at present. Further review of Resident #2's MR showed no evidence that the CP was followed for 1:1 monitoring. Also, the facility could not provide evidence at the time of the survey that the CP was implemented or what actions were taken when Resident #2 removed his/her WG, refused the WG, or was found without his/her WG in place. A review of the Screening Form for Employees, Visiting Healthcare Personnel, and Visitors dated 8/20/2022 revealed Resident #2's spouse did not visit that day. A review of the All Home Active time sheet for the Receptionist revealed on Sat (Saturday), 8/20/2022, a clock-in time of 8:12 a.m. A review of the timesheet for the OT revealed on the Selected Date of 8/20/2022, a clock-in time of 8:40 a.m. A review of the C-Wing Nursing Assignment 7-3 shift for 5 CNAs, dated 8/20/2022, revealed the morning break time for the CNA assigned to Resident #2 was 10:45 a.m. A review of the C-Wing Nursing Assignment 7-3 (7:00 a.m.- 3:00 p.m.) shift, 3-11 (3:00 p.m.- 11:00 p.m.) shift for 5 CNAs, dated 8/20/2022 and C-Wing Nursing Assistant 11-7 (11:00 p.m. - 7:00 a.m.) shift for 3 Aids dated 8/20-8/21/22 did not reveal designated staff assigned to Resident #2 after the incident occurred. At the time of the survey, LPN #3 and #4; and LPN #5, assigned to Resident #2 on 8/20/2022, were unavailable for an interview. During an interview on 9/21/2022 at 10:20 a.m., the Unit Manager/LPN stated the WG is usually on the lower extremity, either the right or left ankle, but if a difficult patient [Resident], then it is placed on the wheelchair. When a resident goes to the elevator, the WG goes off and beeps loudly. The Resident can get on the elevator, but the door does not close, and a code is needed to reset the elevator. She continued to say Resident #2 is very combative, he/she likes to smoke, and we check on him/her from 8:00 p.m. to 8:00 a.m., and the worst time is on weekends. In the same interview, the UM/LPN stated Resident #2 takes off the WG, and we sneak to put it back on; the resident curses and screams because he/she does not like the WG noise. There is a WG on the back of the wheelchair now, and I don't know how he/she takes it off; Resident #2 is in a w/c and has Dementia; he/she thinks he/she can walk and stand, but he/she cannot. During an interview on 9/21/2022 at 11:27 a.m., the Maintenance Director stated all the doors in the facility are checked weekly; all the doors have the WG feature and have egress. He continued to say the electronic front doors have a breakaway feature, pushing on the door to open it. In the same interview, the MD stated he was called on 8/20/2022 and told someone had gotten through the front door. He said the door was put on lockdown at night after 8:00 p.m., there are no visitors, the front door is locked, there is a keypad at the top of the door to keep the doors locked, and a code is needed to unlock it. During an interview on 9/21/2022 at 12:34 p.m., the CNA stated Resident #2 is combative and has Dementia. The CNA said, when I try to wake (Resident #2) up, he/she screams and curses; he/she wears a WG and takes it off. The CNA explained that on 8/20/2022, she went to Resident #2's room to deliver the breakfast tray; the Resident was still asleep and did not want to wake up, so at approximately 7:45 a.m., she left the breakfast tray in the room. The CNA further stated the next time she saw Resident #2 was when she was on her break outside the building, near the employee entrance. She explained to the Surveyor, I was sitting and checking my phone, then I saw a person through the trees. I said, who was that? I followed the person and saw him/her holding onto branches . Resident #2 was in the parking lot of the building next to the facility, and the Resident's wheelchair was in front of the facility. The CNA continued to say, I tell him/her to sit down; let me call someone to help me. According to the CNA, Resident #2 stated he/she was looking for his/her spouse; the spouse didn't pick up the Resident's call, and so he/she was looking for the spouse. I had my cell phone, so I called the nurse to come (and) help, and we both took the Resident back to the facility and called the Director of Nursing (DON). In the same interview, when the Surveyor asked the CNA, did Resident #2 have on the WG and how did he/she get outside, the CNA replied, I don't remember if (the Resident) had WG on. The CNA further stated Resident #2, takes the WG off; I don't know how he/she came outside. I think (Resident #2) had the WG on, maybe on the w/c, I can't remember, but it was not on [Resident #2's] foot. We were busy . She continued to say, the w/c was upright in the [parking lot] street, right off the curb of the front lobby. During an interview on 9/21/2022 at 2:18 p.m., when the Surveyor asked the DON if a timeline was done for the elopement incident, she stated, I don't believe so [that] a timeline was done for the elopement . During an interview on 9/21/2022 at 3:10 p.m., when the Surveyor asked the Assistant Director of Nursing (ADON) about elopement in-services, she stated that none had been done on elopement since the incident. During a telephone interview on 9/21/2022 at 3:45 p.m., the previous DON stated, I was called and told, Resident #2 got outside, and I did an investigation. She continued to say, Resident #2 was by the reception desk and went around the corner, so the Receptionist thought he/she went with therapy. Then thirty minutes later, the CNA when on break and saw Resident #2 in the parking lot beside the facility. The CNA called the nurse and went to get the Resident to bring him/her inside. She further stated that Resident #2 was confused and going to get his/her spouse. In the same interview, the previous DON stated, The Resident had WGs, but he/she would take the WG off, and I don't know how he/she was getting them off; we put WG on the resident and the w/c. Following the incident, we put (the Resident) on one-to-one throughout the weekend until the following Monday [8/22/2022]. She further stated, one-on-one means a CNA or a staff member is assigned directly to stay with the Resident continuously . After the incident, LPN #5 evaluated Resident #2, and (the Resident) had no injuries. The DON said she did not recall or remember specific times surrounding the elopement; however, she did obtain statements from the staff members involved, that is, the CNA, nurse, secretary [Receptionist], and the therapist. During the survey, the facility could not provide the statement obtained from the facility staff. On 9/21/2022 at 4:10 p.m., the ADON stated she could not find the employee [staff] statements from the incident. During a telephone interview on 9/21/2022 at 4:11 p.m., the weekend Receptionist stated she arrived at work a little after 8:00 a.m. on Saturday, 8/20/2022; the [front] door was locked, so she entered a code to open the door about 9:00 a.m. Resident #2 was in the lobby with the OT being taken to rehab, but the Resident refused. The last time the Receptionist saw Resident #2, he/she was sitting in the lobby at the front window waiting for his/her spouse, but she did not see him/her go out the door or hear the alarm sound. During an interview on 9/21/2022 at 4:32 p.m., the Occupational Therapist (OT) stated I did not see Resident #2 elope. The OT continued to say the Resident was on my schedule; I helped him/her get out of bed and took the Resident down to rehab. I brought him/her down in the elevator, I believe the Resident had on a WG, but I don't remember if it [the WG] beeped as we got on the elevator. As I was wheeling Resident #2 to the gym, he/she stated that he/she couldn't go because his/her spouse was coming to visit, so I left (the Resident) in the lobby alone at about 9:20 a.m., and she did not report this to facility staff. She also stated that the Receptionist was at the desk. During an interview on 9/26/2022 at 10:50 a.m., the Staffing Coordinator stated on 8/20/2022, she was the Manager on Duty (MOD), but it was her first day, she arrived at work at 7:30 a.m., the door was locked; she entered a code to unlock it, the door slides open, then automatically locks again. She continued to say she did not see Resident #2, and there was nobody in the lobby, nor did she hear a door alarm. During an interview on 9/26/2022 at 11:06 a.m., the Surveyor asked Resident #2 if he/she attempted to elope on 8/20/2022. Resident #2 stated he/she was outside in the parking lot waiting for the spouse and saw him/her go into the other parking lot because he/she was trying to get the spouse's attention by waving and calling out, honey, honey. Resident #2 stated he/she then decided to go to the next parking lot to get his/her spouse. When asked by the Surveyor if the front lobby door was locked and how did he/she get to the other parking lot, Resident #2 stated, the door was open, and he/she used his wheelchair. During an interview on 9/26/2022 at 11:07 a.m., the Director of Rehabilitation/Physical Therapist stated Resident #2 is noncompliant with [therapy] services, has an unsteady gait, keeps falling, cannot walk, and when he/she transferred to Long Term Care (LTC) the Resident could no longer walk with supervision. She continued to say, .if he/she is not in the wheelchair, he/she can't ambulate, he/she was not walking in LTC with us [Physical Therapy], he/she hardly walked 20-25 feet. During an interview on 9/26/2022 at 11:57 a.m., when asked by the Surveyor how was Resident #2 monitored every thirty minutes. The ADON stated, at least one of us (Administrator, DON, Unit Manager (UM), Infection Preventionist), including myself, knows the whereabouts of (Resident #2) during the day shift during the week, at all times, but it was not documented anywhere; only documented between the hours of 8:00 p.m. to 8:00 a.m. and on the weekends, the primary nurse does visual checks on (the Resident #2), but she did not know if it was documented. The ADON continued to say the Rehab staff should notify the nurse when a resident leaves the unit with the Rehab staff, but it is only a verbal communication; no documentation is done. During a second interview on 9/26/2022 at 1:07 p.m., the Surveyor asked the OT if she notified staff on the unit that she was taking Resident #2 to rehab. She said she usually notifies the nurse, and the nurse could also call down to the gym for the patient [Resident]. But the OT could not confirm telling the nurse when she took Resident #2 off the unit on 8/20/2022 or if she notified anyone that the Resident was left in the lobby. She continued to say she came into work between 8:00-9:00 a.m. on 8/20/2022, and the front door was open. Resident #2 was her first or second patient resident that day. She stated, I helped (Resident #2) with the daily tasks, to get his/her clothes on, then wheeled the Resident down to the gym. When we came down to the gym, (Resident #2) was adamant and wanted to wait for his/her spouse in the lobby, so she left (him/her) there. The OT did not check if the spouse was visiting that day. In the same interview, the OT stated she left Resident #2 in the lobby at approximately 9:30 a.m. with the Receptionist, talking to the Resident and keeping an eye on him/her. During a second interview on 9/26/2022 at 1:55 p.m., the CNA stated when she was on break at approximately 10:00 a.m., she saw Resident #2 standing, holding onto branches, and the w/c was to the front of the building. She stated, I told him/her to sit down on the ground, and I went back inside to call the nurse. The CNA stated Resident #2 told her he/she walked to find his/her spouse and wanted to go home. She continued to say the last time she saw the Resident was at 7:45 a.m. when she delivered breakfast and left the Resident sitting in the wheelchair with the tray in front of the Resident. During a second telephone interview on 9/26/2022 at 2:12 p.m., the former DON stated she implemented visual checks every 30 minutes after hours, after 5:00 p.m., overnights, and weekends due to there being less staff on duty. She continued to say visual checks were to be done every 30 minutes on weekends from Friday at 5:00 p.m. until Monday at 8:00 a.m. The UM/LPN created monitoring forms to use. The visual checks were noted on the care plan and verbally passed onto the next shift in report. She continued to say that the UM on C-wing should have documented that Resident #2 had a staff member assigned to him/her since the incident occurred on 8/20/2022, 24/7 (24 hours/7 days a week) through the rest of the weekend, the one-on-one monitoring should be documented in a nurse's note. The former DON further stated, I told the floor nurse (LPN #5) to assign designated staff to Resident #2 over the weekend of 8/20/2022 after the incident occurred. During an interview on 9/26/2022 at 3:26 p.m., the Licensed Practical Nurse (LPN #6) assigned to Resident #2 on 8/20/2022, on the 3:00 p.m. to 11:00 p.m. shift stated, we were already working short with only three CNAs for 55 residents, and they did not have an extra staff to put (Resident #2) on 1:1. The LPN explained that he went to Resident #2's room periodically during the shift and observed the Resident (Resident #2) sleeping. The LPN further stated, I don't know the process for one-to-one (1:1); I guess someone will be outside of the resident's room door and sit. A review of the facility policy titled Accidents and Incidents with a revision date 05/01/22 revealed the following: Under Policy: included Center staff will report, review, and investigate all accidents/incidents which occurred, or allegedly occurred, on or off Center property and involving, or allegedly involving, a patient who is receiving services. An accident is defined as any unexpected or unintentional incident which may result in injury or illness to a patient. This does not include adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current standards of practice (e.g. (for example), drug side effects or reaction). An incident is defined as any occurrence not consistent with routine operation of the Center or normal care of the patient. An incident can involve a visitor or staff member, malfunctioning equipment, or observation of a situation that poses a threat to safety or security. The licensed nurse will: .Updated the care plan and communicate with the patient and appropriate representative; Complete appropriate nursing documentation and change of condition. Under Purpose: To provide standards of review and investigation of accidents/incidents . Under Process: included Follow-up/Investigation: .4.4 When conducting an investigation, the Administrator, DON (Director of Nursing) or designee will: 4.4.1 Make every effort to ascertain the cause of the accident/incident; 4.4.2 Initiate a timeline chronology; 4.4.3 Observe the environment, assess available documentation and previous accidents/incidents as appropriate. (Consider reconstructing or recreating the event.) 4.4.4 Conduct witness interview from all staff and visitors who may have knowledge of the accident/incident .4.4.7 Complete the investigation within five working days. A review of the facility policy titled Person-Centered Care Plan with a revision date 07/01/19 revealed the following: Under Policy included: The Center must develop and implement a baseline person-centered care plan within 48 hours for each patient that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. The baseline care plan will ensure that patients who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for patients' experiences and preferences. Under Person-centered care means to focus on the patient as the locus of control and support the patient in making his/her own choices and having control over his/her daily life .The care plan will be reviewed and revised by the interdisciplinary team after each assessment. Under Purpose: To attain or maintain the patient's highest practicable physical, mental and psychosocial well-being. Under Practice Standards: .6. The PointClickCare (PCC) are plan library is used the develop the patient's care plan. 6.1 The care plan must be customized to each individual patient's preferences and needs .7. Care plans will be: 7.1 Communicated to appropriate staff, patient, resident representative(s), family; . A review of the facility policy titled Elopement of Patient with a revision date 05/01/22 revealed the following: Under Policy: included: Patients/Residents (hereinafter patient) will be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the clinical assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Elopement occurs when a patient leaves the premises or safe area without authorization (i.e. (for example), an order for discharge or leave of absence (LOA) and/or any necessary supervision to do so. State definitions for elopement vary; follow state definition if different. Under Purpose: To provide a process for managing patients at risk for elopement. Under Process: included: .5. Documentation / Investigation: 5.1 The nurse will: .5.2 The Elopement investigation will be completed within 5 days . N.J.A.C.: 8.39- 27.1 (a)

Based on interviews, medical record review, and review of other pertinent facility documents on 9/21/2022, 9/26/2022, and 9/29/2022, it was determined that the facility failed to develop a smoking care plan for a resident who is a smoker and implement care plan interventions for a 1:1 supervision for safety for 1 of 3 residents (Resident #1). The facility also failed to follow its policy titled, Person-Center Care Plan. This deficient practice was evidenced by the following: During a tour of the second floor on 9/26/2022 at 10:50 a.m., the Surveyor observed Resident #2 self- propelling in a wheelchair in the hallway. The Resident asked the Surveyor, I can get my cigarettes; it is upstairs, correct? The Surveyor told the Resident she was unsure of where the cigarettes were. The Licensed Practical Nurse (LPN) came to Resident #2 and wheeled the Resident down to the first-floor main lobby to retrieve the cigarettes. Review of the Electronic Medical Record (EMR) was as follows: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Anoxic Brain Damage, Cognitive Communication Deficit, Unspecified Dementia with Behavioral Disturbances, Generalized Muscle Weakness, and unspecified Altered Mental Status. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/19/2022, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 12/15, which indicated the Resident had moderate cognitive impairment. The MDS also showed Resident #2 was independent with Activities of Daily Living (ADLs) but required set-up and supervision for dressing. A review of Resident #2's Smoking Evaluation (SNF) -V1 form dated 7/1/2022 revealed Resident #2 was a smoker. A review of the Resident's Care Plan (CP) initiated on 06/24/2022 revealed under Focus: that Resident #2 is at risk for elopement related to Hypoxic brain injury, Dementia. Under Goal indicated Resident/Patient will not attempt to leave the facility without an escort by next review. Under Interventions included: Med (Medication) Review PRN (as needed) with a date initiated 08/13/2022, Observe risk factors/triggers for exit seeking behavior and adjust care delivery, Monitor the nature and the circumstances (i.e. [for example] triggers) of attempted elopement: during specific activities, involvement of others with resident/patient, patterned etc. and adjust care delivery, Monitor the residents/patients location with visual checks at least every 30 minutes, as needed, date initiated 08/20/2022; Encourage resident/patient participation in activity preferences date initiated 08/16/2022, Allow time for expression of feelings; provide empathy, encouragement, and reassurance, 1:1 monitoring throughout the weekend, date initiated 08/20/2022; STP (Stop): Coach and encourage resident/patient to communicate the desire to leave the program in an appropriate manner, date initiated 08/13/2022, Divert resident/patient by giving alternative objects or activities, date initiated 08/16/2022, Listen to resident/patient try to calm, As appropriate redirect Resident/Patient if near exits or doorways, Wander guard with staff to check frequently as he/she removes it him/her self, date initiated 08/16/2022. Further review of Resident #2's CP initiated 06/14/2022, included under Focus: Resident #2 is at risk for falls: cognitive loss, lack of safety awareness, Hypoxic Brain Injury, Cardiac Hx (history). The CP showed under Goal: Resident #2 will have no falls with injury x 90 days. Under Interventions: .Encourage resident to notify staff if he/she fall, date initiated 6/30/2022, Observe for changes in medical status, pain status, mental status and medication side effects that may contribute to cognitive loss/dementia/delirium and can lead to increase fall risk, report MD (Physician) as indicated, .Encourage resident to utilize w/c (wheelchair) as instructed by therapy, date initiated 7/18/2022. Resident #2's CP initiated on 6/24/2022 revealed no smoking care plan for Resident #2. During an interview on 9/26/2022 at 11:57 a.m., when asked by the Surveyor if a resident who is a smoker needs a smoking care plan, the Assistant Director of Nursing (ADON) stated, Yes, if a resident is a smoker, it should be on the care plan. The ADON said the Unit Manager puts smoking on the care plan. She also stated that there is a smoking assessment that is completed which is in the computer. A review of Resident #2's Progress Notes (PNs) did not reveal any documentation that a baseline care plan was initiated for smoking. A review of Resident #2's PNs dated 8/20/2022 through 8/22/2022 did not reveal any documentation that the Resident (Resident #2) was on 1:1 as care planned. At the time of the survey the facility was unable to provide evidenced that Resident #2's CP was developed for smoking or the 1:1 intervention was implemented. During an interview on 9/26/2022 at 2:13 p.m., the previous Director of Nursing (DON) stated Resident #2 was placed on a 1:1 monitoring for safety throughout the weekend (8/20/2022-8/22/2022). The DON further stated that 1:1 meant for a staff to be with Resident #2 around the clock until Monday morning. The DON said, Yes, I would expect the assigned nurse to document that the Resident (Resident #2) was on 1:1 monitoring in the PNs. I would have documented this in the PNs if I was the nurse caring for the Resident (Resident#2). During an interview on 9/26/2022 at 3:26 p.m., the Licensed Practical Nurse (LPN) assigned to Resident #2 on 8/20/2022, from the 3:00 p.m. to 11:00 p.m., shift stated, we were already working short with only three CNAs for 55 residents, and they did not have an extra staff to put (Resident #2) on 1:1. The LPN explained that he went to Resident #2's room periodically during the shift and observed the resident (Resident #2) sleeping. The LPN further stated, I don't know the process for one-to-one (1:1); I guess someone will be outside of the resident's room door and sit. A review of the Person-Center Care Plan revised on 7/1/2019 under Policy reveals: The Center must develop and implement a baseline person-centered care plan within 48 hours for each patient that includes the instruction needed to provide effective and person-centered care plan that meet professional standards of quality care. The baseline care plan will ensure that patients who are trauma survivors receive culturally competent trauma-informed care in accordance with professional standards of practice and accounting for patient's experiences and preferences. N.J.A.C.: 8.39- 27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to maintain readily accessible and systematically organized medical records. This deficient practice was identified for 5 of 25 residents reviewed, Resident #80, #304, #306, #754, and #757. The deficient practice was evidenced by the following: 1. On 3/15/22 at 12:15 PM, the surveyor reviewed the electronic medical records (EMRs) and could not find documented evidence that an Initial Social Service Assessments ([NAME]) was completed for Residents #80, #304, and #306. On 3/16/22 at 8:59 AM, the Center Nurse Executive (CNE) provided the surveyor with the ISSAs for Resident #80, #304, and #306. A review of Resident #80's Admission Record reflected an admitted [DATE]. A review of the resident's [NAME] revealed that the [NAME] was documented, completed and signed on 3/15/22 in the EMR. A review of Resident #304's Admission Record reflected an admitted [DATE]. A review of the resident's [NAME] revealed that the [NAME] was documented, completed and signed on 3/15/22 in the EMR. A review of Resident 306's Admission Record reflected an admitted [DATE]. A review of the resident's [NAME] revealed that the [NAME] was documented, completed and signed on 3/15/22 in the EMR. On 3/23/22 at 9:31 AM, the survey team met with the SASW. The SASW stated that I try to meet with the patients before each care conference meeting. Sometimes the meeting is the first point of contact. I contact families before the care conference meeting. At that same time, a surveyor asked the SASW when the assessments had to be completed. The SASW stated that the ISSAs needed to be in the EMR within the 5 days. Upon surveyor inquiry as to when the ISSAs are entered into the EMR, the SASW stated that, No, they are not entered right away. The truth of the matter is, I only work 24 hours a week and I don't get the time to finish my assessments. On 03/21/22 at 09:55 AM the facility provided the surveyor with the facility policy Social Service Progress Notes with a revised date of 1/15/21, indicated that Progress notes will be completed in [name redacted], the facility's EMR program. A document that was attached to the provided policy was titled Social Services Documentation Requirements, with a revised date of 9/13/19, reflected that a resident's [NAME] should be completed by day five of the admission. 2. On 3/15/22 the surveyor reviewed the EMR for residents, #754 and #757. The [NAME] were labeled incomplete. A review of Admission Record indicated that Resident #754 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Admission Record indicated that Resident #757 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/15/22 at 12:15 PM, the surveyor interviewed the Director of Social Service (DSS) in the presence of the survey team who stated that the Subacute Unit Social Worker (SUSW) handled the residents [NAME], and the assessments have been completed but not documented into EMR. A review of the ISSAs for Resident #754 and #757, indicated that they were documented, completed and signed on 3/15/22 in the EMR. On 3/22/22 at 12:10 PM, the surveyor interviewed the CNE who stated that the [NAME] must be completed and documented in EMR within 5 days of admission. She acknowledged that Resident #754 and #757 ISSAs were not completed timely. On 3/23/22 at 12:10 PM, the surveyor interviewed the SUSW in the presence of the survey team who stated that she writes her assessment on paper and documented later in EMR. She further stated that the [NAME] must be completed and documented in EMR within 5 days of admission. Furthermore, she acknowledged that Resident #754 and #757's [NAME] were not completed timely. NJAC 8:39-35.2(c)(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] .) administer an over the counter medication as indicated in the directions on the medication bottle for 1 of 4 residents observed during medication pass (Resident # 308), and c.) ensure that treatments were administered according to Physician's Orders and professional standards of clinical practice for 1 of 1 resident reviewed for skin conditions (Resident #757). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 03/14/22 at 10:27 AM, 3/15/22 at 10:09 AM, and 03/16/22 at 9:47 AM, the surveyor attempted to interview Resident #50, and the resident was unable to interview. The surveyor reviewed the medical record of Resident #50. A review of the resident's Admission Record (face sheet) reflected that Resident #50 was admitted to the facility in January 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Admission Record reflected that the section labeled, Advanced Directives (AD; a living will/health care proxy) was blank with no further information. A review of the electronic Medical Record (eMR) profile for Resident #50 reflected a blank section for Code Status. A review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate management of care dated 1/19/22 revealed Resident #50 had a Brief Interview for Mental Status (BIMS) of 15 which reflected that the resident was cognitively intact. A review of the New Jersey Practitioner Orders for Life-Sustaining Treatment form (POLST; end of life medical treatment based on the resident's known preferences) from 1/8/22 to 3/14/22 for Resident #50 was not initiated. A review of the Clinical Physician Orders (CPO) revealed the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the electronic progress notes from 1/8/22 to 3/15/22 reflected there was no documentation for code status. On 3/15/22 at 12:12 PM, the surveyor interviewed the Director of Social Services (DSS). The DSS stated that all residents who are admitted to the facility are interviewed for a psychosocial assessment. The DSS also stated she meets with admitted residents several times and discusses the end of life preferences. The DSS further stated end of life preferences are discussed during the Interdisciplinary Team (IDT) meeting within 72 hours of admission. Furthermore, the DSS confirmed Resident #50 did not have a code status and a POLST. The DSS acknowledged Resident #50 should have had a documented code status and POST status. The DSS further stated that the POLST was done after the surveyor's inquiry. On 3/17/22 at 11:12 AM, two surveyors interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN) assigned to the B wing, where Resident #50 resided. The LPN/CN and two surveyors reviewed the resident's eMR and chart together. The LPN/CN confirmed that the resident did not have a code status and POLST on file. She further stated that it should have been obtained upon admission. On 03/17/22 at 11:45 AM, two surveyors interviewed the Registered Nurse/Unit Manager (RN/UM) who stated all residents who are admitted should have a POLST and code status in the eMR. The RN/UM further stated a code status can be documented by obtaining the resident's end-of-life preferences during the care plan conference that would occur within 72 hours of admission, quarterly, or followed up on since code status could change. On that same date and time, the RN/UM acknowledged the code status and POLST should have been documented with each readmission. The RN/UM confirmed Resident #50 did not have a POLST and code status from 1/9/22 to 3/14/22. She stated a code status was important should an emergency happen we know what to do. On 3/17/22 at 12:21 PM, two surveyors interviewed the Assistant Director of Nursing (ADON) and reviewed the eMR. At that time, the ADON stated that she could not find evidence of the code status for the resident. In addition, there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON confirmed the code status indicated how we know how to treat a patient. 03/21/22 at 11:53 AM, in the presence of the Director of Nursing (DON) and two surveyors. The DON stated that the Nurse Practitioner (NP) and Physician should have completed the history and physical (H&P) for newly admitted residents which should have addressed a code status, POLST, and completed by 24 to 48 hours of admission. The DON further added the Interdisciplinary team meets 72 hours after a resident's admission and formulated the resident's care plan which should have included the resident's code status and POLST. 03/21/22 at 01:30 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the DON acknowledged there were four (4) opportunities between four (4) different disciplines of practice that could have obtained an order and documented the code status and/or end of life preferences of the resident. A review of the facility's Social Services Documentation Requirement with a revised date of 9/13/19, under section Social Service Assessment and Documentation revealed, A Social Service Assessment and Documentation /Initial Assessment will be automatically scheduled upon patient's admission. It is to be completed by day 5 of admission. A review of the facility's policy Social Services Progress Notes with a revision date of 1/15/21 included Progress notes will be completed on [name redacted]. A review of the facility's policy Health Care Decision Making with a revised date of 3/1/22 included To assure that patient's wishes concerning health care issues are communicated to all staff . and their wishes will be executed at the appropriate time .Upon admission, determine whether the patient has an advanced directive .Advanced care planning includes two key parts: 1. Face to face conversations with physician and other health care professionals and patients and their health care decision makers to discuss advance directives and treatment decisions with or without completing relevant legal forms; and 2. Documenting treatment and wishes. A review of the facility's policy Code Status Orders with an effective date 1/31/20 included, each patient's code status . will be easily accessible to the clinical staff for all patients . 1. Upon admission /re-admission, a code status order is required as soon as possible as part of the patient's admission order set .1.1 orders for code status include Full Code .2. Staff should verify the patient's wishes with regard to code status .upon admission. 2. The surveyor reviewed the resident's Admission Record which indicated Resident #308 was admitted to the facility and had medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/15/22 and 03/16/22, the surveyor observed medication pass on the Subacute Unit and the C-wing unit. The observation included observing three nurses with four residents for a total of 25 medication pass opportunities. On 03/16/22 at 09:15 AM, the surveyor observed Unit Manager/Licensed Practical Nurse (UM/LPN) administer medications on the C-Wing of the facility. The UM/LPN administered medications to two residents, Resident #26, and Resident #308 with a total of eight opportunities. The surveyor observed medication pass with Resident #308. The UM/LPN prepared the medication [MEDICATION(S)] (for constipation) which was an over-the-counter medication in a powder form. The surveyor observed the UM/LPN open the bottle of [MEDICATION(S)] and poured the white powder into a 30 cubic centimeter (cc) medicine cup. The surveyor asked the UM/LPN how she measured 17 grams and she stated, usually you pour it into the cap and then into the medicine cup, but this is the same amount. The surveyor asked to see the bottle of [MEDICATION(S)], and the directions on the bottle indicated that one capful equaled 17 grams. The UM/LPN stated that it is equal to this and held up the medicine cup. On 03/16/22 at 10:45 AM, the surveyor reviewed the Order Summary Report for March 2022 for Resident #308. There was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/22/22 at 09:07 AM, the Center Executive Nurse (CEN) provided the surveyor with documentation on [MEDICATION(S)] usage, dosage, and side effects which the facility used to educate the nursing staff on proper administration of the medication. Under the section titled, How should I take [MEDICATION(S)] ?, indicated that To use [MEDICATION(S)] powder, measure your dose with the medicine cap on the bottle. This cap should contain dose marks on the inside of it. Pour the powder into 4 to 8 ounces of a cold or hot beverage such as water, juice, soda, coffee, or tea. Stir this mixture and drink it right away. Do not save for later use. 3. On 03/14/22 at 9:45AM, the surveyor observed the Resident #757 lying in bed, alert and responsive, and receiving oxygen via nasal cannula. The resident's feet were elevated on a pillow and there was an uncovered blister to the right medial foot. A review of the resident's Admission Record indicated that Resident #757 was admitted to the facility and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission MDS dated [DATE], with a BIMS score of 8, which reflected that the resident's cognition was moderately impaired. A review of resident's Physician Order Summary for March 2022, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply protective dressing behind left ear fold every shift. On 3/15/22 at 10:36 AM, the surveyor observed the resident lying in bed. There was no protective dressing behind the resident's left ear and the blister to right medial foot remained uncovered. On 3/16/22 at 12:30 PM, the surveyor observed the resident in the presence of the Licensed Practical Nurse (LPN) #1. There was no protective dressing to the left ear and the right medial foot blister remained uncovered. The surveyor asked LPN #1 if the resdient's left ear should have a protective dressing and if the blister to the right medial foot should have been covered with [MEDICATION(S)]. She stated, the blister is usually not covered with a dressing. On that same date and time, in the presence of the surveyor, LPN #1 reviewed the Treatment Administration Record (TAR) and acknowledged that there were physician's orders for a protective dressing to the left ear and a dressing change to the right medial foot blister every 3 days and as needed. She further acknowledged that these dressings should have been in place. On 3/16/22 at 1:57 PM, the surveyor interviewed the Center Nurse Executive (CNE) who stated that the nurses should have followed the treatment orders. On 3/17/22 at 10:38 AM, the surveyor observed the resident's left ear and right medial foot wounds in the presence of LPN #2. The surveyor observed that the right medial foot blister was covered with a dressing. However, the protective dressing was still not in place behind the resident's left ear . LPN #2 could not state if there should have been a protective dressing behind the resident's left ear. A review of policy titled Treatments, with a revised date of 6/1/21, indicated that A licensed nurse or medical technician, per state regulations, will perform ordered treatments. Accepted standards of practice will be followed. Under Practice Standards, 5. Perform treatment as ordered. No additional documentation was provided to the survey team during the survey. NJAC 8:39-19.6 NJAC 8:39-27.1(a) NJAC 8:39-29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to provide documentation that the resident declined an Advance directive (AD). This deficient practice was identified for 1 of 7 residents reviewed for Advanced Directives (Resident #50), and was evidenced by the following: On 03/14/22 at 10:27 AM, 3/15/22 at 10:09 AM, and 03/16/22 at 9:47 AM, the surveyor attempted to interview Resident #50, and the resident was not available. The surveyor reviewed the medical record of Resident #50. A review of the resident's Admission Record (face sheet) reflected that Resident #50 was admitted to the facility in January 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Admission Record reflected that the section labeled, Advanced Directives (AD; a living will/health care proxy) was blank with no further information. A review of the Admission Minimum Data Set (MDS) an assessment tool dated 1/19/22 revealed Resident #50 had a Brief Interview for Mental Status (BIMS) of 15 which means that the resident's cognition was intact. A review of Resident #50's medical chart, did not reveal an AD. A review of the resident's individualized care plan (CP) initiated on 1/9/22 revealed the AD was not addressed. A review of the progress note for Post Admission Patient/Family Conference dated 1/11/22 revealed: Advance Directives not yet in place. A review of Social Services Assessment and Documentation (SSAD) dated 1/13/22 section 5, revealed that Resident #50 did not have an Advance Directive (AD) in place. A conversation regarding advanced care planning was provided and information was given. The section under further elaborate information on health care decision making was blank. On 3/15/22 at 12:12 PM, the surveyor interviewed the Director of Social Services (DSS). The DSS stated that all residents who are admitted to the facility are interviewed for a psychosocial assessment. The DSS also stated she meets with admitted residents several times and discusses AD. The DSS further stated an AD was discussed during the Interdisciplinary Team (IDT) meeting within 72 hours of admission. The DSS confirmed Resident #50 did not have an AD, but it was discussed and should have been documented. On 3/17/22 at 11:12 AM, two surveyors interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN) assigned to the B wing, where Resident #50 resided. The LPN/CN printed the resident's face sheet and confirmed the category for the advanced directive was blank with no further information. The LPN/CN confirmed that the resident did not have an advanced directive on file, and further stated that it should have been obtained and documented upon admission. On 3/17/22 at 12:21 PM, two surveyors interviewed the Assistant Director of Nursing (ADON) and reviewed the eMR. The ADON stated Resident #50 did not have an advance directive on file. The ADON acknowledged there should have been an Advanced Directive for Resident #50. 03/21/22 at 11:53 AM, in the presence of the Director of Nursing (DON) and two surveyors. The DSS confirmed an Advanced directive, that should have been documented before the surveyor's inquiry. The DON stated upon a resident's admission, the nurse should have obtained and documented advanced directives within 24 hours of admission. The DON also stated SW meets with newly admitted residents for SSAD within 24 hours of admission and completed by day five (5) of admission. The DON further added the Interdisciplinary team meets 72 hours after a resident's admission and formulated the resident's care plan which should have included the resident's AD status. 03/21/22 at 01:30 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the DON acknowledged there were four opportunities between four different disciplines of practice that could have been obtained and documented the AD and/or end of life preferences and was not done. 03/23/22 at 09:15 AM, in the presence of the survey team the SW stated Resident #50 was alert, oriented, and was able to make his/her own decision. The SW stated Resident #50 did not have an AD and was offered advanced health care planning but declined. The SW acknowledged she did not document in the SSAD, care plan, and on the eMR that Resident #50 declined. She further acknowledged that an AD could change with each readmission and should have been obtained and documented with each readmission. She confirmed Resident #50 did not have a documented AD with each readmission. The SW acknowledged she was not aware of Federal regulations regarding AD. A review of the facility's Social Services Documentation Requirement with a revised date of 9/13/19, under section Social Service Assessment and Documentation, revealed, A Social Service Assessment and Documentation /Initial Assessment will be automatically scheduled upon patient's admission. It is to be completed by day 5 of admission. A review of the facility's policy Social Services Progress Notes with a revision date of 1/15/21 included Progress notes will be completed on [name redacted]. A review of the facility's policy Health Care Decision Making with a revised date of 3/1/22 included Advanced care planning includes two key parts: 1. Face to face conversations with physician and other health care professionals and patients and their health care decision-makers to discuss advance directives and treatment decisions with or without completing relevant legal forms; and 2. Documenting treatment and wishes .To assure that patients' wishes concerning health care issues are communicated to all staff . and their wishes will be executed at the appropriate time .Upon admission , determine whether the patient has an advanced directive . NJAC 8:39-19.6

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code a resident's Minimum Data Set (MDS) for falls in accordance with the Resident Assessment Instrument (RAI) Manual (a guide for completing resident assessments). This deficient practice was identified for 1 of 1 residents reviewed for falls, (Resident #2) as was evidenced by the following: On 03/14/22 at 10:24 AM, the surveyor observed Resident #2 lying in bed. The surveyor further observed a discoloration on the resident's left eye, cheek bone and temple area that was purple, reddish-blue, and yellow in color. The surveyor attempted to interview the resident on how he/she obtained the bruise and the resident stated, they were taking [name redacted] to see the monkeys and the monkey got [name redacted]. The surveyor reviewed the Admission Record (face sheet) which reflected Resident # 2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Resident Manager System (RMS) Event Summary Reports dated 12/02/21 at 1:15 PM reflected that Resident #2 had a fall with minor injury. Further review of the facility's RMS Event Summary Report dated 02/19/22 at 6:55 PM reflected that Resident #2 had an additional fall which resulted in minor injury. A review of the Quarterly MDS dated [DATE], which revealed the resident's cognitive skills for daily decision making were moderately impaired. Further review of the resident's MDS, Section - J1800 - Any falls since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent, indicated that the resident had no falls during the assessment review period. The falls with minor injury previously mentioned were not accurately coded in the MDS. The surveyor interviewed the Assistant MDS Coordinator on 03/21/22 at 12:37 PM, who stated that she made a mistake and did not accurately code the falls on the resident's quarterly MDS. The surveyor interviewed the MDS Coordinator on 03/22/22 at 9:57 AM, who acknowledged that the quarterly MDS was inaccurately coded for falls. NJAC 8:39-33.2(d)