Every finding on record at Lincoln Park Care Center

Based on interviews, review of medical records, and review of other pertinent facility documents on 3/19/2026 and 3/24/2026, it was determined that the facility failed to maintain a safe environment to ensure adequate supervision to prevent the elopement of a resident (Resident #2). Resident #2, who was noted to exhibit in the presence of staff exit seeking behavior, was transferred to a secure unit on 03/04/2026. Resident #2 also had a Wander Guard in place since admission to the facility since 2024. This device would initiate an alarm and alert staff in the event of an attempt to leave the secured unit. This deficient practice was identified for 1 of 3 (Resident #2) reviewed for elopement. During the survey a finding that constituted an Immediate Jeopardy (IJ) was identified under CFR 483.12(a) (1) for F689. The facility failed to maintain a safe environment on a secured unit with adequate supervision to prevent an elopement of Resident #2 who was a known elopement risk. On 03/08/2026, between 9:00 PM-10:00 PM, Resident #2, who had a Wander Guard in place was able to exit their secured third floor nursing unit and exited through an exit door that was not supervised by staff. The resident left the facility which is in densely wooded area. The facility staff became aware that Resident #2 was missing at approximately 10:00 PM, when the licensed Practical Nurse (LPN #3) who was assigned on the second-floor nursing unit heard the door alarm sounding and activated Code Grey/ Resident/Guest Elopement Policy. LPN#1 and LPN#2 with the assistance of the Certified Nursing Assistant (CNA#1) searched the third-floor secured unit. A facility head count was completed, and Resident #2 could not be accounted for in the building and on the facility grounds. The Licensed Nursing Home Administration (LNHA) and the Director of Nursing (DON) were notified of the missing resident (Resident #2) at approximately 10:30 PM. The police were notified and a missing person report was filed at approximately 11:00 PM. Resident #2 was found 4.5 hours later on 3/09/2026 at approximately 2:00 AM by the police and transported by ambulance to the hospital. Resident #2 returned to the facility on [DATE] at approximately 5:00 PM. The facility's failure to maintain a safe environment on the secured unit with adequate supervision to prevent Resident #2 from leaving the facility without staff knowledge, placed this resident as well as all residents at risk for elopement, the risk of likelihood of serious harm, injury, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 03/08/2026. The LNHA and the DON were informed of the F689 IJ and were provided with the IJ template on 3/19/2026 at 7:08 PM. An acceptable Removal Plan (RP) was received on 3/23/2026 at 3:13 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring.The surveyor verified the implementation of the RP during the continuation of the on-site survey on 3/24/2026 and determined the immediacy was removed as of 03/19/2026. The evidence was as follows: The facility policy titled: policy and standard manual, Code Grey /Resident/Guest Elopement policy, with a reviewed date of 04/08/2025, Under Policy Statement, revealed that Code Grey Elopement is defined as an unannounced, unplanned departure from the facility boundaries. Under Mitigation, To lessen the likelihood and effects of resident elopement, a prevention plan contains protocols that are taught to all employees during orientation and reviewed on an annual basis. Under Prevention . Controlling the exit access of residents is essential to secure units and decrease the risk of a resident leaving the facility and wandering off the property .e. Each door has a code to leave the unit . The facility policy titled: Safety and Supervision of Residents, with a revised date of 01/25/2026, Under Policy Statement, Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. Under System Approach to Safety 2. Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision are determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision vary among residents and over time for the same resident and are determined on a case-by-case basis. For example, resident supervision may need to be increased during temporary illness or a change in mental status/behaviors. Nursing staff will evaluate the need for supervision. A review of the Facility Reportable Event (FRE) dated 03/09/2026, that the facility submitted to the New Jersey Department of Health (NJDOH), revealed that at approximately 10:30 PM on 03/08/2026, an alarm was activated, prompting a Code Grey alert. A facility head count was conducted. During the head count, it was noted that Resident #2 was not in their room and was identified as missing. The FRE further revealed the local police were contacted and located Resident #2 approximately 4.5 hours later and transferred to the hospital. Resident #2 was returned to the facility at 5:05 PM on 03/09/2026.A Conclusion of event revealed: Despite all safety precautions and progressive interventions that were put in place, Resident #2 removed their Wander Guard after staff checked placement and function on the 3-11 shift and exited their unit. However, staff were alerted to Resident #2 egress by the door alarm. A review of the facility's Investigation Timeline (IT) includes the following: Resident #2's admission assessment in 2024, identified the resident as at risk for elopement and indicated that the resident had a Wander Guard (a wearable device that triggers alarms and/or locks) in place. The IT further indicated that the resident was placed in a non-secured unit at the time. The resident's family member was the main relative that was supportive to the resident. The relative visited and/or interreacted with the resident frequently. The resident's [family member] in 2026 reduced the frequency of visits with the resident. On 3/3/2026, the resident met with the facility Social Worker and requested a transfer to a facility closer to the relative.On 3/04/2026, Resident #2's behavior escalated with the resident attempting to leave the floor and was hard to redirect; and that the facility placed the resident on a one-to-one monitoring pending availability of a secured unit. The Director of Nursing (DON) stated during interview that the resident was then transferred to a secured unit on 3/4/2026 and discontinued the one-to-one monitoring.A review of the medical record revealed the following;According to the admission Record face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: schizoaffective disorder (chronic mental health condition), major depression (a serious mental condition characterized by persistent sadness) and factitious disorder (a serious mental health condition where a person intentionally produces, feigns or exaggerates physical or psychological symptoms in themselves).According to the quarterly Minimum Data Set (MDS), an assessment tool dated 01/29/2026, Resident #2 had a BIMs score of 15 out of 15, which indicated the resident's cognition was intact. A review of Resident #2's Elopement/Wandering Risk Evaluation dated 03/04/2026 at 2:02 PM, indicated that Resident #2 was a high risk for elopement. The evaluation under behavior and mood noted that Resident #2 indicated yes to a history of actual/attempt of elopement and verbally expressed desire to go home or stay near exit door. Under cognition, it noted that Resident #2 was cognitively impaired with poor decision-making skills. A review of Progress Note (PN) dated 03/04/2026 at 7-3, which was written by the Assistant Director of Nursing (ADON), stated that resident #2 was showing possessive behaviors. and that psych met with the resident. A review of Resident #2's Care Plan (CP) revealed a focus initiated on 11/03/2024, with revision date of 12/30/2025 which stated that Resident #2 is an elopement risk, and a wanderer related to history of attempts to leave the facility unattended. The CP also stated that Resident #2 had a Wander Guard placed on their ankle and that the resident's behaviors should be monitored. The CP further stated that Resident #2 was noted to be actively exit seeking. The care plan included an intervention to do frequent monitoring. During interview with Resident #2 on 03/19/2026 at 11:10 AM, Resident #2 stated they exited the facility on 03/08/2026 wearing their Wander Guard on their ankle. Resident #2 stated they left the facility through the exit door on the unit and got onto the elevator to the front entrance, where they exited the building. Resident #2 also stated they walked to the bus stop which is close by the facility. Resident #2 stated they took the public transportation bus to go and visit their relative. Resident #2 stated while at their [family member] address, the police came and took them to the hospital. A telephone interview was conducted on 03/19/2026 at 12:43 PM. LPN#1 stated, she last saw Resident #2 at around 9:00 PM on 03/08/2026 after she provided their ordered snack (milkshake). Resident #2 said, I want a soda but then proceeded to their bedroom. At approximately 10:00 PM, I went in to check on Resident #2, I observed the milkshake on the bedside table sealed and untouched and observed Resident #2 was not present at that time in their room. I thought Resident #2 had gone to the soda machine on the other unit, so I went to the soda machine and did not see the resident (Resident #2). LPN #1 further stated, Resident #2 and other residents on the secured unit are allowed to go off the unit unaccompanied to the soda machine. During the same interview, LPN #1 stated, upon her return to the secured unit, she alerted CNA #1 and other staff members to conduct a thorough search in all the rooms, bathrooms and closet for Resident #2. After the head count and the resident was not accounted for and the Charge Nurse was notified. A Code Grey was activated for the missing resident. LPN #1 said there was no alarm sounding on the unit prior to code grey been activated. LPN #1 stated she did not see Resident #2's Wander Guard in the room during the search of the resident.An interview was conducted with CNA #1 on 03/19/2026 at 1:35 PM. CNA #1 stated she was assigned to Resident #2 on 03/08/2026. At 9:00 PM, I saw the resident (Resident #2) in their room and on the phone. At 10:00 PM, I went to do my last round and noticed Resident #2 was not in their room. I immediately told the nurse, and we checked everywhere, and Resident #2 was not found. CNA #1said, No, i did not hear the alarm sounding.An interview was conducted with LPN #2 on 03/19/2026 at 3:50 PM. LPN #2 stated he was the nurse assigned to Resident #2 on 03/08/2026 the day the resident eloped. LPN #2 stated the process for leaving the secured unit is for the residents to always be accompanied by staff. On 03/08/2026, I checked the function and placement of Resident #2's Wander Guard during my shift. LPN #2 said, I saw Resident #2 at 9:00 PM in their room and at approximately 10:00 PM code grey was activated by a staff on another unit. A head count was done on the secured unit, and it was determined that Resident #2 was not on the secured unit or in the building. LPN #2 stated, I did not know Resident #2 was missing until code grey was activated at 10:00 PM. LPN #2 stated, no alarm sounded on the secured unit prior to code gray been activated. There were two nurses working on the secured unit on 03/08/2026 and we did not activate code grey. LPN #2 further stated a resident on the secured unit with a wander guard should not leave the unit unaccompanied. An interview was conducted with the DON in the presence of the Licensed Nursing Home Administrator (LNHA) on 03/19/2026 at 4:33 PM. The DON stated, a resident on a secured unit should not be able to leave unit unaccompanied by staff.An off-site telephone interview was conducted on 03/23/2026 at 2:38 PM with LPN #3, who stated he was the charge nurse for the second floor on 03/08/2023. LPN #3 said at 10:00 PM, he heard the door alarm sounding but did not recall which door was alarming. He activated the code grey. LPN #3 stated, once code grey was initiated, a head count was performed on each unit and it was at that time, Resident #2's nurse (LPN#2) informed him that Resident #2 was unaccounted for. LPN #3 stated, staff searched all rooms, buildings and grounds and were unable to locate Resident #2. He notified the DON and ADON of the missing resident (Resident #2). LPN #3 stated a resident on a secured unit should not leave the unit unaccompanied at any time.An acceptable Removal Plan (RP) was received on 03/23/2026 at 3:13 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice, including:On 03/08/2026, the DON and ADON provided immediate in-service training, and reeducation began regarding the safety and protocols for residents at risk for wandering and elopement.On 03/09/2026 at 5:00 PM, Resident #2 returned to the facility safely and was reassessed. A new wander guard with a secure band was placed on the resident's ankle, and the resident's room was moved adjacent to the nurses' station for monitoring. Resident #2 was placed on 1:1 monitoring for all shifts.On 03/19/2026, DON and ADON provided facility staff with education on the importance of monitoring residents' doors on secure units to prevent residents from exiting.On 03/19/2026, the DON and ADON serviced all staff on: A. Monitoring doors on secured units to prevent unauthorized exits; B. Residents living on the secured units need to be escorted by staff members when leaving the unit.On 03/19/2026, a test on all door alarms/door locks was completed and is working as designed by Northeast Protection Partners. B. The Wander Guard installer, Northeast Protection Partners, completed testing of all Wander Guard alarms and magnetic locks, and they are all working as designed. C. Effective immediately, as we evaluate the security of our secured unit doors, a trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors to prevent unauthorized exit by all residents living on that unit. D. All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.The surveyor verified the implementation of the Removal Plan on-site on 03/24/2026, and determined the immediacy was removed as of 03/19/2026. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to prepare resident meals in the proper consistency for 3 of 6 residents (Resident #53, #224, and #326) reviewed on a modified diet during dining observation.This deficient practice was evidenced by the following: 1. On 12/8/25 at 12:17 PM, the surveyor observed Resident #53 in the 2nd floor dining room. Certified Nursing Assistant (CNA#1) provided Resident #53 with their lunch tray. The surveyor observed the resident received whole French fries. Surveyor interviewed CNA#1, who stated Resident #53's diet is chopped consistency. CNA#1 cut Resident #53's French fries to the chopped consistency prior to eating.On 12/8/25 at 12:19 PM, the surveyor reviewed Resident #53's electronic medical record (E-mar). A review of the resident's Face sheet (FS) (an admission summary) revealed Resident #53 was admitted to the facility with diagnoses that included: dementia (loss of cognitive functioning thinking, remembering, and reasoning), protein-calorie malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients), and hypertension (high blood pressure).A review of the annual MDS, (an assessment tool used to facilitate care management) dated 9/12/25, reflected a Brief Interview for Mental Status (BIMS) score was unable to be calculated as Resident #53 was unable to complete a BIMS interview due to cognitionA review of the Physician Order (PO) summary dated 12/10/25, identified an order with an original date of 4/25/25, Lactose free diet, Chopped texture and thin liquid consistency.A review of Resident #53's care plan (CP) revealed a nutrition CP with an initiation date of 11/25/18, the focus portion of the CP revealed, Resident requires a mechanically altered diet due to poor dentition and the intervention portion of the CP revealed two nutrition interventions both initiated on 11/25/18, all staff to be informed of resident's special dietary and safety needs and provide diet per MD orders,.2. On 12/8/25 at 12:18 PM, the surveyor observed Resident #224 in the 2nd floor dining room. CNA#1 provided Resident #224 with their lunch tray. The surveyor observed the resident received whole French fries and macaroni salad. Surveyor interviewed, CNA#1 who stated Resident #224's diet is chopped consistency. CNA#1 cut Resident #224's French fries, salad and macaroni salad to the chopped consistency prior to eating.On 12/8/25 at 12:22 PM, the surveyor reviewed Resident #224's E-mar. A review of the resident's FS was admitted to the facility with diagnoses that included: dementia, protein-calorie malnutrition, and type 2 diabetes mellitus (chronic disease characterized by high levels of sugar (glucose) in the blood).A review of the quarterly MDS, dated [DATE], reflected a BIMS score of 7 of 15, indicating Resident #224's cognition was severely impairedA review of the Resident's PO summary dated 12/10/25, identified an order with an original date of 9/25/25, Regular diet, Chopped texture and thin liquid consistency.A review of Resident #224's CP revealed a nutrition CP with an initiation date of 7/1/25, the intervention portion of the CP revealed, provide and serve diet as ordered per MD orders.3. On 12/8/25 at 12:19 PM, the surveyor observed Resident #326 in the 2nd floor dining room. CNA#1 provided Resident #326 with their lunch tray. The surveyor observed the resident received whole French fries and macaroni salad. The surveyor interviewed CNA#1, who stated Resident #326's diet is chopped consistency. CNA#1 cut Resident #326's French fries and macaroni salad to the chopped consistency prior to eating.On 12/8/25 at 12:24 PM, the surveyor reviewed Resident #326's E-mar. A review of the resident's FS was admitted to the facility with diagnoses that included: type 2 diabetes mellitus, vitamin D deficiency (a condition in which the body does not have enough vitamin D) and hyperlipidemia (a condition of excess of lipids or fat in the bloodstream).A review of the quarterly MDS, dated [DATE], reflected a BIMS score of 5 of 15, indicating Resident #326's cognition was severely impairedA review of the Resident's PO summary dated 12/10/25, identified an order with an original date of 11/19/25, Regular diet, Chopped texture and thin liquid consistency.A review of Resident #326's CP revealed a nutrition CP with an initiation date of 6/18/21, the focus portion of the CP revealed, Resident is at risk of alteration in nutrition related to need for mechanically altered diet. The intervention portion of the CP revealed, provide diet per MD orders.On 12/8/25 at 12:40 PM, the surveyor interviewed the Speech Language Pathologist (SLP#1). The SLP and surveyor observed the 2nd floor dining room and observed Resident's #53, #226 and #326 who were all confirmed to be on a Chopped consistency diets and the residents received items that had not been chopped. Per the SLP#1 both the French fries and macaroni salad should have been served chopped. On 12/8/25 at 12:50 PM, the surveyor interviewed the Food Service Director (FSD), who stated for residents on the chopped diet consistency, should have all items served at the appropriate consistency, unable to explain why French Fries and macaroni salad had been chopped prior to being served. FSD further revealed the meal trays are checked prior to being sent to the residents.On 12/10/25 at 1:30 PM, the director of nursing (DON) provided the surveyor with a facility policy titled, Tray Identification, with a revised date of 3/4/25. The policy interpretation revealed, 2. The Food Service Director or supervisor will check trays for correct diets before the food carts are transported to their designated areas.On 12/10/25 at 1:53 PM, the surveyor met with the DON and Licensed Nursing Home Administrator (LNHA) to review concerns found during the survey. The DON stated the kitchen concerns would be corrected immediately.On 12/12/25 at 12:15 PM, the surveyor met with the LNHA and DON for the exit conference; no further pertinent information was provided.N.J.A.C. 8:39 - 17.4(a)

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and followed for 5 of 5 residents (Resident #53, #134, #224, #326 and #501) reviewed for dietary preferences during meal observations.This deficient practice was evidenced as follows:1. On 12/8/25 at 12:17 PM, the surveyor was observing the lunch meal on the second-floor dining room. The surveyor observed Resident #53's tray, per the tray ticket, Resident #53 was supposed to receive an egg salad sandwich, 1/2 cup fortified mashed potatoes and 4 ounces (oz) sherbet, all three items were missing from the resident's tray. On 12/8/25 at 12:19 PM, the surveyor reviewed Resident #53's electronic medical record (E-mar). A review of the resident's Face sheet (FS) (an admission summary) revealed Resident #53 was admitted to the facility with diagnoses that included: dementia (loss of cognitive functioning thinking, remembering, and reasoning), protein-calorie malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients), and hypertension (high blood pressure).A review of the annual MDS, (an assessment tool used to facilitate care management) dated 9/12/25, reflected a Brief Interview for Mental Status (BIMS) score was unable to be calculated as Resident #53 was unable to complete a BIMS interview due to cognition.A review of the Physician Order (PO) summary dated 12/10/25, identified an order with an original date of 4/25/25, Lactose free diet, Chopped texture and thin liquid consistency.A review of Resident #53's care plan (CP) revealed a nutrition CP with an initiation date of 11/15/22, the focus portion of the CP revealed, Resident is a risk for alteration in nutrition, history of malnutrition, need for therapeutic diet and mechanically altered diet. and the intervention portion of the CP revealed two nutrition interventions both initiated on 11/15/22, provide supplements as ordered.fortified mashed potatoes twice per day (BID) and provide diet per MD orders,.2. On 12/8/25 at 12:18 PM, the surveyor was observing the lunch meal on the second-floor dining room. The surveyor observed Resident #224's tray, per the tray ticket, Resident #224 was supposed to receive a sliced tomato and 8 ounces (oz) hot coffee, both items were missing from the resident's tray. On 12/8/25 at 12:22 PM, the surveyor reviewed Resident #224's E-mar. A review of the resident's FS was admitted to the facility with diagnoses that included: dementia, protein-calorie malnutrition, and type 2 diabetes mellitus (chronic disease characterized by high levels of sugar (glucose) in the blood).A review of the quarterly MDS, dated [DATE], reflected a BIMS score of 7 of 15, indicating Resident #224's cognition was severely impaired.A review of the Resident's PO summary dated 12/10/25, identified an order with an original date of 9/25/25, Regular diet, Chopped texture and thin liquid consistency.A review of Resident #224's CP revealed a nutrition CP with an initiation date of 7/1/25, the focus portion of the CP revealed, Resident is a risk for malnutrition due to history of weight loss. The intervention portion of the CP revealed, provide and serve diet as ordered per MD orders.3. On 12/8/25 at 12:19 PM, the surveyor was observing the lunch meal on the second-floor dining room. The surveyor observed Resident #326's tray, per the tray ticket, Resident #326 was supposed to receive a 1/2 cup fortified mashed potatoes, the item was missing from the resident's tray. On 12/8/25 at 12:24 PM, the surveyor reviewed Resident #326's E-mar. A review of the resident's FS was admitted to the facility with diagnoses that included: type 2 diabetes mellitus, vitamin D deficiency (a condition in which the body does not have enough vitamin D) and hyperlipidemia (a condition of excess of lipids or fat in the bloodstream).A review of the quarterly MDS, dated [DATE], reflected a BIMS score of 5 of 15, indicating Resident #326's cognition was severely impaired.A review of the Resident's PO summary dated 12/10/25, identified an order with an original date of 11/19/25, Regular diet, Chopped texture and thin liquid consistency.A review of Resident #326's CP revealed a nutrition CP with an initiation date of 6/18/21, the focus portion of the CP revealed, Resident is at risk of alteration in nutrition related to need for mechanically altered diet. The intervention portion of the CP revealed, provide diet per MD orders.4. On 12/8/25 at 12:20 PM, the surveyor was observing the lunch meal on the second-floor dining room. The surveyor observed Resident #501's tray, per the tray ticket, Resident #501 was supposed to receive a 1 slice whole wheat bread, 1 fresh orange, and 4oz Orange juice; all three items was missing from the resident's tray.On 12/8/25 at 12:25 PM, the surveyor reviewed Resident #501's E-mar. A review of the resident's FS was admitted to the facility with diagnoses that included: hypertension, hyperlipidemia and schizophrenia (mental illness that affects how a person thinks, feels, and behaves). A review of the quarterly MDS, dated [DATE], reflected a BIMS score was unable to be calculated as Resident #501 was unable to complete a BIMS interview due to cognition.A review of the Resident's PO summary dated 12/10/25, identified an order with an original date of 3/27/24, Regular diet, regular texture and thin liquid consistency.A review of Resident #501's CP revealed a nutrition CP with an initiation date of 11/6/18, the focus portion of the CP revealed, Resident is at risk for nutrition and hydration deficits due to his history of variable intake. The intervention portion of the CP with an initiation date of 2/26/24, revealed provide and serve diet per MD orders.5. On 12/8/25 at 12:22 PM, the surveyor was observing the lunch meal on the second-floor dining room. The surveyor observed Resident #134's tray, per the tray ticket, Resident #134 was supposed to receive a 6oz yogurt, 1/2 cup fortified mashed potatoes and 1/2 cup grapes; all three items was missing from the resident's tray.On 12/8/25 at 12:28 PM, the surveyor reviewed Resident #134's E-mar. A review of the resident's FS was admitted to the facility with diagnoses that included: hypertension, hyperlipidemia and congestive heart failure (condition when your heart can't pump blood well enough to give your body a normal supply). A review of the quarterly MDS, dated [DATE], reflected a BIMS score was 14 of 15, indicating the resident cognitionA review of the Resident's PO summary dated 12/10/25, identified an order with an original date of 8/15/25, Regular diet, regular texture and thin liquid consistency.A review of Resident #134's CP revealed a nutrition CP with an initiation date of 2/19/21, the focus portion of the CP revealed, Resident has a nutritional problem related to history of weight loss. The intervention portion of the CP with an initiation date of 2/21/21, revealed provide and serve diet per MD orders and provide fortified mashed potatoes daily, with an initiation date of 8/14/25.On 12/8/25 at 12:50 PM, the surveyor interviewed the Food Service Director (FSD), who stated for resident meal trays should be checked for accuracy prior to being sent to the nursing units.On 12/10/25 at 1:30 PM, the director of nursing (DON) provided the surveyor with a facility policy titled, Tray Identification, with a revised date of 3/4/25. The policy interpretation revealed, 2. The Food Service Director or supervisor will check trays for correct diets before the food carts are transported to their designated areas.On 12/10/25 at 1:53 PM, the surveyor met with the DON and Licensed Nursing Home Administrator (LNHA) to review concerns found during the survey. The DON stated the kitchen concerns would be corrected immediately.On 12/12/25 at 12:15 PM, the surveyor met with the LNHA and DON for the exit conference; no further pertinent information was provided.NJAC - 17.4(a)1, (e)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.On 12/04/25 at 9:24 AM, the surveyor in the presence of the Food Service Director observed the following during the kitchen tour:1. In preparation area #1, the surveyor observed dietary aide (DA#1) and the Chef both wearing hooped earrings. DA#1 stated hooped earrings are ok as long as they do not hang down to your shoulders.2. In the walk-in freezer, the surveyor observed multiple items stored higher than 18 inches from the ceiling and a full tray of meatloaf labeled with a use by date of 12/2/25. Per the FSD the meatloaf was mislabeled and the 12/2/25 date was when the item was placed into the freezer and was not the use by date but would dispose of the meatloaf due to the mislabeling. 3. In the walk-in refrigerators, the surveyor observed two containers of egg salad and tuna salad with use by labels dated for 12/3/25. Per the FSD those items should have been disposed of yesterday.On 12/4/25 at 1:24 PM, the FSD provided the surveyor with multiple facility policies. The employee dress code policy with no created or revised date revealed under the section N Personal Appearance, 7. Jewelry that could cause a safety hazard is not permitted. The food safety policy with a revised date of 1/4/25 revealed under the explanation and compliance, 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.6. The Head [NAME] or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. On 12/10/25 at 1:53 PM, the surveyor met with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) to review concerns found during the survey. The DON stated the kitchen concerns would be corrected immediately.On 12/12/25 at 12:15 PM, the surveyor met with the LNHA and DON for the exit conference; no further pertinent information was provided.NJAC 8:39-17.2(g)

Based on observation, interviews, and review of facility policies, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris.This deficient practice was observed and evidenced by the following:On 12/4/25 at 9:24 AM, the surveyor in the presence of the Food Service Director (FSD) toured the kitchen and garbage area and found the following: There was garbage debris that included carboard, food wrappers, food containers, cups, gloves, paper products, plastic bottles, medication cups, and around the dumpster and surrounding areas. The FSD stated the maintenance department should have cleaned the area.On 12/4/25 at 1:24 PM, the FSD provided the surveyor with a facility policy titled, Refuse Receptacle/Dumpster Use with a revised date of December 2008. The policy interpretation and implementation revealed, 4. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.On 12/10/2025 at 1:50 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to review concerns found during the survey. The DON stated that the garbage area concerns will immediately be addressed.On 12/12/25 at 12:15 PM, the surveyor met with the LNHA and DON for the exit conference; no further pertinent information was provided.NJAC 8:39-19.7

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 8 of the 35 residents (Resident #3, 6, 9, 13, 135, 209, 365, and #481) reviewed for reasonable accommodations of needs/preference.The deficient practices were evidenced by the following: 1. On 12/8/25 at 7:30 AM, the surveyor observed Resident #135 in bed. The surveyor observed that the call bell was wrapped around the light, on the wall above the bed, which was not within the resident's reach. A review of Resident #135's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; dementia and schizophrenia (a brain disorder that disrupts how a person thinks, behaves, and feels, leading to a distorted perception of reality). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 9/17/25, reflected that the resident had a brief interview for mental status (BIMS) score 3 out of 15, which indicated a severe cognitive impairment. A further review of the MDS assessed that Resident #135 required staff assistance for Activities of Daily Living (ADL). A review of Resident #135's Individual Comprehensive Care Plan (ICCP) initiated on 12/27/23 had a focus that indicated the resident was at risk for falls, with interventions that included but were not limited to; Be sure call light is within reach and encourage to use it for assistance as needed. 2. On 12/8/25 at 7:40 AM, the surveyor observed Resident # 365 in bed. The surveyor observed the call bell on the floor behind the head of the bed, which was not within their reach. A review of Resident #365's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; dementia and diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels.) A review of the quarterly MDS dated [DATE] reflected the resident had a BIMS score 10 out of 15, which indicated a moderate cognitive impairment. A further review of the MDS assessed that Resident #365 required staff assistance for ADL care. A review of Resident #365's ICCP, initiated 12/3/24, revised on 9/22/25, had a focus that indicated the resident was a risk for falls, with interventions that included but were not limited to; be sure call light is within reach and encourage to use it for assistance as needed. 3. On 12/8/25 at 7:50 AM, the surveyor observed Resident # 209 in bed. The surveyor observed the call bell on the floor behind the head of the bed, which was not within their reach. A review of Resident #209's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; dementia and diabetes mellitus. A review of the quarterly MDS dated [DATE] reflected that the resident had severely impaired cognition for daily decision making. A further review of the MDS assessed that Resident #209 was dependent on staff for ADL care. A review of Resident #209's ICCP, initiated 3/6/23, revised on 8/26/25, had a focus that indicated the resident was at risk for falls, with interventions that included but were not limited to; Be sure call light is within reach and encourage to use it for assistance as needed. On 12/8/25 at 7:55 AM, the surveyor showed the Licensed Practical Nurse (LPN) on the 3 [NAME] Nursing Unit the call bells in each of the above residents' rooms. The LPN acknowledged that the call bells were not within the residents' reach and confirmed that staff should ensure all call bells were placed within the residents' reach. 4. On 12/04/2025 at 11:20 AM, the surveyor observed Resident #6 in bed. The surveyor observed the call bell clipped to the wall behind the resident's oxygen concentrator, which was not within the resident's reach. A review of Resident #6's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; dementia, schizophrenia (a brain disorder that disrupts how a person thinks, behaves, and feels, leading to a distorted perception of reality), diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) and hypertension. A review of Resident #6's quarterly Minimum Data Set (MDS), an assessment tool dated 11/21/25 reflected the resident had short-term and long-term memory deficits and was assessed as severely cognitively impaired. A further review of the MDS assessed that Resident #6 required staff assistance for ADL care. A review of Resident #6's Individual Comprehensive Care Plan ICCP initiated on 2/18/25 had a focus that indicated the resident was at risk for falls, with interventions that included but were not limited to; Be sure call light is within reach and encourage to use it for assistance as needed. 5. On 12/04/25 at 11:40 AM, the surveyor observed Resident #9 in bed. The surveyor observed that the resident's call bell was draped over the light fixture on the wall above the bed, which was not within the resident's reach. A review of Resident #9's admission Record reflected the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to; chronic obstructive pulmonary disease, hypertension, and schizophrenia (a brain disorder that disrupts how a person thinks, behaves, and feels, leading to a distorted perception of reality). A review of Resident #9's quarterly MDS 9/4/25, reflected that the resident had a brief interview for mental status (BIMS) score 8 out of 15, which indicated a moderate cognitive impairment. A further review of the MDS assessed that Resident #9 required staff assistance for Activities of Daily Living (ADL) care. A review of Resident #9's ICCP initiated on 2/1/23 had a focus that indicated the resident was at risk for falls, with interventions that included but were not limited to; Be sure call light is within reach and encourage to use it for assistance as needed. On 12/09/25 at 11:45 AM, the surveyor observed the call bells for resident #6 and Resident # 9 were in the same position as the previous observations and the surveyor showed the third floor Charge Nurse the call bell placement for both residents. The Charge Nurse acknowledged that the call bells were not within either resident's reach and confirmed that staff should position call bells within the reach of residents. 6. On 12/4/25 at 10:27 AM, the surveyor observed that Resident #3 in bed and the call light was hanging on top of the wall light. On 12/8/25 at 11:15 AM, the surveyor observed that Resident #3's call light was on the floor under the bedside table. The resident stated that they could find the call light. On 12/8/2025 at 9:49 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #3, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #3 was admitted with diagnoses that included but were not limited to; dementia (loss of memory) with mood disturbance. A review of the quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) dated 9/15/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated that the resident had moderate impairment in cognition. Further review of the Q/MDS, as reflected in section GG, revealed that the resident requires assistance from staff for daily living activities. A review of the Care Plan (CP) report initiated on 12/20/24 focused on Resident #3, who is at risk for falls related to cognitive impairment, confusion, deconditioning, gait/balance problems, incontinence, and psychoactive drug use. Interventions included, but were not limited to, the following: Be sure Resident #3's call light is within reach and encourage the resident to use it for assistance as needed. 7. On 12/4/25 at 10:15 AM, the surveyor observed that Resident #13's call light was lying on the floor. The resident stated they do not know where the call light is located. Resident #13 added that they would keep on screaming if they could not find the call light. A review of the AR reflected that Resident #13 was admitted with diagnoses that included but were not limited to; vascular dementia (decreased blood flow to the brain that results in impaired cognition), unspecified severity, with agitation. A review of the significant change Minimum Data Set (SC/MDS) dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 5 out of 15, which indicated that the resident had severe impairment in cognition. Further review of the SC/MDS, as reflected in section GG, revealed that the resident requires assistance from staff for daily living activities. On 12/8/2025 at 1:16 PM, the surveyor reviewed the CP report with an initiated date of 7/7/25, with the focus on Resident #13, who is at risk for falls related to gait/balance problems, psychoactive drug use, antihypertensive medication, and a history of falls. Interventions included, but were not limited to, the following: Be sure Resident #13's call light is within reach and encourage them to use it for assistance as needed. 8. On 12/4/25 at 10:25 AM, the surveyor observed that Resident #481 in bed and the call light was located under their bed. On 12/08/2025 at 11:10 AM, the surveyor observed Resident #481 in bed and call light was on the floor. A review of the AR reflected that Resident #481 was admitted with diagnoses that included but were not limited to; dementia (loss of memory) in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. A review of the Q/MDS dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 0 out of 15, which indicated that the resident had severe impairment in cognition. Further review of the Q/MDS, as reflected in section GG, revealed that the resident requires assistance from staff for daily living activities. On 12/8/2025 at 12:57 PM, the surveyor reviewed the CP report with an initiated of 9/25/18 with the focus on Resident #481, who is at risk for falls due to poor safety awareness, history of falls, impaired vision, limited mobility, and hypertensive medication. Interventions included, but were not limited to, the following: the call light to be within reach so the resident could call for assistance. On 12/08/2025 11:18 AM, the surveyor interviewed the Certified Nurse Assistant (CNA), who stated that the call light should be within the resident's reach. On 12/08/2025 11:22 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the call light should be near the resident so they can reach it in case they need to call for help. It's for their safety. On 12/11/2025 at 9:52 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON stated that the entire staff would make sure that the call bell is in bed and within reach of the residents. A review of the facility policy titled: Answering the Call light with the revised date of 6/10/25 under General Guidelines, 5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident 6. Some residents may not be able to use their call light. Be sure you check these residents frequently. NJAC 8:39-31.8(c)9

Based on observation, interview, and record review, it was determined that the facility failed to provide a homelike environment for residents on 4 of 13 units and was evidenced by the following.On 12/10/25 at 9:10 AM, the surveyor knocked on the door of room W218 and asked Resident #11 if he could inspect their bathroom. The surveyor entered the bathroom in W218 and observed approximately a 7-foot white trim molding, one urinal, and one bucket inside the bathtub. The bathtub which contained staining in the front near the faucet. On 12/10/25 at 11:30 AM, the surveyor showed the picture of the bathroom to the Licensed Nursing Home Administrator who stated that those items should not be inside the bathtub and that he was going to the room and have the items removed. The surveyor toured Unit 3 [NAME] on 12/04/2025 at 11:30 AM. On 12/4/25 at 11:30 AM, the surveyor observed in room [ROOM NUMBER] that the bathroom floor, toilet seat, and toilet bowl were heavily soiled with a yellow substance. On 12/4/25 at 11:33 AM, the surveyor observed in room [ROOM NUMBER] that the window bed had a broken end table. On 12/4/25 at 11:50 AM, the surveyor observed in room [ROOM NUMBER] that the wall and molding by the door bed were heavily soiled; the bathroom door was heavily soiled, the bathroom floor had broken tiles, the bedside table was in disrepair, and the cover to the heater vent was broken. On 12/4/25 11:55 AM, the surveyor observed in room [ROOM NUMBER] that the floor was heavily soiled with food debris and a brown substance, the walls by the window and door beds had chipped peeling paint, and the door to the bathroom was heavily soiled. On 12/10/25 at 10:45 AM, the surveyor toured the 3 [NAME] Unit with the Licensed Nursing Home Administrator (LNHA). The LNHA told the surveyor that the Director of Maintenance was out of the building and unavailable for the tour/interview. The surveyor showed the LNHA the above observations and concerns. The LNHA confirmed the surveyor's environmental findings. He stated that the facility utilized the Tels electronic system and that the above issues should have been reported and addressed as soon as possible, ideally within a day. On 12/10/25 at 1:49 PM, the survey team discussed the above observations and concerns with the LNHA and DON. On 12/4/25 at 11:00 AM the surveyor toured the 3rd floor nursing units. On 12/4/2025 at 11:20 AM, the surveyor observed in room [ROOM NUMBER]E-307 a splattered, dried, dark brown substance on the wall behind the middle bed. The surveyor further observed a splattered, dried, light brown substance on the top and front of the oxygen concentrator to the right side of the middle bed. On 12/4/25 at 11:25 AM, the surveyor observed in room [ROOM NUMBER]E-307 the bathroom sink was pulling away from wall in and was loose. On 12/4/25 at 11:40 AM, the surveyor observed in room [ROOM NUMBER]S-310 the baseboard radiator cover to the right of the middle bed was damaged and hanging off. On 12/4/25 at 12:36 PM, the surveyor observed in room [ROOM NUMBER]S-316D large area of scraped, peeling and damaged paint with sheetrock exposed on the wall next to the bathroom door. The surveyor observed large black horizontal scuff marks on same wall above the damaged paint. On 12/10/25 at 10:00 AM the surveyor interviewed the Director of Environmental Services (DES). The DES confirmed the dried, splattered substances on the wall and the oxygen concentrator in room [ROOM NUMBER]E-307 should have been cleaned by housekeeping and detracted from the facility's home like environment. On 12/10/25 at 10:40 AM, the surveyor interviewed the Director of Maintenance (DOM). The DOM stated the facility utilizes and electronic reporting system (TELS) to report issues in need of attention. The Dom states every employee in the facility has access to make a report. The DOM states he or one of his staff reviews this report daily to prioritize repairs. The DOM acknowledged he was unaware of the findings of the surveyor from the tour of the third floor. The DOM acknowledged all the surveyor's observations on the third floor detracted from the facility's homelike environment. A review of the TELS report for November and December of 2025 did not reflect the issues the surveyor on the tour of the third floor had been reported. The surveyor toured Unit 1 South on 12/09/2025 at 10:49 AM. The surveyor observed in room [ROOM NUMBER], behind the head of the first bed (nearest the door) – a length of approximately 4 feet of vinyl cove base molding lying on the floor exposing the plywood baseboard underneath. The surveyor observed the following concerns on 12/10/2025 at 9:26 AM. In room [ROOM NUMBER], the corner cove base molding on the left near the bathroom was jagged and torn. In room [ROOM NUMBER], the wall behind the head of the bed nearest the door had peeling paint exposing the wall board. In room [ROOM NUMBER], there was an approximately 5-inch diameter hole in the wall behind the doorknob of the door to the entrance of the room. In room [ROOM NUMBER], the head of the bed of the bed closest to the door had peeling paint exposing the wall board. rooms [ROOM NUMBERS] had no signage identifying the room numbers of room [ROOM NUMBER] and 120. The surveyor discussed the environmental concerns with the Director of Nursing Services and the Licensed Nursing Home Administrator (LNHA) on 12/10/2025 at 1:49 PM The LNHA confirmed the surveyor's environmental findings on 12/11/2025 at 9:48 AM. He stated the repairs had been done and the room numbers were replaced. NJAC 39-4.1(a)

Based on observation, interview, and record review, it was determined that the facility failed (a).to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 2 of 34 residents (Resident#7 and Resident #11) observed during the medication review and 1of 6 residents (Resident #584) observed during medication administration and b) accurate reconciliation and administration of narcotic medication with potential for drug diversion.Repeat deficiency The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 12/04/25 at 11:05 AM, the surveyor observed Resident #11 in bed on a pressure relieving mattress and was watching television. A review of the admission Record (an admission summary) reflected that Resident #11 was admitted to the facility with diagnoses that included Parkinson's Disease (a progressive brain disorder causing movement issues like tremors, stiffness, and slowness (bradykinesia), anxiety disorder( mental health conditions marked by excessive, persistent worry and fear that significantly disrupt daily life), and hypertension (the force of blood against the artery walls is consistently too high). A review of the admission Minimum Data Set, an assessment tool used to facilitate the plan of care, dated 11/10/25, reflected that the resident's cognitive skills for daily decision-making score was 9 out of 15, which indicated that the resident's cognition was mildly impaired. A review of the December 2025 Order Summary Report (OSR) revealed the following Physician's Order (PO) dated 11/27/25 for Midodrine HCL tablet 5 mg (medication given for hypotension), give 1 tablet by mouth three times a day hold for systolic blood pressure (SBP) more that than 130. A review of the December 2025 OSR revealed a PO dated 11/8/25 for Clonazepam oral tablet 1 mg, give 1 tablet by mouth three times a day for anxiety. A review of the November and December 2025 electronic medication administration record (e-MAR) revealed a PO dated 11/27/25 for Midodrine HCL tablet 5 mg, give 1 tablet by mouth three times a day hold for SBP more than 130 with an administration time of 0930 (9:30 AM), 1330 (1:30 PM), and 1730 (5:30 PM). A further review of the e-MAR revealed that nurses were not plotting the BP (blood pressure) (which included the SBP). A review of the December 2025 e-MAR revealed a PO dated 11/8/25 for Clonazepam oral tablet 1 mg, give 1 tablet by mouth three times daily for anxiety. On 12/10/25 at 9:20 AM, the surveyor interviewed a Licensed Practical Nurse (LPN#1) who stated that she was going to administer Resident #11's medication which included Midodrine. The surveyor observed LPN #1 knock on the resident's door and checked Resident #11's identification and informed the resident that she was going to take the resident's vitals and then administered their medication. The surveyor observed the nurse take the resident's vitals which had a SBP of 116. The surveyor then observed LPN#1 write the resident's vitals on a piece of paper and then informed the surveyor that she was going to administer the Midodrine since the SBP was less than 130. At that time, the surveyor interviewed LPN#1 regarding documenting the SBP in the e-MAR. LPN#1 stated that she seen other blood pressure medications with a perimeter being documented in the e-MAR and wasn't sure why she couldn't enter the BP in the e-MAR for the resident's midodrine. LPN#1 acknowledge that she would have the order updated so the BP could be entered in the e-MAR. During the medication preparation of the resident's midodrine, the surveyor observed an order for Clonazepam. The surveyor asked LPN#1 if she was going to administer that medication to the resident. LPN#1 stated that she already administered the medication to the resident but forgot to sign out the e-MAR. The surveyor reviewed the Individual Patient's Controlled Drug Record (IPCDR) which revealed that the nurse signed out the medication on 12/10/25 at 9:00 AM. In the presence of LPN#1 the surveyor reviewed the resident's clonazepam 1 mg bingo card (pharmacy delivery system) which revealed the count matched the amount remaining on the IPCDR which was 39 tablets. At that time, the surveyor interviewed LPN #1 who acknowledge that she should have signed off the e-MAR after administering Resident #11's clonazepam. On 12/10/25 at 1:45 PM, the surveyor discussed the above concerns with the facility administration team that consisted of the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). There was no additional information provided. A review of the facility's policy for Medication Administration that was dated 09/05/25 and was provided by the DON revealed the following: 12. The individual administering the medication must initial the resident's MAR on the appropriate line after giving the medication. 13. When administering Controlled Substance, the declining sheet inventory sheet will be completed when the medication is removed from the locked drawer. Enter date, time, dose, and legible signature and amount remaining. Once the medication is administered to the resident the nurse will document on the administration record. 2.) On 12/04/25 at 11:51AM, the surveyor observed Resident #7 in bed asleep, and had a catheter attached to the side of the bed with a privacy cover. On 12/8/25 at 12:30 PM, in the presence of the Certified Nursing Assistant (CNA), the surveyor smelled a strong scent of urine. The CNA who was not assigned to resident confirmed the scent and stated she would inform the CNA assigned to change the catheter bag. The surveyor reviewed the medical record for Resident #7. A review of the admission Record reflected that Resident #7 was admitted to the facility with diagnoses that included urethral stricture male meatal (narrowing of the urethra causing weak urine flow, paroxysmal atrial fibrillation (a type of irregular heartbeat) and hypertension. A review of the most recent quarterly Minimum Data Set, an assessment tool used to facilitate the of care, dated 9/26/25, reflected a Brief Interview for Mental Status (BIMS) score of 99 which indicated the interview was unable to be completed. J1800. Falls since admission/entry/reentry reflected the resident had no falls. A review of the individualized comprehensive care plan (CP) included a focus for risk for falls related to cognitive impairment, impaired balance and diagnoses that included hypertension initiated on 7/6/22 and revised on 7/13/22. The interventions included to evaluate and treat as ordered or as needed, initiated on 7/6/22. A review of the medical provider Progress Notes (MP/PN) dated 11/12/25, included that Resident #7 was seen, examined and was documented as nonverbal at baseline, appearing lethargic.The chart, medications and vitals were thoroughly reviewed with nursing staff. A review of the December 2025 Order Summary Report (OSR) revealed the following Physician's Order (PO) for December 2025, included a physician's order (PO) that was started on 11/12/25 for 40 mg of Olmesartan (Benicar) to be given 1 tablet via gastronomy tube (g-tube; a flexible tube inserted into an individual's to receive nutrition) one time a day for hypertension and held for less than 130 of systolic blood pressure (SBP; (measures the pressure in your arteries when your heart beats). A review of the November and December 2025 electronic medication administration record (e-MAR) included a PO dated 11/12/25, with an administration time of 7:30 AM, for Olmesartan 40mg, give 1 (one) tablet once a day hold for SBP less than 130 revealed the following administrations outside the parameters: - On 11/13/25, the BP was documented as 128/80 and documented as administered. - On 11/14/25, the BP was documented as 112/66 and documented as administered. - On 11/17/25, the BP was documented as 120/59 and documented as administered. - On 11/18/25, the BP was documented as 128/67 and documented as administered. - On 11/24/25, the BP was documented as 128/88 and documented as administered. - On 11/26/25, the BP was documented as 106/64 and documented as administered. - On 11/27/25, the BP was documented as 120/79 and documented as administered. - On 11/28/25, the BP was documented as 122/60 and documented as administered. -On 12/1/25, the BP was documented as 123/ 68 and documented as administered. -On 12/2/25, the BP was documented as 129/ 73 and documented as administered. - On 12/8/25, the BP was documented as 127/66 and documented as administered. On 12/10/25 at 1:53 PM, in the presence of the survey team, the Licensed Nursing Home Administrator, the Director of Nursing, the surveyor discussed the concern with the nurses who administered Olmesartan to Resident #7 outside the physician ordered parameter. A review of the facility policy; Administering Medications dated/revised on 9/5/25, included that medications must be administered in accordance with the orders, including any required time frame. 3.) On 12/9/25 at 9:14 AM, the surveyor observed Licensed Practical Nurse LPN #2 who was assigned to the third-floor low side, prepared the medications for Resident #584. The medications included a PO for Lidoderm Patch 5%, apply to the right hip topically one time a day for right hip pain, 12 hours on and 12 hours off. The PO was started on 12/5/25. On 12/9/25 at 9:33 AM, LPN #2 stated that she was going to check Resident #584's BP. On 12/9/25 at 9:42 AM, from the hallway the surveyor observed the resident well dressed and was seated on the side of the bed. At 9:44 AM, the surveyor observed LPN #2 knocked on the door, checked the resident's name band, took the resident's blood pressure and performed hand hygiene using an alcohol-based hand rub. At 9:45 AM, the surveyor overheard Resident #584 asked LPN #2 for their pain medication. The Resident described their pain, by placing their hand on the front of their hip, the groin area and placed their hand on the back of the hip. At that time, the Resident stated that the pain also radiated downward from the back of the hip. The resident described their pain level as 7 out of 10, at the highest level. At 9:58 AM, LPN #2 applied one (1) Lidoderm patch to the back side of the resident's hip. On 12/9/25 at 12:47 PM, the surveyor and LPN #2 reviewed the eMAR together. At that time, LPN #2 acknowledged that the order did not include a quantity and that the patch that was applied to the back hip did not provide coverage for the resident's pain on the groin area. LPN #2 stated she would inform the medical provider. On 12/10/25 at 9:35 AM, during an interview with the surveyor, the Unit Manager/Assistant Director of Nursing (UM/ADON) stated that physician orders contained the name of the medication, the route of administration, the dosage form (i.e.capsule, tablets, liquid etc.) parameters, the prescribers name, duration of administration, location of administration and the quantity. On 12/10/25 at 9:52 AM, the surveyor, and the UM/ADON reviewed the eMAR together. The UM/ADON acknowledged and confirmed that the Lidoderm order did not include the number of patches that needed to be administered. On 12/10/25 at 1:53 PM, in the presence of the survey team, the Licensed Nursing Home Administrator, the Director of Nursing, the surveyor discussed the concerns with the medication pass observation wherein the Lidoderm 5% patch did not include the number of patches to be administered. A review of the facility provided policy; Administering Medication dated/reviewed on 9/5/25 included that the individual administering the medication will record in the resident's medical record: the dosage. 4.) On 12/11/25 at 10:44 AM, the surveyor and LPN #3 began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart B (narcotic box), located on the west side of the first floor. At that time, in the presence of LPN #3, the surveyor reviewed the Narcotic Card Count (a narcotic, shift to shift count sign in sheet) for December 2025 revealed that the 7:00 AM to 3:00 PM shift, LPN #3 on duty did not sign that day, 12/11/25. A review of the Individual Patient's Controlled Drug Record (IPCDR; a declining inventory log used for accountability of controlled drugs) against the bingo card (a blister packet that contained medications) revealed the following: -Resident #495's bingo card for Oxycodone/Acetaminophen 5-325 mg (used for pain relief) contained three (3) tablets and the IPCDR indicated four (4) tablets remained. - Resident #475's bingo card for Lorazepam 1 mg (used as an anti-anxiety) contained 38 tablets and the IPCDR indicated 39 tablets remained. - Resident #542's bingo card for Pregabalin 25 mg (used for pain relief) contained four (4) capsules and the IPCDR indicated five (5) capsules remained. - Resident #146's bingo card for Clonazepam 0.5 mg (an anti-anxiety medication) bingo card could not be located and the IPCDR indicated one (1) tablet remained. - Resident #358's bingo card for Lacosamide 50 mg (Vimpat; an anti-seizure medication) contained 31 tablets and the IPCDR indicated 32 tablets remained. - Resident #563's bingo card for Lacosamide 150 mg contained 26 tablets and the IPCDR indicated 27 tablets remained. - Resident # 27's bingo card for Lorazepam 1 mg contained 54 tablets and the IPCDR indicated 55 tablets remained. - Resident # 560's bingo card for Lorazepam 1 mg contained 5 tablets and the IPCDR indicated 6 tablets remained. - Resident # 276's bingo card for Clonazepam 0.5 mg (used to relieve paranoia) contained 23 tablets and the IPCDR indicated 25 tablets remained. A review of the December 2025 eMAR included a PO for Clonazepam 0.5mg, give one (1) tablet three (3) times day (9:30 AM, 1:30 PM and 5:30 PM). The eMAR reflected that 1 tablet was administered on 12/11/25 and that one tablet was unaccounted for. At that time, LPN #3 stated that one (1) tablet inadvertently fell out which he wasted (destroyed/disposed) in the drug disposal solution without a witness and without documentation on the IPCDR At that time, LPN #3 informed the surveyors that he administered the morning narcotic medications to the residents and did not sign the IPCDR for all the residents he administered to that morning . The LPN stated that the facility policy was to sign the IPCDR as soon as the medication was removed/ dispensed from the bingo card. LPN #3 could not say why he did not follow the facility policy. 4.) On 12/11/25 at 11:59 AM, the surveyor and LPN #4 began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart B (narcotic box), located on the south side of the first floor. At that time, in the presence of LPN #4, the surveyor reviewed Resident #549's IPCDR for Lorazepam 2mg/ml which revealed 4 (four) blank spaces. Each space represented 0.5mg of Lorazepam and did not indicate when and who removed each dose. The omissions were found between the dates of 10/24/25 and 11/7/25. Further review of the IPCDR reflected 2 (two) more blanks between 12/9/25 and 12/11/25. A review of Resident #549's eMAR reflected the resident had a PO for Lorazepam Oral Concentrate 1mg/0.5ml, give 0.5 ml by mouth four (4) times a day for agitation. The order was started on 9/5/25. On 12/11/25 at 12:34 PM, in the presence of LPN #4, the surveyor reviewed the quantity remaining for the Lorazepam that reflected 10.5 ml. At that time, during an interview with the surveyor, LPN #4 stated she did a shift-to-shift count with the outgoing nurse and acknowledged she did not address the omission on the IPCDR and did not inform her supervisor, On 12/10/25 at 1:53 PM, in the presence of the survey team, the LNHA and the DON, the surveyor discussed the concern with the facility's failure to ensure proper destruction of narcotic medication that required two (2) nurses signatures, the inconsistent reconciliation of narcotic medications removed from the Resident's inventory by the nurses and the missing narcotic accountability of when and who removed each dose was not reflected on the IPCDR and went unnoticed from October 24, 2025 and totaled 6 mg of Lorazepam. On 12/11/25 at 9:00 AM, the surveyor received documentation that the facility investigated the concern, utilizing cameras, resident/staff interviews and reconciliation after surveyor inquiry to rule out that diversion occurred. No further information was provided. A review of the provided facility policy, Controlled Substances dated/revised 6/16/25 included the following: Policy Statement: The facility shall comply with all laws, regulation and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances. Section 8. Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must count together. They must document and report any discrepancies to the Director of Nursing Services. Section 9. The Director of Nursing shall investigate any discrepancies in narcotic reconciliation to determine the cause and identify any [responsible] parties. A review of the provided facility policy, Discarding and Destroying Medications dated/revised 6/15/25 included that whoever witnesses the destruction/disposal of medications must sign and date the medication disposition record. NJAC 8:39-27.1 (a), 29.2 (b) (d), 29.4 (g)(h)(k), 29.7 (c)

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 4 of 13 medication carts and 2 of 4 medication room refrigerators inspected.This deficient practice was evidenced by the following: a). On 12/11/25 at 10:15 AM, the surveyor inspected the 2nd floor east wing high-side medication cart in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened multi-dose vial of Fluphenazine Decanoate 25 mg/ml (anti-psychotic) that had an opened date of 10/31/25 and was expired. At that time, the surveyor interviewed LPN#1 who acknowledge that the Fluphenazine Decanoate multi-dose vial once opened had a 28-day expiration date and that it was expired and should have been removed from active medication. b). On 12/11/25 at 10:25 AM, the surveyor inspected the 3rd floor east wing high-side medication cart in the presence of LPN#2. The surveyor observed an opened and undated Humalog insulin pen. At that time, the surveyor interviewed LPN#2 who acknowledge that the Humalog insulin pen was opened and not dated. LPN#2 further stated that once an insulin pen is opened it should have been dated. c). On 12/13/25 at 10:35 AM, the surveyor inspected the 3rd floor south wing high-sided medication cart in the presence of LPN#3. The surveyor opened an unopened vial of Retacrit (medication for anemia) that had a pharmacy label date of 12/10/25. At that time, the surveyor interviewed LPN#3 who acknowledge that the Retacrit vial should have been stored in the refrigerator. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Fluphenazine Decanoate multidose vial once opened have an expiration date of 28-days. 2. Humalog insulin pen once opened have an expiration date of 28-days. 3. Retacrit vial should be stored in the refrigerator. On 12/13/25 at 1:30 PM, the surveyor discussed the above observations and findings with the administrative team which included the Director of Nursing (DON) and the Licensed Nursing Home Administrator. There was no additional information provided. A review of the facility's policy for Storage of Medications dated 8/15/25 and provided by the DON included the following: 5. The facility shall not use discontinued, outdated, or deteriorated drugs, or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 10. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be label accordingly. d.) On 12/11/25 at 11:40 AM, in the presence of the Registered Nurse/Charge Nurse (RN/CN), the surveyor inspected the medication room located on the First floor West-wing. The medication room was observed to have contained a refrigerator, that had a Medication Refrigerator Temperature log (med temp log) posted on the door of the refrigerator. A review of the refrigerator log reflected instructions: Refrigerator log must be 36 to 46 degrees. If the temperature is not in the proper range, (NOTIFY YOUR SUPERVISOR IMMEDIATELY). A note must be made in the action column as to what action was taken and the new temperature after the corrective action was done. Further review of the med temp log revealed that on 12/5/25 the temperature was recoded as 48, and under action taken was a dash. No temperature was recorded on 12/6/25 and 12/8/25. The temperature recorded on 12/11/25 was 45 Fahrenheit ( ). At that time, the surveyor opened the refrigerator, observed frost inside the refrigerator and the thermometer inside the refrigerator was 48 . The RN/3 confirmed visualization of the frost and same temperature. The medications inside the refrigerator included the following: -Resident #119's Mounjaro (injectable medication used to manage type 2 diabetes). -Resident #470's Novolin 70/30 (injectable medication used to control high blood sugar). -Resident #362's Mounjaro -Resident #100;s Lantus and Mounjaro -Resident #409's insulin aspart (Novolog; rapid acting insulin used to manage blood sugar levels in individuals with type 1 and type 2 diabetes and insulin glargine (long-acting insulin used to manage blood sugar levels for type 1 and type 2 diabetes). -Resident #542's Dupixent (an injectable, biologic medication used to treat a variety of chronic inflammatory conditions). At that time, the RN/CN stated the temperature within the refrigerator should have been between 36 to 46 and confirmed that an expiration date found was the manufactured labeled expiration. The RN/CN stated that she would report the 48 -temperature found that morning to maintenance and the temperature found on the med log on 12/5/25 of 48 . On 12/11/25 at 11:48 AM, the surveyor informed the Licensed Practical Nurse/ Assistant Director of Nursing (LPN/ADON) of the concern that the temperature log policy was not followed on 12/5/25, and that the staff failed to consistently record the temperature on the med log on 12/6/25 and 12/8/25. On 12/11/25 at 1:28 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the above concerns during the medication storage and labeling inspection. On 12/12/25 at 9:00 AM, the surveyor reviewed the provided receipt of a newly purchased refrigerator and education provided to the staff to ensure notification to administration when the medication refrigerator was out of range. On 12/12/25 at 10:32 AM, the surveyor observed the temperature within the refrigerator was 43 and was within the 36-46 range. e.) On 12/11/25 at 11:59 AM, in the presence of the Licensed Practical Nurse (LPN), the surveyor inspected medication cart B, located on the First floor South-wing and observed an opened vial of Tuberculin Purified Protein Derivative, diluted (PPD; Aplisol, a diagnostic antigen used in the skin to help detect tuberculosis infection) which reflected, Refrigerate. The surveyor reviewed manufacturer specifications on 12/11/25 which also indicated that this biological should be stored under refrigeration. At that time, the LPN stated she had not used the PPD and that she checked her cart that morning and must have missed it. The LPN also stated that every nurse that takes over the medication cart should check for expiration and appropriate storage of its contents. The LPN acknowledged that the PPD should have been kept in the refrigerator and informed the surveyor that she would alert the charge nurse of the PPD that was left out at room temperature. f.) On 06/28/22 at 1:00 PM, the surveyor, in the presence of the LPN, observed the following within the refrigerator located in the medication room of the First-floor, South Unit: -one opened, dated 11/22/25 vial of Acetylcysteine 20% solution, (Mucomyst: medication used to thin and loosen thickened mucus in the airway, allowing ease with coughing up and clearing the lungs). At that time, the Registered Nurse/ Charge Nurse RN/CN) arrived in the medication room and was informed of the findings. The RN/CN stated that all nurses on all shifts were responsible to ensure that expired biologicals and medications were removed from active inventory and that the nurses on every shift from 11/22/25 must have missed it. On 12/11/25 at 1:28 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the above concerns during the medication storage and labeling inspection. A review of the facility policy, Storage of Medications, dated/revised 8/15/25 included that the facility shall not use discontinued, outdated, or deteriorated drugs, or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. NJAC 8:39-29.4 (g) (h)

Based on observation, interview, and record review, it was determined that the facility failed to provide a communication device for Resident #468 identified with a language barrier. This deficient practice was identified for one (1) of six (6) residents (Resident #468) observed during the medication administration and was evidenced by the following: Reference: According to the manufacturer's specifications for Breo Ellipta (fluticasone furoate and vilanterol trifenatate powder) section 2.3 Administration Information: After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis (fungal infection in the mouth, and the throat). On 12/9/25 at 8:30 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #468 that included, Breo Ellipta 100-25 milligram (mg), give 1 puff by mouth, one time a day for Chronic Obstructive Pulmonary Disease (COPD; a progressive lung condition that blocks airflow, making breathing difficult). The physician order for Breo was started on 4/16/25. At 8:37 AM, the LPN stated she was ready to administer the medications to Resident #468, turned and entered the resident's room. At 8:40 AM, the LPN handed the Breo to the resident explained to the resident to rinse and spit the after inhalation, handed the resident a small cup of water then informed the surveyor that the resident did not understand English. The surveyor observed the resident inhale one (1) inhalation and drank the water the LPN gave. No communication device/board was found in the room for the medication Breo Ellipta. At that time, the surveyor and the LPN returned to the cart. The LPN acknowledged that she knew the resident did not understand English. The LPN stated she thought she could not ask another staff to translate. During the interview with the surveyor, the LPN looked in the medication cart and the resident's room then confirmed that there were no communication board/devices to help her instruct the resident to rinse and spit after inhalation of Breo. The LPN also stated that it was important to rinse and spit to remove the residue of the steroid contained in the Breo after inhalation. On 12/9/25 at 8:46 AM, during an interview with the surveyor, the LPN/Assistant Director of Nursing of the first floor stated that there were communication sheets in the charts, picture board with basic language and the other nurse on the same floor spoke the same language as Resident #468. The surveyor reviewed the medical record for Resident #468. According to the admission Record, an admission summary, reflected that Resident #468 was admitted to the facility with diagnoses that included COPD, and type 2 diabetes (high blood sugar).A review of the most recent quarterly Minimum Data Set, (qMDS), an assessment tool used to facilitate the management of care dated 10/20/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident had a severely impaired cognition. Further review of the qMDS section A. 1100 revealed the resident needed or wanted an interpreter to communicate with doctor or health care staff. A review of the individualized comprehensive care plan (CP) included a focus that indicated the resident's primary language was [language redacted] initiated on 4/16/25. The interventions included the resident's preferred language, the use of communication board with basic words and pictures, initiated on 4/16/25 and revised on 7/17/25. On 12/10/25 at 1:53 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the observation made during the medication pass wherein the LPN knowingly administered the Breo Ellipta to Resident #468 who had a language barrier and did not use a communication device/board or asked for another staff to translate in order for the medication to be administered in accordance with the manufacturer's specifications. On 12/11/25 at 9:48 AM, in the presence of the survey team, and the LNHA, the DON stated that she had contacted the agencies, and the remediation of a medication pass observation had to be done by the agencies for the nurse to be allowed back to work within the facility. The DON also stated that she and the team went there to speak with the resident who had a low BIMS score and could not rinse and spit after the administration. The DON did not state how the individualized care plan would be addressed after their assessment. The DON stated that the LPN chose not to utilize the resources available, such as a translator during the medication pass observation. A review of the facility provided policy for Communication dared 1/10/25, included that the facility staff would utilize different modes of communication to help maintain lines of communication with the residents that included but not limited to, the use of language boards, interpreters, family members, etc. NJAC 8:39-27.1 (a)

Complaint #2561471 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 5 residents (Resident #302, #320, and # 275) observed for incontinence care on 1 of 2 units (3rd-floor North Nursing Unit).This deficient practice was evidenced by the following:On 12/8/25 at 7:30 AM, the surveyor completed an incontinence tour on the 3rd floor Nursing Unit and observed the following: 1.On 12/8/25 at 8:06 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA) observed Resident #302 in bed. The CNA exposed Resident #302's incontinence brief, and the surveyor observed that it was saturated with urine. The CNA confirmed that the brief was saturated with urine. A review of Resident #302's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to, Alzheimer's Disease and diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels). A review of Resident #302's annual Minimum Data Set (MDS), an assessment tool dated 5/21/25 revealed Resident #302 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated Resident #302 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance for toileting, and was always incontinent of bowel and bladder.A review of Resident #302s Individualized Care Plan (CP) initiated on 9/19/22 and revised on 11/26/25, had a focus area that included the resident was at risk for development of a pressure ulcer due to limited mobility, diabetes and incontinence with interventions that included but were not limited to; provide incontinent care as needed. 2. On 12/8/25 at 8:10 AM, the surveyor, accompanied by the CNA, observed Resident #320 in bed. The CNA exposed Resident #320's pull-on, and the surveyor and CNA observed an incontinence brief inside the pull-on. The surveyor observed that the incontinence brief and pull-on were both saturated with urine. The CNA acknowledged that the brief and pull-on were saturated with urine and stated that the resident should not have a pull-on and an incontinence brief in place, as it was against the facility's policy. A review of Resident #320's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to, dementia and epilepsy (a neurological disorder that causes recurring seizures.) A review of Resident #320's annual MDS dated [DATE], revealed that Resident #320's cognitive skills for daily decision making were severely impaired. The MDS further revealed that the resident was dependent on staff for toileting and was always incontinent of bowel and bladder. A review of Resident #320's CP initiated on 4/25/2022 and revised on 11/4/2025, included a focus area that the resident was at risk for the development of a pressure ulcer due to incontinence, The CP had interventions that included, but were not limited to; provide incontinent care as needed. 3. On 12/8/25 at 8:15 AM, the surveyor, accompanied by the CNA, observed Resident #275 in bed. The CNA exposed Resident #275's adult brief, and the surveyor observed that the brief was saturated with urine. The CNA confirmed that the brief was saturated with urine. A review of Resident #275's admission Record revealed Resident #275 was admitted to the facility with diagnoses which included but were not limited to; diabetes mellitus and dementia. A review of Resident #275's quarterly MDS dated [DATE], revealed Resident #275 had a BIMS score of 2 out of 15, which indicated Resident #275 had severe cognitive impairment. The MDS further revealed that the resident required staff assistance for toileting, and was incontinent of bowel and bladder. A review of Resident #275's CP initiated on 4/4/2024, included a focus area that the resident was at risk for the development of a pressure ulcer due to fragile skin, impaired mobility, incontinence, malnutrition, and poor safety awareness. The CP had interventions that included but were not limited to; check for incontinence and assist with incontinence care as needed. On 12/8/25 at 8:30 AM, during an interview with the surveyor, the CNA stated that incontinence care should be provided to residents every 2 hours and that it was obvious that the above three residents had not been changed per the facility's policy. On 12/10/25 at 12:45 PM, during an interview with the surveyor, the Licensed Practical Nurse/ Charge Nurse for the 3rd floor confirmed that incontinence care should be provided every 2 hours on all shifts and that the CNA had told her about the three residents who had saturated incontinence briefs.The CNAs assigned to the above residents on the 11-7 AM shift were unavailable for interviews.On 12/10/25 at 1:30 PM, during an interview with the surveyor, the Assistant Director of Nursing stated that incontinence care should be provided to the residents every 2 hours.On 12/10/25 at 1:56 PM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator and the Director of Nursing (DON). The DON confirmed that incontinence care should be provided every 2 hours. A review of the facility's Activities of Daily Living (ADL) policy dated as revised 3/2025 reflected.the facility will ensure that ADLs are provided in accordance with accepted standards of practice, the residents care plan, and the residents choices and preferences.the facility nursing staff will provide the residents who are unable to carry out ADLs on their own the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.A review of the facility's Urinary Incontinence policy dated as reviewed on 6/25/25 reflected.check the resident's incontinent brief every 2 to 2.5 hours or more often, if needed, to ensure dryness and cleanliness.diaper resident with no more than 1 adult incontinent brief.NJAC 8:39-27.1 (a), 27.2 (h)

Repeat Deficiency Based on observation, interview, record review, and review of facility policies it was determined that the facility failed to clarify the medication route for a resident from the Consultant Pharmacist (CP) monthly medication review for 1 of 6 Residents, (Resident #425).The deficient practice was evidenced by the following:On 12/4/25 at 11:19 AM, the surveyor observed Resident #425 in their bed with their eyes closed. The surveyor observed an enteral feeding machine (delivers liquid nutrition through a flexible tube directly into the stomach or small intestine) and enteral feeding (TF) products at bedside.On 12/4/25 at 11:45 AM, the surveyor reviewed Resident #425's electronic medical record (e-MAR) which revealed the following: A review of Resident #425's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but not limited to; dysphagia (difficulty swallowing), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and unspecified severe protein-calorie malnutrition (imbalance between the nutrients the body needs to function and the nutrients consumed). A review of the Medicare 5 Day Minimum Data Set (MDS), (an assessment tool used for the management of care) dated 9/5/25, documented the resident was unable to have a Brief Interview for Mental Status (BIMS) due to current cognition. The MDS further revealed under Section K, that the resident was receiving a TF.A review of the November 2025 Physician Orders (PO) included a PO dated 9/28/25, Senna Oral Liquid, Give 10 milliliter (ml) by mouth at bedtime for constipation and an addition PO dated 9/27/25, Acetaminophen Tablet (Tylenol) 325 milligram (mg) give two tablet by mouth every 4 hours as needed for temperature above 101 degrees Fahrenheit (F) do not exceed 3grams in 24 hours.A review of the CP medication reviews for October and November 2025 revealed for Resident #425, Please clarify the route of administration for Tylenol and senna.On 12/9/25 at 10:14 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1), who reviewed the resident's medications and noted that there are two medications that are listed to give by mouth. LPN#1 stated those medications are not given during her shift but would contact the MD for clarification.On 12/9/25 at 10:18 AM, the surveyor interviewed the Unit Manager (UM#1), who stated the medications ordered by mouth is definitely an error. UM#1 further revealed the Charge Nurse (CN#1) for the building was assigned to review the CP monthly medication review and clarify orders as needed.On 12/9/25 at 10:21 AM, the surveyor conducted phone interview with Registered Nurse (RN#1), who stated they were normally the 3-11PM nurse for Resident #425. RN#1 stated the resident gets all medications via feeding tube and acknowledged they did not fully read the order, because they did not see the medications were ordered to give by mouth.On 12/9/25 at 11:17 AM, the surveyor interviewed CN#1 who stated they are in charge of clarifying orders from the CP and that they had missed the two medications that needed to be clarified.On 12/10/25 at 1:30 PM, the Director of Nursing (DON) provided the surveyor with a facility policy titled, Medication and Treatment Orders, with a revised date 4/5/25. The policy statement revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing.On 12/10/25 at 1:53 PM, the surveyor met with the DON and Licensed Nursing Home Administrator (LNHA) to review concerns found during the survey. The DON stated all CP medications reports would be rechecked.On 12/12/25 at 12:15 PM, the surveyor met with the LNHA and DON for the exit conference; no further pertinent information was provided. NJAC 8:39- 29.3 (a)

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 12/9/25, the surveyor observed five (5) nurses administer medications to six (6) residents. There were 28 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.14%. The deficient practice was identified for two (2) of six (6) residents, (Resident #318 and #399), that were administered medications by two (2) of six (6) nurses that were observed.The deficient practices were evidenced by the following:1). On 12/09/25 at 8:40 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN#1) entered the room of Resident #399. The surveyor observed RN#1 informing Resident #318 that she would be administering the resident's medications. The surveyor observed the resident who was sitting on their bed.On 12/09/25 at 8:42AM, the surveyor observed RN#1 preparing to administer two (2) medications to Resident #399 which included one tablet of Aripiprazole 10 mg (Abilify) (bi-polar disorder) and two (2) tablets of Memantine (Namenda) (dementia) 5 mg, Error #1. The surveyor observed RN#1 preparing Resident #318's medications and observed RN#1 added one tablet of Memantine into a medication cup with one tablet of Aripiprazole. The surveyor observed RN#1 enter the resident's room with the medication cup. Prior to administering the resident's medications, the surveyor asked RN#1 to step out of the resident's room. The surveyor in the presence of the RN#1 reviewed the resident's electronic medication administration record (e-MAR). At that time, RN#1 acknowledge that the resident should be given two tablets of Memantine. RN#1 further acknowledge that she only poured one tablet of Memantine into the medication cup. The surveyor then observed RN#1 poured an additional tablet into the medication cup and then administered the medications to Resident #318. A review of the admission Record (an admission summary) reflected that Resident #318 was admitted to the facility with diagnoses that included bi-polar disorder (a lifelong mood condition causing extreme shifts between maniac highs and depressive lows), major depressive disorders (a serious mood disorder causing persistent sadness, loss of interest, and significant impact on daily life), and dementia ( cognitive decline (memory, thinking, reasoning) that impairs daily life). A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the care of a resident, dated 11/07/25, reflected that the resident's cognitive skills for daily decision-making score was 12 out of 15, which indicated that the resident's cognition was mildly impaired.A review of the December 2025 Order Summary Report (OSR) revealed a Physician's Order dated 07/31/25, for Memantine HCL oral tablet 5 mg, give 2 tablets by mouth one time a day for dementia. 2 tablets = 10 mg.A review of the December 2025 e-MAR revealed a Physician's Order dated 07/31/25, for Memantine HCL oral tablet 5 mg, give 2 tablets by mouth one time a day for dementia. 2 tablets = 10 mg. 2. On 12/09/25 at 09:10 AM, during the medication administration observation, the surveyor observed a Licensed Practical Nurse (LPN#1) entered the room of Resident #399. The surveyor observed LPN#1 identified Resident #399 and then informed the resident that she would be administering their medications. On 12/09/25 at 9:15 AM, the surveyor observed LPN#1 preparing to administer five (5) medications to Resident #399 which included one tablet of Finasteride 5 mg (medication for the prostate), one tablet of pantoprazole 40 mg (medication for gastroesophageal reflux disease), one tablet of docusate sodium 100 mg (laxative), and one capsule of tamsulosin (medication for benign prostatic hyperplasia), ERROR#2.During medication preparation LPN#1 stated that the resident's medications are administered crush in apple sauce. LPN#1 further stated that Protonix cannot be crushed because it's a delay release medication, but she was allowed to open the capsule of tamsulosin and empty its contents in apple sauce. The surveyor then observed LPN#1 put on gloves and a surgical mask and crush finasteride, docusate sodium, and cyproheptadine individually and add the crush contents in apple sauce. LPN#1 was then observed adding one tablet of pantoprazole and the contents of the opened tamsulosin capsule into apple sauce. The surveyor then observed LPN#1 administered the resident's medications in apple sauce with approximately 4 ounces of water.A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; hypertension (a condition in which the force of the blood against the artery walls is too high), benign prostatic hyperplasia ( enlargement of prostate gland) and gastro-esophageal reflux disease (common disease when the stomach contents move up to the esophagus).A review of the Annual Minimum Data Set, an assessment tool used to facilitate the management of care dated 10/07/25, reflected that the resident's cognitive skills for daily decision-making score indicated that the resident was severely impaired.A review of the December 2025 OSR revealed a PO dated 6/17/25, for Tamsulosin HCL capsule 0.4 mg, give one capsule by mouth one time a day for benign prostatic hyperplasia. A review of the December 2025 e-MAR revealed a PO dated 06/17/25, for Tamsulosin HCL capsule 0.4 mg, give one capsule by mouth one time a day for benign prostatic hyperplasia.A review of the manufacturer's specifications for Tamsulosin HCL revealed the following: Opening tamsulosin capsules and sprinkling the contents in food is not recommended for routine use. The modified -release properties of tamsulosin are essential for maintaining appropriate drug levels and minimize adverse effects.A review of the pharmacy packaging revealed an auxiliary label that indicated that the tamsulosin must be taken whole.A review of the Consultant Pharmacist Monthly Report dated 10/14/25 revealed the following recommendation from the consultant pharmacist: Tamsulosin capsule must be swallowed whole. Do not crush, chew, or open. If the patient cannot swallow whole the medication cannot be changed, please obtain a physician's order of May open capsule.On 12/9/25 at 11:30 AM, the surveyor interviewed LPN#1 and in her presence reviewed the resident's medication for tamsulosin. LPN#1 also reviewed the pharmacy medication packaging and acknowledge they had an auxiliary label that indicated that medication must be taken whole. LPN#1 further stated that they were no physician's order that allowed for tamsulosin to be opened, and its contents could sprinkle in apple sauce. On 12/10/25 at 1:45 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator (LNHA) and the Regional Director of Nursing.No further information was provided.A review of the facility's policy for Medication Administration that was dated 9/05/25 and was provided by the DON revealed the following: The individual administering the medication must check THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administering before giving the medication. NJAC 8:39-11.2(b), 29.2(a)(d)

Based on observations, interviews, record reviews, and other facility documentation, it was determined that the facility failed to follow infection control procedures on 3 of 3 nursing units. This deficient practice was identified with 5 of 13 staff members not wearing required personal protective equipment (PPE).On 12/4/25 at 10:50 AM, the surveyor conducted the initial tour of the JDT building. Per the Unit Manager (UM), the JDT building was having a Covid outbreak and surgical masks must be worn in common area such as the hallways, nursing station and non-Covid positive rooms. Currently Residents #1 and 2 were Covid positive. On 12/4/25 at 10:51 AM, the surveyor observed a laundry employee on the first floor unit without a surgical mask. The surveyor interviewed with housekeeper, who revealed they were unaware a surgical mask was required to be worn in the JDT building.On 12/4/25 at 10:55 AM, the surveyor observed the Licensed Nursing Home Administrator (LNHA) and Information Technology (IT) employee enter the first floor unit without wearing a surgical masks. Both the LNHA and IT were on the first floor unit for approximately two minutes and left the unit. The surveyor interviewed both the LNHA and IT, who both stated they forgot to put on masks prior to entering the unit.During further tour of the first floor unit the surveyor observed rooms: 102, 109, 111, and 117 all with droplet precautions signage and sufficient PPE in bins outside the roomsOn 12/4/2025 at 11:09 AM, while on the 3rd floor nursing unit, the surveyor observed the psychiatrist and student intern sitting at the nursing station, both wearing the surgical masks under their chins. During surveyor interview the psychiatrist acknowledged they both were not wearing the PPE correctly.On 12/4/25 at 11:20 AM, the surveyor observed the 2nd floor nursing unit, all staff wearing PPE correctly, no concerns noted.On 12/4/25 at 12:10 PM, the Director of Nursing (DON) provided the surveyor with facility line list, resident face sheets, floor plans on the JDT building, and facility policy. A review of the facility's Outbreak Response Plan dated revised 1/12/22, included residents with known or suspected COVID-19 (i.e. PUI) will be placed in the COVID designated area unit under droplet isolation standards; personnel entering the room should use PPE, including respiratory protection as described below .gloves .gowns .respiratory protection (i.e. a respirator) . eye protection .Cohort B-isolation individuals who have been exposed but do not display active symptoms should be cohorted with other individuals who have been exposed without active symptoms .PPE must be worn by everyone.12/4/25 at 12:40 PM, the surveyor conducted the exit conference with the LNHA and DON. The DON acknowledged the employees observed in the JDT building should have been wearing surgical masks in the common areas.NJAC 8:39-19.4

Based on observation, interviews, and review of pertinent facility documents, it was determined the facility failed to a.) follow appropriate infection control practices and perform appropriate hand hygiene as indicated during meal service observation in 2 of 12 units (first floor JDT and 2 East) for 2 of 4 staff observed during meal service and, b.) follow appropriate infection control practices and perform hand hygiene as indicated for 1 of 1 Resident (Resident #139) observed during tracheostomy care. This deficient practice was evidenced by the following: A review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. On 8/19/24 at 12:39 PM, the surveyor observed the lunch meal service in the JDT first-floor unit. The surveyor interviewed a Certified Nursing Assistant (CNA #1) who stated that all residents on the unit were served the lunch trays in their rooms. The surveyor observed the CNA #1 approached the food, removed a tray and entered room [ROOM NUMBER]. The CNA #1 placed the food tray on the bed side table (BST) of the resident; removed the plate cover, removed the plastic covering from the food items and silverware on the tray, then opened the hand wipe and cleaned the resident's hands. The CNA #1 moved the BST closer to the resident. The resident requested an alternative food option, so the CNA went directly to the nurse's station and picked up the phone with no observed hand hygiene. The CNA #1 returned to the food cart, removed a tray and entered resident room [ROOM NUMBER]. The CNA #1 placed the food tray on the BST, opened the hand wipe and handed it to the resident. The CNA #1 exited room [ROOM NUMBER], went to a cabinet in the nurse's station, removed a cup and a can of soda, went to the ice cooler removed the lid and filled the cup with ice. The CNA #1 entered room [ROOM NUMBER] with no observed hand hygiene. On 8/19/24 at 12:50 PM, the CNA #1 told the surveyor that all the trays had been passed. The surveyor asked the CNA #1 if it was the facility's policy to perform hand hygiene between residents when assisting with meals. The CNA acknowledged that she should have sanitized her hands between residents. On 8/21/24 at 8:24 AM, the surveyor observed meal service on the 2 East unit. The surveyor observed signage outside room E202 which indicated the resident in room E202 was on Enhanced Barrier Precautions (EBP) which included: everyone must clean their hands, including before entering and when leaving the room; wear gloves and a gown for the following High-Contact Resident Care Activities which included .dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tube (gastrostomy tube), tracheostomy; wound care including any skin opening requiring a dressing. On 8/21/24 at that same time, the surveyor observed the CNA #2 approached the food truck, removed a tray and entered room E202. The CNA #2 placed the tray on the BST of the resident in the window bed. The CNA #2 removed the plate cover, removed the plastic covering from the food items and silverware on the tray. The CNA #2 moved the BST closer to the resident. The CNA #2 exited the room without any observed hand hygiene. The CNA #2 approached the coffee cart, brought a cup of coffee into resident room E215. The CNA #2 exited the room with no observed hand hygiene. The CNA #2 returned to the food cart, removed a tray and entered room E217. The CNA #2 placed the tray on the BST and exited the room with no observed hand hygiene. The CNA #2 returned to the food cart, removed a tray and entered room E216. The CNA #2 placed the tray on the BST of the resident in the door bed. The CNA exited the room with no observed hand hygiene. The surveyor observed signage outside room E214 which indicated the resident was on EBP. The surveyor observed the CNA #2 returned to the food cart, removed a tray and entered room E214 and placed the tray on the BST of the resident in the middle bed. The surveyor observed the CNA #2 performed hand hygiene. The CNA #2 turned on the faucet, applied soap to her hands and immediately placed hands under the stream of water without first lathering or applying friction. On that same date at the same time, the surveyor discussed the breaks in infection control with the CNA #2 who acknowledged she should have performed hand hygiene between residents and when she entered and exited a resident's room who was on EBP. The CNA #2 further stated that she should have washed her hands with soap lathering for 20 to 30 seconds outside the stream of water but acknowledge she did not wash correctly because she forgot. 2. On 8/20/24 at 9:28 the surveyor observed the Licensed Practical Nurse (LPN) on 2East unit perform hand hygiene. The LPN turned on the faucet, applied soap and immediately placed her hands under the stream of water without first lathering outside of the water. The LPN turned off the faucet with her bare hands, then dried her hands with a papertowel. On 8/21/24 at 8:36 AM, the surveyor observed signage outside room [ROOM NUMBER] East which indicated Resident #139 was on EBP. The surveyor observed the LPN provide Tracheostomy care to Resident #139. The LPN turned on the faucet, applied soap to her hands, and immediately placed her hands under the stream of running water without lathering or applying friction outside of the stream of water. The LPN dried her hands and used the same paper towel to turn off the faucet. The LPN provided tracheostomy care per the physician's order. During the treatment the surveyor observed the LPN performed hand hygiene at three different times. The LPN applied soap to her hands and immediately placed them under the stream of water without lathering, dried her hands and used the same paper towel to turn off the faucet. On 8/21/24 at that same time the surveyor discussed the above observations and concerns with the LPN. The LPN acknowledged that she should have performed hand hygiene by lathering her hands outside the stream of running water for at least 20 seconds and should have used a clean paper towel to turn off the faucet. The LPN stated that she didn't wash her hands properly because she was nervous. A review of the Hand Hygiene policy and procedure, dated as Revised 9/10/23 revealed .the facility considers hand hygiene the primary means to prevent the spread of infections .Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions . Before and after entering isolation precaution settings. Before and after eating or handling food (hand washing with soap and water) Before and after assisting a resident with meals Procedure: Vigorously lather hands with soap and rub them together, creating friction to all surfaces for at least 20 seconds .rinse hands thoroughly .dry hands with paper towels and then turn off faucets with a clean, dry paper towel. Using Alcohol-Based Hand Rubs (ABHR) .apply product to palm of hand and rub hands together, cover all surfaces of hands and fingers until hands are dry. The facility's Enhanced Barrier Precaution Policy dated as revised 3/26/24 revealed .the EBP program is a tool to help control the spread of colonized Multidrug-resistant organisms (MDROs) infections. The facility will use the EBP on all nursing home residents with wounds and indwelling medical devices. These residents are at increased risk for acquisition of and colonization with MDROs .staff shall be adequately trained in the various aspects of EBP to ensure appropriate decision-making in various clinical situations . On 8/21/24 at 11:33 AM, the surveyor interviewed the Registered Nurse/ Infection Preventionist (IPN) who stated that the staff should perform hand hygiene between residents using ABHR or washing their hands following the proper procedure .turn on the faucet, wet hands, apply soap and lather outside the stream of water for 20-30 seconds, rinse hands, dry hands and use a new paper towel to turn off the faucet. The IPN further stated that staff and visitors should sanitize their hands before entering and when exiting the room of a resident who is on EPB. On 8/21/24 at 1:51 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator and Director of Nursing who acknowledged that hand hygiene should be performed according to CDC regulations including before entering and exiting a resident's room who is on EBP. No further information was provided. NJAC 8:39 - 19.4(a); (n)

Based on observation, interview, and record review, it was determined that the facility failed to consistently provide pharmaceutical services in accordance with professional standards to ensure a.) a refrigerator that contained prescription medications was lockable, b.) disposition (destruction) and reconciliation of controlled dangerous substance (narcotic; medications, that due to their high potential for abuse, are tracked with detail) was removed from active inventory when Unsampled Resident # 399 was discharged from the facility, c.) against borrowing medications from other residents to administer to a newly admitted resident (Unsampled Resident #1073), d.) a discontinued medication for Unsampled Resident #359 was removed from active inventory, and e.) a biological supply that required dating was dated. These deficient practices were identified for one (1) of five (5) medication storage rooms and three (3) of 13 medication carts inspected during the medication storage observation. a.) On 8/20/23 at 10:31 AM, the surveyor observed the medication room door located on 3-West was half opened. At that time, the Licensed Practical Nurse (LPN #1) was in the room. On 8/20/24 at 10:35 AM, during the inspection of the medication room refrigerator in the presence of LPN #1, the surveyor observed the refrigerator had a metal string, that was bolted on the side, and the front of the refrigerator door. The metal string was easily unhooked from the front, and not locked. The refrigerator contained prescription medications such as insulin (injectable medication to reduce blood sugar) and an empty storage box for refrigerated narcotic medication. At that time, LPN #1 stated that the refrigerator was unlocked from the beginning of her shift that morning and did not know if there was a lock for the medication refrigerator. LPN #1 used the telephone to call her supervisor. On 8/20/24 AM at 10:58 AM, LPN #2 walked into the medication room and stated that there was a lock for the medication room refrigerator located on the bolted side of the refrigerator. LPN #2 tried several keys in her possession to demonstrate that the lock was functional. At that time, both nurses tried multiple keys in their possession and could not show the lock for the medication room refrigerator was lockable. On 8/20/24 at 11:01 AM, the Assistant Director of Nursing (ADON) entered the medication room in 3-West. In the presence of LPN #1, LPN #2, and the surveyor the ADON for the 3rd floor tried LPN#1's, LPN#2's and her own set of keys to demonstrate that the prescription refrigerator door was lockable. At that time, the ADON confirmed she did not have the key to lock the refrigerator door, had not received a report from any nurses concerning the lock and was unsure how long the medication room refrigerator door was not lockable. On 8.21/24 at 1:53 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concern regarding the unlockable refrigerator. At that time, the DON stated that the lock was changed, the staff did not have any prior problems with the lock and was not sure what went wrong. b.) On 8/20/24 at 10:42 AM, in the presence of LPN #1, the surveyor began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart B (narcotic box) located on 3-West. The medication cart B parked inside the medication room. A review of the facility's Record of Narcotic Use Drug Count and Syringe Count (a shift-to-shift count/sign in sheet, used to account for the narcotics and syringes within the medication cart) for August 2024, reflected that the counts were conducted on three shifts (7:00 AM, 3:00 PM and 11:00 PM), daily from 8/1/24 at 7:00 AM, to at 8/20/24 at 7:00 AM. At that time, the surveyor and LPN #1 observed Resident #399's Lorazepam 1 mg (Ativan; milligram) bingo card (a multidose card containing individually packaged medications) contained 22 tablets. At that time, the surveyor compared the count of the bingo card against the Individual Patient Controlled Substance Administration Record (declining inventory log) for Resident #399's Lorazepam 1 mg tablet which reflected a balance of 23 tablets and was last signed by the administering nurse on 8/13/24 at 9:46 PM. At that time, the surveyor questioned the one (1) tablet discrepancy of the count. LPN #1 stated that she usually signed the declining inventory log but had forgotten that day. LPN #1 stated she removed the Lorazepam 1 mg for administration to Resident #399 that morning, and at the same time was informed that Resident #1073 was seizing at center court. LPN #1 stated she administered the Lorazepam 1 mg to Resident #399 before running to center court, and that was the reason she had forgotten to sign the declining inventory log. At that time, the LPN #1 stated she should have signed the declining sheet upon removal of the Lorazepam 1 mg from the narcotic box. The surveyor reviewed the hybrid medical record for Resident #399. According to the Admission Record, Resident #399 was admitted to the facility with diagnoses that included suicidal ideations, schizoaffective disorder, major depressive disorder, and generalized anxiety. A review of Resident #399's electronic Medical Record reflected the resident was transferred out of the facility on 8/14/24. A review of the resident electronic Medication Administration Record (eMR) reflected the last administration was on 8/13/24. A review of the paper-based chart contained the Universal Transfer Form that indicated Resident #399 was transferred out of the facility on 8/14/24 at 2:19 PM for suicidal ideations. On 8/20/24 at 10:42 AM, the surveyor and LPN #1 reviewed Resident #399's eMR together which revealed Resident #399 was transferred out of the facility on 8/14/24 and had not returned to the facility at that time. The LPN confirmed the Resident #399 was discharged . The missing one tablet of the Lorazepam 1 mg for Resident #399 could not have been administered to Resident #399 since the resident was not in the facility that morning. On 8/20/24 at 10:46 AM, LPN #1 stated she was part of the error with the shift-to-shift count for the missing narcotic. The LPN stated that she and the 11-7 AM nurse miscounted the narcotics that morning and was unsure when the one tablet of Resident #399's Lorazepam went missing. At that time, the LPN #1 stated the Resident #399's bingo card should have been removed from the cart, should have been sent back to the pharmacy, or should have been disposed by two (2) nurses. On 8/20/23 at 11:03 AM, in the presence of LPN #1 and the surveyor, the ADON confirmed that Resident #399's Lorazepam should have been pulled when they learned the resident was admitted to the hospital on 8/14/24 or 8/15/24. The ADON also stated that this was important to avoid medication errors, misplacement, theft, and proper count of pills should have been returned [when applicable, for credit towards the resident's account]. At that time, the ADON stated she would investigate and inform the Director of Nursing. On 8/20/24 at 1:14 PM, during a meeting with the DON, the surveyor discussed the concern regarding the missing one tablet of Lorazepam 1 mg for Resident #399. At that time, the DON stated that all discharged medications should have been removed once the resident was admitted to the other facility. The DON stated that she would investigate Resident #399's missing narcotic. c.) A review of the provided facility policy dated/revised on 6/12/24. included the following under Policy Interpretation and Implementation. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such findings. The surveyor reviewed the hybrid medical record for Resident #1073. According to the Admission Record, Resident #359 was admitted to the facility with diagnosis that included generalized idiopathic epilepsy syndromes, not intractable, with status epilepticus, and other seizures. A review of the New Jersey Universal Transfer Form reflected Resident #1073 was admitted the day before the unit inspection at 8:00 PM and was transferred out of the facility on that morning at 8:25 AM. A review of the Order Summary Report for Resident #1073 included the following: -Carbamazepine 100 mg chewable, give 2 tablet(s) by mouth three times a day for seizure disorder, ordered on 8/19/24, with a start date of 8/20/24. -Lacosamide 50 mg tablet, give 2 tablet(s) by mouth two times a day for seizure disorder, ordered on 8/19/24, with a start date of 8/20/24. -Lamotrigine 200 mg, give 1 tablet by mouth two times a day for seizure disorder, ordered on 8/19/24, with a start date of 8/20/24. -Levetiracetam [Keppra] 750 mg tablet, give 2 tablet(s) by mouth every 12 hours for seizure disorder, ordered on 8/19/24 with a start date of 8/20/24. A review of the electronic Medication Administration Record (eMAR) for August 2024 did not reflect an order and an administration of Lorazepam 1 mg. A review Resident #1073's paper-based chart, under progress note, reflected a documentation on 8/20/24 [without time or department], revealed a stat order for Keppra 750 mg and Ativan 1 mg ordered and given. On 8/21/24 at 9:20 AM, during a meeting with the surveyors, the DON stated that she had investigated the missing narcotic after surveyor inquiry, removed the nurse from the cart, counted the narcotics, reviewed the cameras, informed the LNHA, the Medical Director and the Consultant Pharmacist, and filed a reportable with the state and the police department. The DON explained that Resident #1073 had a seizure at approximate 7:30 AM. The physician was notified and placed a stat (immediate) order of Lorazepam 1 mg and Keppra 750 mg. Resident #1073 was admitted the night before and their medications had not yet arrived for the 9:00 AM administration. At that time, the DON stated that LPN #1 borrowed the Lorazepam from Resident #399 and the Keppra from Resident #217. At that time, the DON showed a paper-based Medication Administration for Resident #1073 that revealed, one (1) time administration of the Ativan 1 mg and Keppra 750 mg on 8/20/24 at 7:35 AM. At that time, the DON confirmed the nurse should have gone to the back-up box to get the emergency order of Ativan and Keppra for Resident #1073. At that time, the DON also stated that LPN #1 tried to deny the act of borrowing while the camera showed that she had. At that time, the DON stated that she would contact the pharmacy to ensure Resident #359 received a credit for the misappropriated medication (Keppra). The surveyor reviewed the hybrid medical record for Resident #217 According to the Admission Record, Resident #359 was admitted to the facility with diagnosis that included convulsions. A review of the eMAR for August 2024, reflected an order for Levetiracetam (Keppra) 750 mg, give 1 tablet orally every 12 hours for seizure, started on 4/4/24. The eMAR also reflected that Resident #359 received their scheduled doses. No further information was provided. d.) On 8/20/24 at 11:57 AM, in the presence of the Registered Nurse (RN #1), the surveyor began the medication cart B inspection located on 2-East. On 8/20/24 at 12:06 PM, the surveyor observed an amber vial that contained Erythromycin Ophthalmic Ointment (antibiotic) for Resident #359. At that time, the surveyor and RN #1 reviewed the electronic Medication Administration Record (eMAR) together which revealed a physician's order for Erythromycin Ophthalmic Ointment, instill 1 application in both eyes two times a day for eye infection until 8/5/24. The eMAR did not reflect the exact measurement (in inches or centimeter) to indicate the dose for each administration. At that time, RN #1 stated that the Resident was sent out of the facility and was admitted to another facility. RN #1 stated the antibiotic ointment should have been removed. RN #1 also stated that Resident #359 was back in the facility but had no current orders for Erythromycin Ophthalmic Ointment. The surveyor reviewed the hybrid Medical Record for Resident #359. According to the Admission Record, Resident #359 was admitted to the facility with diagnosis that included type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy (a diabetic eye disease that can lead to vision loss). A review of the Order Summary Report for August 2024 did not include a current order for Erythromycin Ophthalmic Ointment. On 8/21/24 at 1:53 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concern regarding the Resident#359's antibiotic ointment, discontinued on 8/5/24, that was intermingled with the active inventory. No further information was provided. e.) On 8/20/24 at 12:30 PM, in the presence of LPN #3, the surveyor began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart B (narcotic box) located on 2-West. At that time, in the back of the narcotic box buried underneath vials of Haldol injectable, the surveyor and LPN #3 observed an opened, undated blood glucose (bg) test strips bottle (used with a glucometer to provide immediate reading of blood sugar, or glucose level). The package insert indicated use within 90 days after first opening. At that time, LPN #3 confirmed the bg test strips should have been dated. LPN #3 stated she would discard the bg test strips since she was unsure when it was opened. A review of the Manufacturer Specification for Assure Platinum included the following under FAQs. What is the operating range for the Assure Platinum Test Strips and how should I store them? Operating range: 39 F-86 F (4 C - 30 C). Use within 90 days of first opening. Do not freeze or refrigerate. Do not use beyond expiration date. On 8.21/24 at 1:53 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concern regarding the undated bg test strips that was stored in the narcotic box. No further information was provided. A review of the provided facility policy dated/revised on 6/12/24, included the following under Policy Interpretation and Implementation: 6. The Nurse will maintain the keys to controlled substance for their medication cart. The Director of Nursing Services will maintain a set of back-up keys for all drug storage areas including keys to controlled substance containers. 8. Nursing staff count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing. A review of the provided facility policy, Administering Medications, dated/revised on 11/5/23, included the following under Policy Interpretation and Implementation: Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services. A review of the provided facility policy, Charting and Documentation dated/reviewed on 3/7/24, under policy statement reflected: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. A review of the provided facility policy, Storage of Medications dated/revised on 6/15/24, included the following under Policy Interpretation and Implementation: 3 .there is a secured medication locked cabinet to ensure the medication cannot be accessed by other residents 5. The facility shall not use discontinued, outdated, deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. NJAC 8:39-29.2 (d), 29.4(g)(d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure an antipsychotic medication was administered in accordance with professional standards of clinical practice to Resident #112 who had episodes of auditory hallucinations. This deficient practice was observed for one (1) of four (4) nurses who administered to one (1) of six (6) residents during the medication administration observation and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The nurse practice act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 8/20/24 at 9:29 AM, during the medication pass observation, the Registered Nurse (RN) reviewed with the surveyor the four (4) medications to be administered to Resident #112 which included Risperidone Solution 1 mg/ml (Risperdal; milligram/milliliter), give 4 ml orally in the morning for schizophrenia, with a start date of 3/26/24. The RN stated he had to add the Risperidone Solution into the cup of water because the resident did not like the taste, and the resident preferred the medication to be taken this way. On 8/20/24 at 9:45 AM, the RN and the surveyor entered the resident's room. The RN verified the resident's name and gave the resident their medication pills, followed with the Risperidone Solution that was diluted in the water. Resident #112 drank the cup that contained the diluted Risperdal and gave the cup back to the RN. On 8/20/24 at 9:46 AM, while the RN and the surveyor were walking back to the cart, the RN spilled liquid from the cup that contained the diluted Risperidone solution on his hand and threw the cup into the trash bin attached to his cart. The surveyor observed the cup in the trash bin that contained more liquid. On 8/20/24 at 9:49 AM, the surveyor observed the RN sign the electronic Medication Administration Record (eMAR) that he had administered all four medications to Resident #112. At that time, the surveyor, and the RN both looked at the cup in the trash bin and the RN confirmed that he saw the remaining amount of liquid in the cup, and he had not administered the full dose. On 8/20/24 at 10:04 AM, in the presence of the Licensed Practical Nurse, and the surveyor, the RN stated that he should have given the remainder of the diluted Risperdal Solution to the resident. The RN stated he did not think the resident received the entire 4 mg dose as ordered by the physician. At that time, the RN stated in the future he would ensure the resident would receive the full dose. The RN stated he would contact physician, psychiatrists and inform his supervisors. The surveyor reviewed the hybrid medical record for Resident #112. According to the Admission Record, Resident #112 was admitted to the facility with diagnoses which included paranoid schizophrenia, anxiety disorder. A review of a Quarterly Minimum Data Set, an assessment tool, dated 5/31/24, revealed that the resident had a Brief Interview for Mental Status score of 10 out of 15 which indicated that the resident had mild cognitive impairment. A review of the resident's Order Summary Report as of 8/21/24, included an order, dated 3/12/24, for Risperidone 1 mg/1 ml, give 4 ml orally in the morning for schizophrenia. A review of Resident #112's Psychoactive Monitoring Form/Monthly Summary for August 2024 reflected monitoring of resident's behavior, non-drug interventions for the documented behaviors, and the behaviors exhibited and monitored by the nursing staff. The behaviors exhibited were: -two episodes of auditory hallucinations on 8/4/24. -one episode of auditory hallucination on 8/6/24. -one episode of the resident who became verbally upset when asked if it was time to smoke. No confrontation on 8/11/24. A review of the RN's Medication Pass Observation competencies reflected the following: -on 12/1/23, the RN had 0% errors -on 4/18/23, the RN had 9.09% errors -on 5/15/24, the RN had 0% errors On 8/21/24 at 1:53 PM, in the presence of the survey team, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), the surveyor discussed the concern regarding the medication pass wherein Resident #112 did not receive the full dose of the Risperidone 4 mg that was diluted in water. At that time, the DON stated that the RN was in-service (educated) to ensure the residents received the correct dose. On 8/20/24 at 9:00 AM, the surveyor received a copy of the in-service provided to the RN. A review of the policy provided Administering Medication dated 11/5/23, reflected under Policy Statement that medications shall be administered in a safe and timely manner, and as prescribed. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure Resident #114 was offered pneumococcal vaccination according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations. This deficient practice was identified for one (1) of five (5) residents reviewed for immunization status. The deficient practice was evidenced by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 2/13/23, included the following. The CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults [AGE] years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown . A review of the facility's policy for Pneumococcal Vaccine dated/reviewed 9/10/23, included the following: Policy Statement: All residents will be offered Pneumovax (pneumococcal vaccine) to aid in preventing pneumococcal infections (e.g. pneumonia). Under Policy Interpretation and Implementation subsection 7 reflected that Administration of the pneumococcal vaccination or revaccination will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. A review of the facility's policy for Vaccination of Residents dated 9/10/23, included the following under Policy Interpretation and Implementation. All new residents shall be assessed for current vaccination status upon admission. If the resident receives a vaccination, at least the following information shall be documented in the resident's medical record: site of administration, date of administration, lot number of the vaccine (located on the vial), expiration date (located on the vial), and name of the person administering the vaccine. Inquiries concerning the policy should be referred to the Infection Preventionist or the Administrator. On 8/14/24 at 12:08 PM, a surveyor observed Resident #114 wheeled out of the bathroom by a Certified Nursing Assistant. The resident stated that they had about 6 strokes (reduced or blocked blood flow to the brain) and was on insulin because of diabetes. The resident stated that their antidepressant was working well and did not feel depressed. The surveyor reviewed the hybrid (combination of paper and electronic) medical record for Resident #114. According to the Admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus and hypertension (high blood pressure). Resident #114's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 5/29/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out 15 which indicated the resident's cognition was intact. Further review of the qMDS dated [DATE], under section O0300 A. Is the resident's Pneumococcal vaccine to date? The response was marked 1, which reflected Yes. A review of the electronic Medical Record (eMR) reflected Resident #114 had received Prevnar 13 on 12/20/23. Additionally, the eMR did not reflect historical information of prior pneumococcal immunization received in or out of the facility. A review of the paper-based chart reflected an undated Permission [request] for Pneumococcal Vaccination [administration consent] form. The administration consent form was signed by the resident and did not specify which pneumococcal vaccine was to be administered. A review of the resident's Immunization Record Sheet, under Pneumococcal Vaccine, revealed a blank space for the following: the type of the pneumococcal vaccine administered, previously received, site of administration, date of administration, lot number of the vaccine (located on the vial), expiration date (located on the vial), and the name of the person administering the vaccine. A review of the hybrid medical record did not reflect documentation that PCV15 or PCV20 was offered to the resident or the rationale for administration of Prevnar 13. On 8/21/24 at 11:01 AM, in the presence of the survey team, the Registered Nurse/ Infection Preventionist (RN/IP) stated that she participated with the immunization activities for the facility and identified that the policy on hand was the most recent pneumococcal vaccination policy. On 8/21/24 at 11:33 AM, during an interview with the surveyor, the RN/IP stated that before every influenza season during QAPI (Quality Assurance and Performance Improvement) meetings, the infectious disease doctor, the pharmacy, the DON and medical director discussed immunizations for the residents using the recommendation from the CDC. We (the RN/IP, the Director of Nursing, the Medical Director and the Licensed Nursing Home Administrator) sat down and reviewed the immunization for each new admission. The documentation of the immunization was hybrid and contained the type of vaccine given, the lot number, site of administration and the date the vaccine was administered in the facility. The surveyor asked why the policy did not reflect the current CDC and the ACIP recommendations for the pneumococcal vaccine. The IP had no response. On 8/21/24 at 1:53 PM, in the presence of the survey team, the DON and the LNHA, the surveyor discussed the concern regarding Resident #114 who was not offered pneumococcal vaccination according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations. On 8/22/24 at 10:35 AM, during an interview with the surveyor, the DON stated that the policy was updated after surveyor inquiry to reflect the current pneumococcal vaccination recommendation. The DON also stated that Prevnar 13 was administered to Resident #114 because that was what the physician ordered. The surveyor asked the DON why there were no documentations made by the staff on the resident's hybrid medical record of the communication made to the physician regarding the current CDC recommendation for pneumococcal vaccine and the physician's rationale for choosing Prevnar 13, which was not in line with the current CDC recommendation for a resident who was over [AGE] years old who had no documented history of prior pneumococcal vaccination. The DON stated moving forward that they will document that the current CDC ACIP recommendations were communicated to the physician. On 8/22/24 at 10:53 AM, during an interview with the survey team, the physician stated that Prevnar 13 was still pertinent and can administer PCV20 as the following dose. A review of the provided facility policy, Charting and Documentation dated/reviewed on 3/7/24, under policy statement reflected: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. No further information was provided. N.J.A.C. 8:39-19.4 (i)

Based on observation, interview, and record review, it was determined that the facility failed to provide care and services according to acceptable standards of clinical nursing practice by the following: 1.) administer and sign for medication according to physician's orders and facility policy for 4 of 4 nurses; 2.) follow the facility's policy on cleaning shared medical equipment for 1 of 1 nurse observed cleaning shared medical equipment; and 3.) failed to obtain a physician's order for a treatment performed during urinary catheter care for 1 of 3 residents (Resident #193) reviewed for urinary catheter care. The deficient practice is evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing a 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 7/17/22 at 10:30 AM, the surveyor entered the room of Resident #894. The resident was alone in their room and no staff were present. The surveyor observed two white capsules in a medicine cup sitting on the resident's bedside table. The surveyor interviewed Resident #894 about the capsules. Resident #894 stated that they were, not sure what the capsules were. On 7/27/22 at 10:41 AM, the surveyor interviewed Charge Nurse/Registered Nurse (CN/RN) who stated that she was working with and training the Licensed Practical Nurse (LPN #1) who was caring for Resident #894. The surveyor asked if the CN/RN could accompany the surveyor into Resident #894's room. The surveyor and CN/RN entered Resident #894's room and the surveyor observed that the there was another LPN #2 was in the resident's room. The surveyor asked the nurses what the two capsules observed in the resident's room were. LPN #2 stated that the two capsules were acidophilus probiotics (probiotics are good bacteria that are either the same or similar to bacteria naturally found in the body) and stated that she just gave Resident #894 the acidophilus probiotic. The surveyor asked LPN #2 if she should have left the medication at the resident's bedside and then returned to administer it. LPN #2 stated that she should have given the acidophilus probiotic right away. The CN/ RN agreed that the medication should not have been left at the bedside and should have been administered to Resident #894 before LPN #2 left the room. The July 2022 Medication Administration Record (MAR) for Resident #894 indicated that the resident had an order for acidophilus two capsules twice a day for 20 days to be administered at 9 AM and 5 PM. A further review of the MAR revealed that the LPN signed that she administered the acidophilus at 9 AM. On 7/27/22 at 10:55 AM, the surveyor observed LPN #2 exit the hallway where resident rooms were located and approach the nurse's station desk. At this time the surveyor showed LPN #2 the MAR and interviewed her. LPN #2 stated that she signed the MAR prior to giving the medication and that medications should be signed for on the MAR after they are administered. The surveyor asked what the timeframe is for when medications should be given. LPN #2 stated that medications should be given an hour before or an hour after the time when they are ordered to be given. The surveyor asked if the acidophilus probiotic was given within an hour of when it was ordered to be given. LPN #2 stated that it was a, little bit more than an hour. A review of the hybrid paper and electronic medical record for Resident #894 revealed the following: The Admission Record revealed that Resident #894 had diagnoses including but not limited to Enterocolitis (inflammation that occurs in a person's digestive tract) due to Clostridium Difficile (a bacteria that causes infection of the large intestine), Sepsis (the body's extreme response to an infection), and Urinary Tract Infection (an infection in any part of the urinary system). The 7/21/22 Admission Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care indicated that Resident #894 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that the resident was cognitively intact. The MDS also indicated that the resident was receiving antibiotic (medicine that inhibits the growth of or destroys microorganisms) medication. The Physician's Orders indicated a 7/19/22 order to start Acidophilus one capsule by mouth twice a day, and a 7/22/22 the order was changed to give Probiotic two caps by mouth twice a day. The Clostridium Difficile Care Plan initiated on 7/20/22 indicated to, give all meds as ordered. On 7/27/22 at 2:14 PM, the surveyor discussed the above concern to the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). No further information was provided. A review of the facility policy, Administering Medications with a revised date of 11/5/2021 indicated under the Policy Interpretation and Implementation section that 3. Medications must be administered in accordance with the orders, including any required time frame, 9. Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed time, 12. The individual administering the medication must initial the resident's MAR on the appropriate line after giving the medication, and 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 31656 2. On 7/18/22 at 2:07 PM, the surveyor interviewed Resident #484. Resident #484 was seated in a wheelchair in their room. Resident #484 was pleasant and eager to speak with the surveyor. Review of Resident #484's Face Sheet (an admission summary) reflected that Resident #484 was admitted to the facility with diagnoses that included but were not limited to essential (primary) hypertension, Schizophrenia, and acquired absence of left leg below knee. The Quarterly MDS dated [DATE], revealed a BIMS score of 10 out of 15 which indicated that the resident's cognition was moderately impaired. Review of the resident's May, June, and July 2022 MAR revealed a physician's order dated 6/21/18 for Amlodipine 5 mg daily for hypertension (hold for blood pressure (BP) less than 120). The documentation from the May 2022 MAR indicated that on five days of the month Amlodipine 5 mg was administered when the BP was less than 120. The May 2022 MAR documented nurses signatures as administered on 5/3/22 BP 112, 5/16/22 BP 114, 5/22/22 BP 108, 5/23/22 BP 101, 5/28/22 BP 108, 5/29/22 BP BP 118. The documentation from the June 2022 MAR indicated that on seven days of the month Amlodipine 5 mg was administered when the BP was less than 120. The June 2022 MAR documented nurses signatures as administered on 6/14/22 BP 119, 6/17/22 BP 112, 6/18/22 BP 110, 6/20/22 BP 107, 6/21/22 BP 116, 6/27/22 BP 100 and 6/29/22 BP 107. The documentation from the July 2022 MAR indicated that on eight days of the month Amlodipine 5 mg was administered when the BP was less than 120. The July 2022 MAR documented nurses signatures as administered on 7/2/22 BP 114, 7/12/22 BP 104, 7/15/22 BP 118, 7/16/22 BP 101, 7/17/22 BP 112, 7/19/22 BP 118, and 7/21/22 BP 110. On 7/28/22 at 2:23 PM, the surveyor informed the DON and LNHA who could not explain why nursing was administering Amlodipine 5 mg when the BP should have been held according to the physician's order. The DON verified that the Amlodipine should have been held when the BP was less than 120. On 7/29/22 at 9:25 PM, the surveyor interviewed the third floor Unit Manager (UM) in reference to Amlodipine 5 mg parameters ordered for Resident #484. The UM stated that the Amlodipine 5 mg should have been held and the nurses signature should have been circled if the BP was less than 120. 3. On 7/29/22 at 8:20 AM, the surveyor approached the two North LPN (LPN #3) who was preparing to administer medication to a resident. As LPN #3 prepared the medication for administration, she signed the MAR. The surveyor continued to observe LPN #3, as she administered the medication to the resident. On 7/29/22 at 8:30 AM, the surveyor interviewed LPN #3. LPN #3 stated that she should sign the MAR after the administration of the resident's medication, not before. 4. On 7/29/22 at 8:37 AM, the surveyor approached the two East LPN (LPN #4) who was observed flipping the pages of the MAR and signing the medication for a resident as administered. The surveyor approached LPN #4 and observed the preparation of the resident's medication for administration. LPN #4 had already signed for all the medications in the MAR before the medication was administered to the resident it was intended for. On 7/29/22 at 8:45 AM, the surveyor interviewed LPN #4. LPN #4 stated that she should sign the MAR after the administration of the resident's medication, not before. 39399 5. On 7/26/22 at 12:20 PM, the surveyor inspected the medication cart for unit J2 in JDT building in the presence of the Registered Nurse (RN#1). The surveyor observed a blood glucose meter/glucometer (a device used to measure and display the amount of sugar in your blood) on the top drawer of the medication cart. The RN stated to the surveyor that the glucometer was for multi-resident use. The surveyor asked the RN how the glucometer gets disinfected after every use. The RN explained that she uses either an alcohol prep pads or bleach wipes to disinfect. On 7/26/22 at 12:26 PM, the surveyor observed RN #2 came out from room [ROOM NUMBER] after checking the resident's blood sugar. RN #2 then proceeded to disinfect the glucometer using an alcohol prep pad. On 7/26/22 at 2:15 PM, the above concern was discussed to the Administrator and DON. The DON verified that a bleach wipe must be used to disinfect the glucometer. A review of the undated facility's policy and procedure titled, Procedure for Sanitizing Blood Glucose Device that was provided by the DON showed Blood Glucose Monitoring Device must be cleaned and sanitized in between each resident use and PRN. PDI Sani-cloth bleach germicidal disposable wipes are to be used, per manufacturer's instruction: 46049 6. On 7/18/22 at 11:33 AM, the surveyor observed Resident #193 lying in bed, alert and awake. Resident #193 had a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag). The surveyor reviewed Resident #193's hybrid medical records (paper and electronic medical record) that revealed the following: According to the Admission Record, Resident #193 was admitted with diagnoses that included neuromuscular dysfunction of bladder, urethral (a duct by which urine is conveyed out of the body from the bladder) fistula (an abnormal or surgically made passage between an organ and the surface of the body), and retention of urine. The Quarterly MDS dated [DATE], revealed that the facility performed a BIMS which indicated that the resident had a score of 15 out of 15. The resident was assessed to be cognitively intact. On 7/20/22 at 10:27 AM, the surveyor interviewed LPN #5 who was asked about the resident's urinary catheter care. The LPN #5 stated the resident had a history of bladder issues, frequent urinary tract infections and currently had a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder). The LPN #5 stated that the nurses' responsibilities included changing the urinary catheter once a month or as needed, monitoring urine output, and flushing the urinary catheter, if needed. The July 2022 Physician Orders Sheets and July 2022 Treatment Administration Record (TAR) revealed there was no physician's order to flush the resident's urinary catheter. A review of the resident's hard copy chart revealed nurse progress notes from 7/11/22 and 7/12/22 indicated the nurses flushed the resident's catheter. On 7/20/22 at 11:14 AM, the surveyor interviewed LPN #5 about the flushing of the urinary catheter for Resident #193. LPN #5 stated the nurses flushed the catheter with normal saline (NS) when there were clogs or issues with patency. The surveyor asked the LPN if there should be a PO to flush a resident's urinary catheter. LPN #5 replied Yes, there should be. The surveyor asked if there was a physician's order to flush the urinary catheter of Resident #193. LPN #5 replied, I think there is. LPN #5 reviewed the TAR and PO with the surveyor, and no order was observed to flush the urinary catheter with NS. The surveyor asked LPN #5 if the physician was aware the resident's catheter was being flushed. LPN #5 replied Yes. The surveyor asked LPN #5 how long have the nurses been flushing the resident's catheter. LPN #5 stated that she hasn't flushed the resident's catheter recently but believed it may have been since the resident's last hospitalization in April. The LPN #5 stated she would contact the physician to obtain an order to flush catheter. On 7/20/22 at 11:24 AM, the surveyor interviewed a Registered Nurse (RN #2), who had taken care of Resident #193 previously. The surveyor asked RN #2 if she had ever flushed the resident's urinary catheter before and RN #2 replied Yes. The surveyor asked RN #2 if there should be a physician's to flush a resident 's catheter and RN #2 stated Yes. RN #2 was informed upon review with the LPN there were no physician's order found for Resident #193. RN #2 stated the resident had been in and out of hospital a few times and maybe that was how the order was missed. On 7/20/22 at 12:25 PM, the surveyor interviewed the Assistant Director Of Nursing (ADON), who was asked if it would be expected for there to be an order to flush the resident's catheter. The ADON stated It was expected for there to be an order. On 7/26/22 at 2:03 PM, the surveyor discussed the above concern with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the above concern. The DON acknowledged there should have been a PO to flush the resident's urinary catheter. The surveyor reviewed the facility's policy and procedure with a revised date of 1/28/22, titled Catheter Care, Urinary. Under Managing Obstruction it read Catheter irrigation may be ordered to prevent obstruction in residents' at risk for obstruction. The surveyor also reviewed the facility's policy and procedure with a revised date of 1/28/22, titled Suprapubic Catheter Care. The policy did not address obtaining a PO for flushing a urinary catheter. NJAC 8:39-11.2 (b); 27.1 (a); 29.2(d)

Based on observation, interview, and record review it was determined that the facility failed to: 1. maintain ongoing complete communication notes between the facility and the dialysis center and 2. maintain an assessment of a resident's condition and monitoring for complications upon return from dialysis. This deficient practice was identified for 3 of 4 residents reviewed for dialysis, Residents #138, #108 and #135). The deficient practice was evidenced by the following: 1. On 7/18/22 at 11:46 AM, the surveyor observed Resident #138 was not in their room. The unit's Assistant Director of Nursing (ADON) informed the surveyor that the resident was at hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) and had dialysis sessions every Monday, Wednesday, and Friday. The surveyor reviewed Resident #138's hybrid medical records (paper and electronic medical record) that revealed the following: According to the Admission Record, Resident #138 was admitted with diagnoses that included End Stage Renal Disease (ESRD) and dependence on renal (relating to the kidneys) dialysis. The Quarterly Minimum Data Set (MDS), an assessment tool dated 4/26/22, revealed that the facility performed a Brief Interview for Mental Status (BIMS) which indicated that the resident had a score of 15 out of 15. The resident was assessed to be cognitively intact. The care plan titled Resident requires Hemodialysis related to renal failure included the intervention Continue to monitor me upon return to Dialysis. On 7/25/22 at 8:40 AM, the surveyor interviewed a Licensed Practical Nurse (LPN)who stated the resident had a dialysis communication book. The LPN further stated the resident was scheduled to be picked up for dialysis at 9:30 AM and usually came back to the facility between 2 to 3 PM. On 7/25/22 at 8:46 AM, the surveyor interviewed the LPN who was asked where nurses documented besides the dialysis communication book. The LPN stated In the 24-hour report. Resident #138's dialysis communication book included a Communication Log (CL) form that the facility used to communicate with the dialysis center for each of the resident's dialysis sessions. The top section titled CL was to be filled out by the facility nurse before the resident was sent to dialysis. It included for the facility nurse to document the resident's vital signs (blood pressure, pulse, temperature, and respiration rate), medications given, and comments. The second section titled, Dialysis Communication Log, was to be filled out by the dialysis center. It included for the dialysis nurse to document the resident's pre and post dialysis weights and vital signs, and any additional treatment information if required. There was no section for the nurse to complete vital signs assessment upon the resident's return to the facility from dialysis. On 7/25/22 at 10:30 AM, the surveyor interviewed the LPN, about the procedure for sending residents to dialysis. The LPN stated she would take the resident's vital signs, write in the communication log the vital signs and medications the resident was given prior to going to dialysis. The LPN further stated it was documented when the resident returned from dialysis and if the resident refused to go to dialysis in the chart's progress note. The LPN stated the resident had a left arm dialysis access site which was monitored for bruit/thrills (to assess its function), signs and symptoms of bleeding, drainage, or infection. At that time, the surveyor reviewed the chart with the LPN where the nurses' documented. Under Interdisciplinary Progress Notes in the chart, there were entries for 7/20/22 when the resident returned from their dialysis session, 7/22/22 when the resident refused and an entry for 7/25/22 at 9am when the resident was picked up by transport for dialysis. The LPN was asked about her entry for the resident going to dialysis that morning, as she previously stated she did not document in the resident's chart. The LPN stated she sometimes forgot to document in the nurses note and acknowledged she wrote an entry for today because the surveyor was asking about nurses' documentation for a dialysis resident. The LPN was asked about the facility's policy for documentation for residents going to hemodialysis. The LPN stated she wasn't sure of the facility policy for the documentation. On 7/26/22 at 10:23 AM, the surveyor interviewed the unit's ADON and asked about what the nurses were expected to document for residents with dialysis sessions. The ADON stated the nurses were expected to document in the nurses note of the chart upon the resident going to dialysis and upon their return to the facility from dialysis. The surveyor reviewed nurses' notes in the chart with the ADON. The ADON acknowledged the nurses' notes were not consistent and there were dialysis days that were missing nurses' notes. The ADON stated the nurses were expected to document upon the resident's return from dialysis, including their blood pressure, assessment of access site, if there is any bleeding or drainage. The surveyor asked the ADON if there was anywhere else in the medical record where nurses would document. The ADON replied No. The ADON further stated nurses may communicate between shifts using the 24-hour report but were supposed to document in the nurses note. A review of nurses' progress notes in Resident #138's chart, revealed from 7/1/22 to 7/26/22, there was no documentation on the resident's vital signs or status post dialysis for 7 out of 11 dialysis days. The nurses' notes reviewed in the resident's chart, included notes for two dialysis days the resident refused to go to dialysis and two notes on dialysis days which detailed the resident's status post dialysis. On 7/26/22 at 2:03 PM, the surveyor informed the Administrator and the Director of Nursing (DON) of the above concern. No additional information was provided. 31656 2. On 7/27/22 at 10:30 AM, the surveyor interviewed Resident #108 in the resident's room. The resident informed the surveyor that they attend dialysis on Tuesday, Thursday and Saturday each week. Review of Resident #108's dialysis communication book revealed CL for 7/21/2022, 7/23/2022, and 7/26/2022. The CL's were completely filled out except for 7/26/22, that was missing documention for pre and post dialysis values. There were no other CL's for dialysis visits prior to 7/21/22. Review of Resident#108's Face Sheet (an admission summary) reflected that Resident #108 was admitted to the facility with diagnoses that included but were not limited to Essential (primary) Hypertension, Anemia in Chronic Kidney Disease and ESRD. The Quarterly MDS dated [DATE], revealed a BIMS score of 15 out of 15 which indicated that the resident was cognitively intact. On 7/27/22 at 10:30 AM, the surveyor interviewed the third floor Registered RN Charge Nurse (RNCN) who stated that he spoke to the dialysis center when he realized that there were many CL missing for Resident #108. RNCN stated that the dialysis center explained that they fill out the sheets. The RNCN could not identify the specific date that this conversation occurred. RNCN stated that the resident rips up the forms or loses the books when they go to dialysis. The RNCN stated that the nurses should be documenting the residents post dialysis values (Weight, Blood Pressure, Pulse and Temperature) in the nursing progress notes. The RNCN could not provide any evidence that post dialysis values were completed or documented for Resident #108. On 7/27/22 at 11:55 PM, the surveyor interviewed Resident #108 who stated that upon return to the facility from dialysis, the facility does not weigh or evaluate their vitals. Resident #108 stated that a Dialysis Communication Book accompanies the resident to dialysis but that they were not sure what information was in the book. On 7/27/22 at 12:30 PM, the surveyor discussed the missing information in the Dialysis Communication Book as well as the Nurses Progress Notes with the RNCN. The RNCN stated that post dialysis evaluation should be documented on the CL as well as in the resident's nursing progress notes. The RNCN stated that the facility would have to find a different way of keeping track of the CL sheets stored in the book as well as making sure that there is documentation in the Nurses Progress Notes upon return from dialysis. 41679 3. On 7/27/22 at 1:20 PM, the surveyor observed Resident #135 in bed with eyes closed after returning from dialysis. The surveyor interviewed the first floor South Unit RN (SURN), who was assigned to care for Resident #135. The SURN informed the surveyor that Resident #135 went to hemodialysis on Monday, Wednesday, and Friday with a chair time at 11 AM. The SURN explained that Resident #135 receives breakfast and medications before going to dialysis and lunch is sent with the resident. The SURN also stated that the resident had a dialysis communication book that the CL for the day which was completed before and after dialysis and added that a CNA went with the resident because sometimes there were behaviors. The surveyor reviewed Resident #135's hybrid medical records which revealed the following: According to the Admission Record, Resident #135 was admitted with diagnoses that included Acute Kidney Failure and ESRD with Dependence on Renal Dialysis. The Quarterly MDS dated [DATE], revealed the facility performed a BIMS. The BIMS score was 3 out of 15, which indicated that the resident had severe cognitive deficit. The July 2022 Physician's Order Form revealed a physician's order for hemodialysis every Monday, Wednesday, and Friday with chair time at 11 AM. The surveyor reviewed the CL forms that the facility used to receive communication from the dialysis center for Resident #135. The CL contained a pre-dialysis assessment done by the facility and a pre and post section completed by the dialysis center. The CL were completed for the dates of 7/1/22, 7/4/22, 7/6/22, 7/8/22, 7/11/22, 7/13/22, 7/15/22, 7/18/22, 7/20/22, 7/22/22, 7/25/22, and 7/29/22. Review of the Interdisciplinary Progress Notes revealed that the nurses did not document the assessment of the resident's vital signs when Resident #135 returned from dialysis, to ensure there were no complications. A review of the resident's vitals section revealed that there were no documented assessments of vitals taken after Resident #135 returned from dialysis for the entire from July 1, 2022 to July 27, 2022. On 7/27/22 at 2:00 PM, the surveyors discussed concerns regarding two addition residents, Resident's #108 and #135 for lack of post dialysis documentation with the Administrator and DON. No additional information was provided. On 8/2/22 at 9:54 AM, the surveyors reviewed the facility's policy and procedure with a revised date of 1/25/22, titled Hemodialysis Access Care. Under Documentation it read, The general medical nurse should document in the resident's medical record every shift as follows: .3. If dialysis was done during shift 5. Observations post-dialysis. The policy did not address monitoring residents' vital signs post dialysis. The surveyors reviewed the facility's policy and procedure with a revised date of 1/25/22, titled, End-Stage Renal Disease, Care of a Resident with. The policy did not address documentation by nurses for dialysis residents. NJAC 8:39 - 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to ensure a resident who had a medical history of Dysphagia (difficulty swallowing foods or liquids) and was on aspiration precautions (to address liquids that go into the airway), was administered nectar thickened liquids according to physician's orders. During the medication observation on 03/19/19 at 08:50 AM, the surveyor observed the Registered Nurse (RN) give thin liquids (plain water) to Resident #653 with medications. After the observation was completed, the surveyor reviewed and verified the medications that were administered to Resident #653 to the Physician's Orders (PO) and noted that the resident was prescribed nectar thick liquids (NTL) for Dysphasia with risk for aspiration. NTLs are prescribed to make liquids thicker, which makes it less likely to cause aspiration. This resulted in the likelihood of the risk of aspiration and an immediate jeopardy (IJ) situation for the health and safety of Resident #653. The IJ was identified on 03/19/19 at 10:50 AM., after initial investigation. The Administrator and the Director of Nursing (DON) were made aware of the IJ situation and need for Immediate Action on 03/19/19 at 02:02 PM. On 03/19/19 at 04:13 PM, the facility provided the survey team with the IJ removal plan. The survey team reviewed and accepted the removal plan at that time and verified the immediate action interventions during the surveyors interviews with the staff. The team continued to verify the elements of the entire plan of correction for the remainder of the survey. This deficient practice was identified for 1 of 1 resident (Resident #653) reviewed and was evidenced by the following: On 03/19/19 at 08:50 AM, the surveyor observed, during medication observation, the RN prepare medications for Resident #653. The RN told the surveyor that Resident #653 was provided regular thin liquids with resident's medications. The surveyor observed the RN fill a cup of water from a pitcher that was located on top of the medication cart. The surveyor observed the RN administer Resident #653 medication and provided the resident with a cup of water. Resident #653 took the water to swallow the medications. The RN asked if the resident wanted to drink more and the resident said no. On 03/19/19 at 10:50 AM, during medication reconciliation, the surveyor reviewed Resident #653's March 2019 Physician's Order form that revealed that a physician's order dated 03/05/19 for the resident to have a [MEDICATION(S)] swallow as soon as possible and the need for it to be done prior to discharge. In addition, the physician changed the diet to honey thick liquids (HTL). (HTL has a consistency of honey for a more controlled swallow). The physician also included an order for aspiration precautions. Further review of the Physician's Orders revealed a new physician's order dated 03/12/19 to start NTL. After reviewing the Physician's Orders, the surveyor returned to the medication cart and opened the Medication Administration Record (MAR) book to Resident #653's MAR and noted there was a Resident Identification Form/Medication Administration Comments (RIFMAC) form for Resident #653. This form provided additional instructions to the nurses prior to the administration of medications. The RIFMAC indicated that Resident #653 should be provided NTL with medications. On 03/19/19 at 11:02 AM, the surveyor interviewed the RN who stated she was aware the resident was on NTL. The RN stated Resident #653 only drinks NTL, but that she gave the resident regular thin liquids with the resident's medications because if she gave the resident NTL, the resident wouldn't take the medications. The RN stated that she only gives Resident #653 regular thin liquids when she gives the medicine. The RN further stated that she should have contacted the Physician or SLP before giving the resident thin liquids. According to Resident #653 Admission Face Sheet Information form, the resident was readmitted to the facility on [DATE] with a diagnosis of Transient Cerebral Ischemic Attack (a mini stroke). The Admission Face Sheet indicated the resident was in the hospital from 02/03/19 through 02/08/19. According to the Admission Minimum Data Set, (MDS) an assessment tool dated 02/15/19, Resident #653 was admitted to the facility on [DATE] with a diagnoses that included Stroke (when the blood supply to part of the brain is interrupted or reduced , depriving brain tissue of oxygen and nutrients). The resident was subsequently discharged to the hospital on 03/02/19 with a diagnosis of [CONDITION(S)] (a temporary loss of consciousness caused by a fall in blood pressure). According to the hospital records dated 03/04/19, the Speech Language Pathologist (SLP) wrote in the SLP Progress Notes that the resident had been on a pureed diet with HTL prior to the admission to the hospital. During the resident's hospitalization , the SLP performed a Clinical Swallow Evaluation dated 03/04/19. The SLP indicated that Resident #653 was suspected to have Oropharyngeal Dysphagia (difficulty initiating a swallow) characterized by reduced bolus chewing and a delay in swallowing and a sluggish hyolaryngeal excursion (a critical event in swallowing, whereby the muscles in the hyolaryngeal area move the food or liquid from the oral cavity to the esophagus). The STL recommended the resident remain on a chopped HTL. The surveyor reviewed the resident's Physical Examination dated 03/05/19 written by Resident #653's physician that revealed the resident's chief complaint was dysphasia. The surveyor reviewed the physician's Progress Notes dated 03/12/19 that indicated the Modified [MEDICATION(S)] Swallow (MBS) was not done, (A MBS is a procedure designed to determine whether the resident is swallowing properly to prevent food or liquid from entering the lungs, also known as aspiration). The surveyor reviewed the Admission Minimum Data Set (MDS), an assessment tool dated 03/11/19, under the Brief Interview for Mental Status (BIMS) the facility assessed Resident #653 had a BIMS score of 15 which indicated that the resident was cognitively intact. The surveyor reviewed Resident #653's Baseline Care Plan dated 03/04/19 that revealed under Dietary Orders that the resident was on a chopped, cardiac diet with honey thick liquids (HTL). Under Dietary Risks it indicated that Resident #653 was at risk for swallowing problems. The surveyor reviewed Resident #653's care plan dated 03/11/19 under Focus area which indicated that Resident #653 had swallowing difficulties related to Dysphasia and had interventions that included provide and serve diet as ordered. The surveyor reviewed the care plan developed by the SLP dated 03/05/19 that included interventions for the resident to receive skilled Speech Therapy (ST) for Dysphagia treatment, diet modification and patient/caregiver ST education. The surveyor reviewed the Speech Therapy SLP Evaluation and Plan of Treatment form dated 03/05/19, that revealed Resident #653 was admitted to the facility with a diagnoses which included Transient Cerebral Ischemic Attack, Dysphasia and Oropharyngeal Phase (difficulty initiating the swallowing process whereby solids and liquids cannot move out of the mouth properly) The surveyor reviewed the Speech Therapy Treatment Encounter Note (STTEN) dated 03/05/19, which indicated that Resident #653 had a history of Oropharyngeal Dysphasia characterized by aspiration with thin liquids. The SLP recommended that the resident be given a chopped diet with HTL and close supervision for oral intake. The SLP documented swallowing strategies and positioning to facilitate safety and efficiency during oral intake that included general swallow techniques and precautions: body positioning, double swallowing, smaller meals more frequently, increase time between bites and sips, alternating liquids and solids, bolus size modifications, training in hard throat clearing and re-swallowing techniques. The surveyor reviewed the SLP STTEN dated 03/12/19, which the SLP documented the resident had demonstrated good use of small sips and chin tuck and made a recommendation to discontinue HTL and to start NTL. The SLP further documented that aspiration precautions and all therapeutic diets should continue. A review of the SLP STTEN dated 03/18/19 indicated that the resident demonstrated fair oral reception and containment with fair bolus formation. At times double swallows were made to clear bolus. The patient was able to take small controlled sips of NTL via cup. MBS is scheduled for 2/21. The SLP documented on the Therapy Progress Report dated 03/19/19 under Progress and Response to Treatment; The resident was compliant with the treatment. On 03/19/19 at 11:21 AM, the surveyor interviewed the SLP working with Resident #653. The SLP stated that she had been working with Resident #653 for three weeks and that the resident had a chopped diet with NTL. The SLP stated that Resident #653 required this diet related to Dysphasia secondary to a stroke and issues related to swallowing. The SLP further stated that the resident required MBS before the resident's liquid status could be downgraded to thin liquids. She stated the resident's family member stated a MBS was done at the hospital. However, the SLP was unable to obtain an MBS from the hospital and that was the reason the physician ordered an MBS. The SLP stated that the RN should not be providing thin liquids until the MBS results are reviewed. On 03/19/19 at 11:47 AM, the surveyor interviewed Resident #653 who stated that they have no problem drinking NTL with their medications. The resident further stated that he/she never refused medications when NTL was offered. On 03/19/19 at 02:00 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) assigned to Resident #653 who stated that whenever the resident asked for water she would provide the resident with NTL. The CNA also stated that Resident #653 never complained about drinking NTL. The surveyor reviewed the facility's policy titled Therapeutic Diets that revealed the following under Policy Interpretations and Implementation #3; The Clinical Dietitian, nursing staff, and Attending Physician will review, along with the orders, the need for, and resident acceptance of, prescribed therapeutic diets. NJAC: 8:39-17.4 (a) (1) (2)

C# NJ Based on interviews and review of facility documentation, it was determined that the facility failed to consistently and/or thoroughly follow the facility policy on abuse/resident to resident prevention, including incident documentation, thorough investigation, reporting to the appropriate agencies, protecting their residents from further abuse and/or revising and following up on their identified care plan interventions to prevent reoccurrences of sexually inappropriate behaviors. This deficient practice was identified for 1 of 7 sampled residents, Resident #5, who was identified with sexually inappropriate behaviors and which resulted in an Immediate Jeopardy situation which took place from 1/5/12 to 5/3/12 when Resident #5 had ongoing documented incidents of sexual behaviors toward at least 3 residents, Resident #6, #7 and an unsampled resident. The IJ which began on 1/5/12 through 5/3/12 was identified and was relayed by the surveyor to the facility's Administrator and Director of Nursing (DON) during the second day of survey on 5/22/12 at 4:00 PM and was lifted on the same day at 5:10PM based on an acceptable plan of correction submitted by the facility. . A review of Resident #5, Resident #6, and Resident #7's medical records by the surveyor on 5/22/12 revealed the following: 1. According to his face sheet, Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated 4/18/12, reflected Resident #5 with moderately impaired cognitive ability, required supervision with transfers and ambulation, and incontinent of both bowel and bladder. An IDCP dated 11/11, identified Resident #5 with sexually inappropriate behavior such as touching and grabbing ..."CNA". The goal was for Resident #5 to ..."not display sexually inappropriate behavior", and interventions included but were not limited to; 1:1 counseling, psychiatric consult as needed, continue to monitor behavior every shift, and continue to encourage group activities to promote socialization. Further review of the IDCP, revealed that on 1/5/12, Resident #5 was found in a female bed, fully clothed, and touching the female resident inappropriately. The Goal was for Resident #5's behavior to be under control x 90 days. Interventions on 1/5/12 included; to remove Resident #5 to a secure unit, to schedule for psychiatry and psychology consultation for behavior and medication review and to keep the resident in an area where he can be visually monitored when out of bed. It was further documented under the IDCP's Problem section that Resident #5 exhibited inappropriate touching of a female peer on 3/2/12, and forced another female ..." to perform fell atio on ..." him on 5/4/12. The goal for 5/3/12 was for Resident #5 to not sexually assault or be sexually inappropriate x 3 mos. Interventions added included; Resident #5 was sent out for psychiatric evaluation, Department of Health, Ombudsman's office, and the police were contacted, and to reevaluate the resident when he returns to the facility. There was no documentation on the IDCP when and/or if the psychiatry and psychology consult interventions were implemented after the 1/5/12 incident. There was no documented evidence of a change with the interventions/monitoring after the 3/2/12 incident until the sexually inappropriate incident occurred on 5/3/12. A reportable event record/report (AAS-45) dated 5/4/12 faxed by the facility to the Department of Health and Senior Services (DHSS), reflected that on 5/3/12 at 7:45 PM, a certified nursing assistant (CNA) upon making her rounds saw Resident #5 with his pants off and putting his penis in Resident #6 mouth while Resident #6..."was on the floor sitting in the corner of her bed". The residents were separated immediately. Resident #6 sustained a small laceration of her tongue and was slightly bleeding. It was further documented that Resident #5 was sent to the hospital and his primary physician and his psychiatrist were notified. An incident investigative form (IIF) attached to the AAS-45 dated as faxed by the facility to DHSS on 5/7/12, concluded that he was admitted to the facility on "8/16/11", and had ..."few episodes of inappropriate sexual behavior followed by psychiatry and psychology consultations...". On 1/5/12, he was transferred to a secured unit where he could be visually monitored when ambulating and interacting with other residents. While in the secured unit, Resident #5 had ..."few episodes of sexually inappropriate behavior but he was easily redirected by staff." Further review of the IIF corroborated the documentation on the AAS-45 about the incident on 5/3/12, and documented that the police came to investigate. Resident #5 was sent to the hospital on [DATE] for psychiatric evaluation and was admitted to a psychiatric hospital under involuntary commitment with [DIAGNOSES REDACTED]. A review of the interdisciplinary progress (IPN) notes for Resident #5 from 1/12 to 5/12 documented the following: -1/5/12 at 6:00 PM, Resident #5 was transferred to 1 South. (There was no documentation about the incident with Resident #7, and/or reason for transfer). -3/2/12 at "10:30", Resident #5 was in the lounge with other residents and staff when he touched a female resident's (unsampled resident) breast, and she slapped him. Resident #5 had no injuries, was separated from the female resident, and was educated on not touching female residents, the physician was called. -3/4/12 at 10:00 PM, it was documented that .."as of 3/3/12 resident noted exposing himself to CNA, trying to grab her." Placed in close monitoring for behavior and for follow up psychiatric consult. -4/11/12 at 8:15, Resident #5 seen sexually preoccupied, making sexual comments and wandering close to female resident. Staff intervened by counseling and redirecting. -5/3/12 at 7:00 PM, was lying in bed, calm and quiet. At 7:45 PM, a CNA reported that on rounds she saw Resident #5 with his pants off and putting his penis in Resident #6 mouth. Staff intervened and redirected him back to his room. Body check done with no injuries noted. The physician was notified and ordered the resident to be sent to the hospital for evaluation. -5/7/12 at 11:30 AM, Resident #5 was documented as being admitted to a psychiatric facility due to [MEDICAL CONDITION] Disorder and Dementia. There was no documentation on the IPN between 1/5/12 to 3/1/12 that a psychiatry or psychology consult were scheduled and/or ordered by Resident #5's physician or any follow up made by nursing for the resident to be evaluated according to their updated IDCP interventions on 1/5/12. The specific inappropriate sexual behaviors manifested by Resident #5 on 3/2 and 3/4/12 were not documented on the IDCP, and the nursing interventions remained the same on how to supervise the resident after Resident #5 was documented as being sexually preoccupied on the 4/11/12 IPN. The facility was unable to provide the surveyor with documentation of psychiatric and/or psychology consultations completed from 1/5/12 - 2/12 when Resident #5 was moved to a secured unit. There was no documentation of a psychiatric consultation until 3/13/12 and psychology consultation until 3/21/12 after two additional incidents of being sexually inappropriate were documented on the IPN on 3/2 and 3/4/12 aside from the 1/5/12 incident. A review of the progress notes by a psychiatrist dated 3/13/12, documented ..."called to evaluate pt who is grabbing female residents in a sexual manner." The psychiatrist further documented that on examination, Resident #5 had no eye contact, irritable mood, and impaired memory. He was diagnosed with [REDACTED]. A psychology consultation dated 3/21/12, documented Resident #5 with history of inappropriate sexual behavior. Targeted behaviors included; depressed mood and acting out behavior. Recommendations included to socialize with peers who can hold a conversation. During an interview by the surveyor on 5/22/12 at 10:47 AM with the RN/ADON who was covering as unit manager on Resident #5's unit during the surveyor's visit, revealed that she started working in the facility towards the end of March. She was unaware that Resident #5 had a history of [REDACTED]. The ADON further stated that Resident #5 was strange, stared, but did not touch, and had a wife who visited him. Further interview with the ADON on 5/22/12 at 3:10 PM , revealed that the one psychiatric consultation for Resident #5 while in the locked unit was from 3/13/12 which she found in the resident's chart. The ADON also looked in Resident #5's chart for any psychiatry and/or psychology consultations completed between 1/5/12 to 3/13/12, and did not find any. During an interview by the surveyor on 5/22/12 at 1:42 PM with the 3-11 shift Certified Nursing Assistant (CNA) who witnessed the 5/3/12 incident, corroborated what was documented on the AAS-45. She further stated that Resident #5 was "pumping" his penis in Resident #6's mouth; he stopped when he saw her, and sat on the bed with his pants and diapers off. According to the CNA, Resident #5 had a history of [REDACTED]. The CNA stated that Resident #6 is confused, could not talk, did not know what was happening, and had bleeding from her mouth. According to the CNA, Resident #5 was not in any special kind of monitoring when the 5/3/12 incident occurred. During an interview by the surveyor on 5/22/12 at 3:35 PM with the 3-11 shift male CNA assigned to Resident #5 on 5/3/12, revealed that he saw him last at approximately 7:00 PM lying in his bed with his street clothes still on. The male CNA denied going in his room to care for the resident at that time. Approximately 30 minutes to an hour later, the male CNA was told by another CNA that Resident #5 "assaulted" Resident #6 in her room. According to the male CNA, the resident was already in his room when he came to see him, had 1 to 2 spots of blood on his gown, and denied anything happened. The RN who worked and received the report about the 5/3/12 resident to resident incident was unavailable for interview. In a post survey telephone interview with the surveyor on 5/24/12 at 12:20 PM, the 7-3 shift Licensed Practical Nurse (LPN), who documented the 3/2/12 inappropriate touching by Resident #5 revealed that the nursing supervisor reported to her that staff saw Resident #5 inappropriately touching a female resident in the dayroom (unsampled resident). She added that the supervisor instructed her to write an incident report which she did and the CNA also wrote a statement. She could not recall if the physician called back, and when asked by the surveyor, could not recall about the slapping. According to the LPN, both residents sustained no injuries. The LPN denied being aware of Resident #5's history of inappropriate sexual behavior, and revealed that the unsampled resident has a history of kissing men. The facility could not provide the surveyor with an incident report and or and investigation of the incident. Further interview with the LPN about facility practice when incidents occur, revealed that they would write an incident report, give the report to the supervisor, and either the supervisor or the ADON would update the nursing care plan and follow up. She further stated that the supervisor and the ADON at the time of the incident both no longer work for the facility. During an interview by the surveyor on 5/22/12 at 2:55 PM and 3:05 PM with the Quality Assurance/RN (QA/RN), revealed that she was not in the facility when the 3/2/12 incident occurred and became aware that there was no incident report investigation for the 3/2/12 incident when she began reviewing the incidents as QA/RN. She further stated that she spoke with the Social Worker at that time who verified that they did not have an incident report for the 3/2/12 incidents and both residents were seen by their physician. The QA/RN also stated that she did not think the resident to resident incident from 3/2/12 was reported to the DHSS. Further interview with the QA/RN, revealed that there should have been an incident report/investigation when the resident to resident incident occurred on 3/2/12 in order to determine the cause and to prevent the same incident from reoccurring or happening again. The QA/RN further stated that the care plan should be updated after each incident. An interview by the surveyor with the ADON on 5/22/12 at 2:50 PM, revealed the current DON and herself both started in the facility in April 2012. Both the DON and ADON revealed that there should have been incident reports/investigation about the 3/2/12 and 3/4/12 incidents documented on Resident #5's IPN. 2. According to her face sheet, Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated 3/5/12, reflected Resident #6 with poor short and long term memory with severely impaired decision making skills, and required supervision to total assistance with her activities of daily living (ADL's). A 5/3/12 IDCP reflected that Resident #6 had a laceration to her left tongue, and the goal was to heal without complications x (times) 3 months. Interventions included but were not limited to; normal saline solution (NSS) rinse to mouth, monitor for further bleeding, monitor for infection, and to observe for pain or discomfort. During a care tour by the surveyor on 5/22/12 at 11:00 AM, Resident #6 was observed in the dayroom putting her hands/fingers in her mouth and sucking. She had no teeth, was in no apparent pain/discomfort, no mouth/tongue sores/cuts/abrasions, and the skin on her hands/fingers was intact. Resident #6 was not interviewable (non-verbal). A physician's orders [REDACTED].#6 to the emergency room (ER) for evaluation. A review of the IPN dated 5/3/12 at 7:45 PM, corroborated what was documented on the AAS-45 sent to DHSS from 5/4/12. It was further documented that she was sent to the ER at 11:25 PM via ambulance and returned to the facility with no orders on 5/4/12 at 3:00 AM. During an interview by the surveyor on 5/22/12 at 11:10 AM with the 7-3 shift CNA regularly assigned to Resident #6, the CNA indicated that the resident does not usually talk, at times mumbles in Spanish, but could not communicate. She further stated that it was usual for Resident #6 to put her hands in her mouth and in her diaper on and off. She denied that Resident #6 had any incidents with Resident #5 in the past, and did not see any change in her behavior after the 5/3/12 incident. 3. According to her face sheet, Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE], reflected resident #7 with intact cognition, and required supervision to extensive assistance with her ADL's. A review of the IDCP progress notes dated 2/1/11, reflected that Resident #7 remains alert and oriented x 3, and able to make her needs known. She was also documented with no significant change from her last assessment. An IPN dated 1/5/12 at 3:00 PM, documented that the LPN was told by staff that a male resident climbed into the bed of resident #7, and she began to yell. The male resident was removed from her bedroom, and Resident #7 was fine. Further review of the IPN date 1/6/12 from an RN, documented that resident #7 was moving to another room as she requested. In an interview by the surveyor on 5/22/12 at 12:25 PM with Resident #7, the resident revealed that she knows where she is, but had no recollection of the incident from 1/5/12. According to Resident #7, no one touched her inappropriately and she feels safe in the building. An interview by the surveyor on 5/22/12 at 12:10 PM with the 7-3 shift CNA who was in Resident #7's unit on 1/5/12 revealed that Resident #7 usually goes back to bed after lunch. On 1/5/12, while she was feeding another resident she heard a scream coming from resident #7's room. When she went to respond there was another CNA entering her room and they both went in to respond. They found Resident #5 in Resident #7's bed lying behind her and rubbing her buttocks, both were fully clothed. Resident #7 was yelling and wanted Resident #5 out of her room. They removed Resident #5 without a fight. Further interview with the CNA, revealed that there were no incidents between the two residents in the past that she was aware of. On 5/22/12the facility's abuse policy and procedure dated 10/18/11 was reviewed by the surveyor. The policy documentation indicated that all residents have the right to be free from verbal, sexual, physical abuse and neglect. Residents must not be subjected to abuse, neglect or misappropriation of property by anyone, including but not limited to, facility staff and other residents. The facility will strictly follow all guidelines for the prevention and reporting of abuse as required by the Center for Medicare and Medicaid Services (CMS) and the Elder Justice Act. Further review of the abuse policy included that the interdisciplinary team will develop intervention strategies to prevent occurrences of resident to resident abuse and to review these interventions on a quarterly basis; and the interdisciplinary team shall monitor for any changes that would trigger abusive behavior and reassess interventions. All alleged violations will be reported to the Supervisor immediately upon identification; the supervisor shall notify the Administrator and Director of Nursing (DON) immediately and commence an investigation at once. Allegations of abuse must be investigated by a professional. An incident report is initiated immediately by the supervisor on duty, and the Administrator will coordinate and manage all areas of the investigation including reporting. The IDCP team will develop care plan interventions that address the root cause of the abuse and protect the resident from subsequent abuse. The facility will take appropriate action to safeguard the resident from any further occurrences. Reporting included; all allegations of abuse by anyone including staff, relatives, residents or visitors shall be reported to the DON or designee who will notify the Administrator. A reportable event record report is to be completed by the Administrator or the DON for all incidents of abuse that are reported to the New Jersey DHSS. This facility's Abuse policy and procedure was not consistently followed by staff. The Immediate Jeopardy was lifted on 5/22/12 during the surveyor's second day of visit, based on the plan of correction submitted on the same day at 5:10 PM by the Administrator which included the following: 1. Resident #5 was sent to the hospital on [DATE] for psychiatric evaluation, was admitted to a psychiatric facility, and has not returned. 2. In-services of all licensed nursing staff on how to properly complete an incident/accident report was completed in 5/12. 3. A new Minimum Data Set (MDS)/RN has been employed to ensure care plans are updated timely, accurately, and that individualized nursing interventions are included and staff is informed of the changes and updates. 4. New Nursing and Administrative management had been recently hired and are working towards furthering "staff education and competence". 5. Facility psychiatrist has agreed to come twice a week to visit, and any residents exhibiting an acute issue will be seen as soon as possible. 6. In-service education training will be provided to all management personnel to review required items for reportable incidents to the State. 7. A behavioral 24 hour report will be developed and staff in-serviced to ensure that any potential behavioral incident will be captured, identified, corrected, and care planned appropriately. 8. A bi weekly behavioral team review committee has been established. This is attended by all necessary staff, psychiatrist and psychological team members. 9. The QA/RN has been assigned to review all incidents and accident reports, to include care plan updates with specific interventions. The QA/RN has also been assigned to ensure that the facility follows policy and procedure for abuse and neglect, accident/incident, and state [MEDICATION NAME] correctly through her reviews of the above. 10. Subsequently, on 5/25/12 the (DHSS) received and accepted additional information for the plan of correction consisting of the requested psychiatric consultation from 1/12 and the 3/2/12 incident report for Resident #5. NJAC 8:39-27.1 (b) 8:3- 4.1 (a) (5)

C# NJ Based on interviews and review of facility documentation, it was determined that the facility failed to consistently ensure that 2 of 7 sampled residents, (Resident #6 and #7) and at least one other unsampled resident were provided with an environment free from sexual abuse from Resident #5. Resident #5 was identified on the interdisciplinary care plan (IDCP) dated 11/11 with having sexually inappropriate behaviors. Incidents were documented on 1/5/12 and 3/2/12 of Resident #5 touching and/or grabbing other residents. Subsequently on 5/3/12 Resident #5 was found in a female resident's room (Resident #6) standing over the resident with his penis in her mouth. Resident #6 sustained a laceration to her tongue and was noted with bleeding around her mouth at the time of the incident. This ongoing deficient practice posed serious and immediate threat to the residents' health and safety. The Immediate Jeopardy (IJ) which began on 1/5/12 through 5/3/12 was identified and was relayed by the surveyor to the facility's Administrator and Director of Nursing (DON) during the second day of survey on 5/22/12 at 4:00 PM and was lifted on 5/22/12 based on an acceptable plan of correction submitted on the same day at 5:10 PM by the Administrator. A review of Resident #5, Resident #6, and Resident #7's medical records by the surveyor on 5/22/12 revealed the following: 1. According to his face sheet, Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated 4/18/12, reflected Resident #5 with moderately impaired cognitive ability, required supervision with transfers and ambulation, and incontinent of both bowel and bladder. An IDCP dated 11/11, identified Resident #5 with sexually inappropriate behavior such as touching and grabbing ..."CNA". The goal was for Resident #5 to ..."not display sexually inappropriate behavior", and interventions included but were not limited to; 1:1 counseling, psychiatric consult as needed, continue to monitor behavior every shift, and continue to encourage group activities to promote socialization. Further review of the IDCP, documented that on 1/5/12, Resident #5 was found in a female bed, fully clothed, and touching the female resident inappropriately. The goal was for Resident #5's behavior to be under control x 90 days. Interventions on 1/5/12 included; to remove Resident #5 to a secure unit, to schedule for psychiatry and psychology consultation for behavior and medication review, and to keep the resident in an area where he can be visually monitored when out of bed. It was further documented under the IDCP's problem section that Resident #5 exhibited inappropriate touching of a female peer on 3/2/12, and forced another female..."to perform fell atio on ....." him on 5/4/12. The goal for 5/4/12 was for Resident #5 to not sexually assault or be sexually inappropriate x 3 mos (months). Interventions added included; Resident #5 was sent out for psychiatric evaluation, Department of Health, Ombudsman's office, and the police were contacted, and to reevaluate the resident when he returns to the facility. There was no documentation on the IDCP when and/or if the psychiatry and psychology consult interventions were implemented after the 1/5/12 incident. There was no documented evidence of a change with the interventions/monitoring after the 3/2/12 incident until the sexually inappropriate incident occurred on 5/3/12. A facility Reportable Event Record/Report (AAS-45) dated 5/4/12 faxed to the Department of Health and Senior Services (DHSS), included a statement written by a certified nursing assistant (CNA) that on 5/3/12 at 7:45 PM, the CNA "went in room to change my patient when I seen (Resident #6) sitting on the floor and (Resident #5) was standing over her with his penis in her mouth, his pants were off and blood coming from her mouth, he stepped off her when he seen me. I called out for help and (staff member) came to assist me." The residents were separated immediately. Resident #6 sustained a small laceration of her tongue and was slightly bleeding. It was further documented that Resident #5 was sent to the hospital and his primary physician and his psychiatrist were notified. An incident investigative form (IIF) attached to the AAS-45 dated as faxed by the facility to DHSS on 5/7/12, concluded that he was admitted to the facility on "8/16/11", and had "...few episodes of inappropriate sexual behavior followed by psychiatry and psychology consultations...". On 1/5/12, he was transferred to a secured unit where he could be visually monitored when ambulating and interacting with other residents. While in the secured unit, Resident #5 had ..."few episodes of sexually inappropriate behavior but he was easily redirected by staff." Further review of the IIF corroborated the documentation on the AAS-45 about the incident on 5/3/12, and documented that the police came to investigate. Resident #5 was sent to the hospital on [DATE] for psychiatric evaluation and was admitted to a psychiatric hospital under involuntary commitment with [DIAGNOSES REDACTED]. A review of the interdisciplinary progress (IPN) notes for Resident #5 from 1/12 to 5/12 documented the following: -1/5/12 at 6:00 PM, Resident #5 was transferred to 1 South. (There was no documentation about the incident with Resident #7, and/or reason for transfer). -3/2/12 at "10:30", Resident #5 was in the lounge with other residents and staff when he touched a female resident's (unsampled resident) breast, and she slapped him. Resident #5 had no injuries, was separated from the female resident, and was educated on not touching female residents, the physician was called. -3/4/12 at 10:00 PM, it was documented that "...as of 3/3/12 resident noted exposing himself to CNA, trying to grab her." Placed in close monitoring for behavior and for follow up psychiatric consult. -4/11/12 at 8:15, Resident #5 seen sexually preoccupied, making sexual comments and wandering close to female resident. Staff intervened by counseling and redirecting. -5/3/12 at 7:00 PM, was lying in bed, calm and quiet. At 7:45 PM, a CNA reported that on rounds she saw Resident #5 with his pants off and putting his penis in Resident #6 mouth. Staff intervened and redirected him back to his room. Body check done with no injuries noted. The physician was notified and ordered the resident to be sent to the hospital for evaluation. -5/7/12 at 11:30 AM, Resident #5 was documented as being admitted to a psychiatric facility due to [MEDICAL CONDITION] Disorder and Dementia. There was no documentation on the IPN between 1/5/12 to 3/1/12 that a psychiatry or psychology consult was scheduled and/or ordered by Resident #5's physician or any follow up made by nursing for the resident to be evaluated according to their updated IDCP interventions of 1/5/12. The specific inappropriate sexual behaviors manifested by Resident #5 on 3/2 and 3/4/12 were not documented of the IDCP, and the nursing interventions remained the same on how to supervise the resident after Resident #5 was documented as being sexually preoccupied on the 4/11/12 IPN. The facility was unable to provide the surveyor with documentation of psychiatric and/or psychology consultations conducted after 1/5/12 when Resident #5 was moved to a secured unit. There was documentation of a psychiatric consultation on 3/13/12 and psychology consultation on 3/21/12 after two additional incidents of being sexually inappropriate were documented on the IPN on 3/2 and 3/4/12 aside from the 1/5/12 incident. A review of the progress notes by a psychiatrist dated 3/13/12, documented ..."called to evaluate pt who is grabbing female residents in a sexual manner." The psychiatrist further documented that on examination, Resident #5 had no eye contact, irritable mood, and impaired memory. He was diagnosed with [REDACTED]. A psychology consultation dated 3/21/12, documented Resident #5 with history of inappropriate sexual behavior. Targeted behaviors included; depressed mood and acting out behavior. Recommendations included to socialize with peers who can hold a conversation. During an interview by the surveyor on 5/22/12 at 10:47 AM with the RN/ADON who was covering as unit manager on Resident #5's unit during the surveyor's visit, revealed that she started working in the facility towards the end of March. She was unaware that Resident #5 had any sexual or inappropriate behavior, and did not think he was capable of anything like that until his incident from 5/3/12. The ADON further stated that Resident #5 was strange, stared, but did not touch, and had a wife who visited him. Further interview with the ADON on 5/22/12 at 3:10 PM, revealed that one psychiatric consultation for Resident #5 was done while in the locked unit was from 3/13/12 which she found in the resident's chart. The ADON also looked in Resident #5's chart for any psychiatry and/or psychology consultations completed between 1/5/12 to 3/13/12, and did not find any. During an interview by the surveyor on 5/22/12 at 1:42 PM with the 3-11 shift Certified Nursing Assistant (CNA) who witnessed the 5/3/12 incident, corroborated what was documented on the AAS-45. She further stated that Resident #5 was "pumping" his penis in Resident #6's mouth; he stopped when he saw her, and sat on the bed with his pants and diapers off. According to the CNA, Resident #5 had a history of [REDACTED]. The CNA stated that Resident #6 is confused, could not talk, did not know what was happening, and had bleeding from her mouth. According to the CNA, Resident #5 was not in any special kind of monitoring when the 5/3/12 incident occurred. During an interview by the surveyor on 5/22/12 at 3:35 PM with the 3-11 shift male CNA assigned to Resident #5 on 5/3/12, revealed that he saw him last at approximately 7:00 PM lying in his bed with his street clothes still on. The male CNA denied going in his room to care for the resident at that time. Approximately 30 minutes to an hour later, the male CNA was told by another CNA that Resident #5 "assaulted" Resident #6 in her room. According to the male CNA, the resident was already in his room when he came to see him, had 1 to 2 spots of blood on his gown, and denied anything happened. The RN who worked and received the report about the 5/3/12 resident to resident incident was unavailable for interview. A post survey interview by the surveyor on 5/24/12 at 12:20 PM with the 7-3 shift Licensed Practical Nurse (LPN) who had documented on the IPN about the 3/2/12 inappropriate touching resident to resident incident involving Resident #5. The facility could not provide the surveyor with an incident report/investigation, and could not identify the female resident. During the interview the LPN revealed that the nursing supervisor reported to her that staff saw Resident #5 inappropriately touching a female resident whom she named (unsampled resident) in the dayroom. She further stated that the supervisor instructed her to write an incident report which she did and the CNA also wrote a statement. She could not recall if the physician called back, and could not recall about the slapping. According to the LPN, both residents sustained no injuries. The LPN denied being aware of Resident #5's history of inappropriate sexual behavior, and revealed that the unsampled resident has a history of kissing men. Further interview with the LPN about facility practice when incidents occur, revealed that they would write an incident report, give the report to the supervisor, and either the supervisor or the ADON would update the nursing care plan and follow up. She further stated that the supervisor and the ADON at the time of the incident both no longer work for the facility. During an interview by the surveyor on 5/22/12 at 2:55 PM and 3:05 PM with the Quality Assurance/RN (QA/RN), revealed that she was not in the facility when the 3/2/12 incident occurred, and became aware that there was no incident/report investigation for the 3/2/12 incident when she began reviewing the incidents as QA/RN. She further stated that she spoke with the Social Worker at that time who verified that they did not have an incident report for the 3/2/12 incidents, and both residents were seen by their physician. The QA/RN also stated that she did not think the resident to resident incident from 3/2/12 was reported to the DHSS. Further interview with the QA/RN, revealed that there should have been an incident report/investigation when the resident to resident occurred on 3/2/12 in order to determine the cause and to prevent the same incident from reoccurring or happening again. The QA/RN further stated that the care plan should be updated after each incident. During an interview by the surveyor with the ADON on 5/22/12 at 2:50 PM, revealed the current DON and herself both started at the facility on April 2012. Both DON and ADON revealed that there should have been incident reports / investigation about the 3/2 and 3/4/12 incidents documented on Resident #5's IPN. 2. According to her face sheet, Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated 3/5/12, reflected Resident #6 with poor short and long term memory with severely impaired decision making skills, and required supervision to total assistance with her activities of daily living (ADL's). A 5/3/12 IDCP, reflected Resident #6 with a laceration to her left tongue, and the goal was to heal without complications x 3 months. Interventions included but were not limited to; normal saline solution (NSS) rinse to mouth, monitor for further bleeding, monitor for infection, and to observe for pain or discomfort. During a care tour by the surveyor on 5/22/12 at 11:00 AM, Resident #6 was observed in the dayroom putting her hands/fingers in her mouth and sucking. She had no teeth, was in no apparent pain/discomfort, no mouth/tongue sores/cuts/abrasions, and the skin on her hands/fingers was intact. Resident #6 was not interviewable (non-verbal). A physician's orders [REDACTED].#6 to the emergency room (ER) for evaluation. A review of the IPN dated 5/3/12 at 7:45 PM, corroborated what was documented on the AAS-45 sent to DHSS from 5/4/12. It was further documented that she was sent to the ER at 11:25 PM via ambulance, and returned to the facility with no orders on 5/4/12 at 3:00 AM. During an interview by the surveyor on 5/22/12 at 11:10 AM with the 7-3 shift CNA regularly assigned to Resident #6, revealed that the resident does not usually talk, at times mumbles in Spanish, but could not communicate. She further stated that it was usual for Resident #6 to put her hands in her mouth and in her diaper on and off. She denied that Resident #6 had any incidents with Resident #5 in the past, and did not see any change in her behavior after the 5/3/12 incident. 3. According to her face sheet, Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE], reflected resident #7 with intact cognition, and required supervision to extensive assistance with her ADL's. A review of the IDCP progress notes dated 2/1/11, reflected that Resident #7 remains alert and oriented x 3, and able to make her needs known. She was also documented with no significant change from her last assessment. An IPN dated 1/5/12 at 3:00 PM, documented that the LPN was told by staff that a male resident climbed into the bed of resident #7, and she began to yell. The male resident was removed from her bedroom, and Resident #7 was fine. Further review of the IPN date 1/6/12 from an RN, documented that resident #7 was moving to another room as she requested. During an interview by the surveyor on 5/22/12 at 12:25 PM with Resident #7, revealed that she knows where she is, but had no recollection of the incident from 1/5/12. According to Resident #7, no one touched her inappropriately, and she feels safe in the building. During an interview with the surveyor on 5/22/12 at 12:10 PM, the 7-3 shift CNA who was in Resident #7's unit on 1/5/12, revealed that Resident #7 usually goes back to bed after lunch. On 1/5/12, while she was feeding another resident she heard a scream coming from Resident #7's room. When she went to respond there was another CNA entering her room and they both went in to respond. They found Resident #5 in Resident #7's bed lying behind her and rubbing her buttocks, both were fully clothed. Resident #7 was yelling and wanted Resident #5 out of her room. They removed Resident #5 without a fight. Further interview with the CNA, revealed that there were no incidents between the two residents in the past that she was aware of. A review of the facility's abuse policy and procedure dated 10/18/11, documented that all residents have the right to be free from verbal, sexual, physical, and neglect. Residents must not be subjected to abuse, neglect or misappropriation of property by anyone, including but not limited to, facility staff and other residents. The facility will strictly follow all guidelines for the prevention and reporting of abuse as required by the Centers for Medicare and Medicaid Services (CMS) and the Elder Justice Act. Further review of the abuse policy included that the interdisciplinary team will develop intervention strategies to prevent occurrences of resident to resident abuse and to review these interventions on a quarterly basis; and the interdisciplinary team shall monitor for any changes that would trigger abusive behavior and reassess interventions. All alleged violations will be reported to the Supervisor immediately upon identification; the supervisor shall notify the Administrator and Director of Nursing (DON) immediately and commence an investigation at once. Allegations of abuse must be investigated by a professional. An incident report is initiated immediately by the supervisor on duty, and the Administrator will coordinate and manage all areas of the investigation including reporting. The IDCP team will develop care plan interventions that address the root cause of the abuse and protect the resident from subsequent abuse. The facility will take appropriate action to safeguard the resident from any further occurrences. Reporting included; all allegations of abuse by anyone including staff, relatives, residents or visitors shall be reported to the DON or designee who will notify the Administrator. A reportable event record report is to be completed by the Administrator or the DON for all incidents of abuse that are reported to the New Jersey DHSS. This facility's Abuse policy and procedure was not consistently followed by staff. The Immediate Jeopardy was lifted on 5/22/12 during the surveyor's second day of visit, based on the plan of correction submitted on the same day at 5:10 PM by the Administrator which included the following: 1. Resident #5 was sent to the hospital on [DATE] for psychiatric evaluation, was admitted to a psychiatric facility, and has not returned since. 2. In-services of all licensed nursing staff on how to properly complete an incident/accident report was completed in 5/12. 3. A new Minimum Data Set (MDS)/RN has been employed to ensure care plans are updated timely, accurately, and that individualized nursing interventions are included and staff is informed of the changes and updates. 4. New Nursing and Administrative management had been recently hired and are working towards furthering "staff education and competence". 5. Facility psychiatrist has agreed to come twice a week to visit, and any residents exhibiting an acute issue will be seen as soon as possible. 6. In-service education training will be provided to all management personnel to review required items for reportable incidents to the State. 7. A behavioral 24 hour report will be developed and staff in-serviced to ensure that any potential behavioral incident will be captured, identified, corrected, and care planned appropriately. 8. A bi weekly behavioral team review committee has been established. This is attended by all necessary staff, psychiatrist and psychological team members. 9. The QA/RN has been assigned to review all incidents and accident reports, to include care plan updates with specific interventions. The QA/RN has also been assigned to ensure that the facility follows policy and procedure for abuse and neglect, accident/incident, and state [MEDICATION NAME] correctly through her reviews of the above. 10. Subsequently, on 5/25/12 the (DHSS) received and accepted additional information for the plan of correction consisting of the requested psychiatric consultation from 1/12 and the 3/2/12 incident report for Resident #5. NJAC 8:39-27.1 (b) 8:3- 4.1 (a) (5)

C# NJ Based on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to ensure that the Interdisciplinary Care Plan (IDCP) problems, goals and interventions were consistently revised and/or updated for 2 of 7 residents, (Resident #5 and Resident #1). The IDCP for Resident #5 regarding inappropriate sexual behavior (grabbing, touching female's private parts, sexual preoccupation, and/or exposing himself) was not revised and/or updated in order to prevent a recurrence which resulted in the inappropriate sexual contact and injury to Resident #6. In addition, the IDCP interventions for behavior/hitting and/or [MEDICAL CONDITION] medications were not consistently followed, revised, and/or updated as needed for Resident #1. The deficient practice of failing to follow and/or revise interventions on the IDCP resulted in an Immediate Jeopardy (IJ) situation to resident health and safety. The IJ continued from 1/5/12 through 5/3/12 and was identified by the surveyor and relayed to the facility's Administrator and Director of Nursing (DON) during the second day of survey on 5/22/12 at 4:00 PM and was lifted on 5/22/12 based on an acceptable plan of correction submitted on the same day at 5:10 PM by the Administrator. The evidence included: 1. According to his face sheet, Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated 4/18/12, reflected Resident #5 with moderately impaired cognitive ability, required supervision with transfers and ambulation, and incontinent of both bowel and bladder. An IDCP dated 11/11, identified Resident #5 with sexually inappropriate behavior such as touching and grabbing ..."CNA". The goal was for Resident #5 to ..."not display sexually inappropriate behavior".., and interventions included but were not limited to; 1:1 counseling, psychiatric consult as needed, continue to monitor behavior every shift, and continue to encourage group activities to promote socialization. Further review of the IDCP, documented that on 1/5/12, Resident #5 was found in a female bed, fully clothed, and touching the female resident inappropriately, the goal for Resident #5's behavior to be under control x 90 days. Interventions on 1/5/12 included; to remove Resident #5 to a secure unit, to schedule for psychiatry and psychology consultation for behavior and medication review, and to keep the resident in an area where he can be visually monitored when out of bed. It was further documented under the IDCP's problem section problem that Resident #5 exhibited inappropriate touching of a female peer on 3/2/12, and forced another female ..." to perform fell atio on ..." him on 5/4/12. The goal for 5/4/12 was for Resident #5 to not sexually assault or be sexually inappropriate x 3 mos. Interventions added included; Resident #5 was sent out for psychiatric evaluation, Department of Health, Ombudsman's office, and the police were contacted, and to reevaluate the resident when he returns to the facility. There was no documentation on the IDCP when and/or if the psychiatry and psychology consultations were conducted after the 1/5/12 incident occurred. There was no documented evidence of a change with the interventions/monitoring after the 3/2/12 incident until the sexually inappropriate incident occurred on 5/3/12. A reportable event record/report (AAS-45) dated 5/4/12 faxed by the facility to the Department of Health and Senior Services (DHSS), reflected that on 5/3/12 at 7:45 PM, a certified nursing assistant (CNA) upon making her rounds saw Resident #5 with his pants off and putting his penis in Resident #6 mouth who..."was in the floor sitting on the corner of her bed". The residents were separated immediately. Resident #6 sustained a small laceration of her tongue and was slightly bleeding. It was further documented that Resident #5 was sent to the hospital and his primary physician and his psychiatrist were notified. An incident investigative form (IIF) attached to the AAS-45 dated as foxed by the facility to DHSS on 5/7/12, concluded that he was admitted to the facility on [DATE], and had ..."few episodes of inappropriate sexual behavior followed by psychiatry and psychology consultations...". On 1/5/12, he was transferred to a secured unit where he could be visually monitored when ambulating and interacting with other residents. While in the secured unit, Resident #5 had ..."few episodes of sexually inappropriate behavior but he was easily redirected by staff." Further review of the IIF corroborated the documentation on the AAS-45 about the incident on 5/3/12, and documented that the police also came to investigate. Resident #5 was sent to the hospital on [DATE] for psychiatric evaluation and was admitted to the hospital under involuntary commitment with [DIAGNOSES REDACTED]. A review of the interdisciplinary progress (IPN) notes for Resident #5 from 1/12 to 5/12 documented the following: -1/5/12 at 6:00 PM, Resident #5 was transferred to 1 South. (There was no documentation about the incident with Resident #7, and/or reason for transfer). -3/2/12 at "10:30", Resident #5 was in the lounge with other residents and staff when he touched a female resident's (unsampled resident) breast, and she slapped him. Resident #5 had no injuries, was separated from the female resident, and was educated on not touching female residents, the physician was called. -3/4/12 at 10:00 PM, it was documented that ..."as of 3/3/12 resident noted exposing himself to CNA, trying to grab her." Placed in close monitoring for behavior and for follow up psychiatric consult. -4/11/12 at 8:15, Resident #5 seen sexually preoccupied, making sexual comments and wandering close to female resident. Staff intervened by counseling and redirecting. -5/3/12 at 7:00 PM, was lying in bed, calm and quiet. At 7:45 PM, a CNA reported that on rounds she saw Resident #5 with his pants off and putting his penis in Resident #6 mouth. Staff intervened and redirected him back to his room. Body check done with no injuries noted. The physician was notified and ordered the resident to be sent to the hospital for evaluation. -5/7/12 at 11:30 AM, Resident #5 was documented as admitted to a psychiatric facility due to [MEDICAL CONDITION] Disorder and Dementia. There was no documentation on the IPN between 1/5/12 to 3/1/12 that a psychiatry or psychology consult was scheduled and/or ordered by Resident #5's physician or any follow up made by nursing for the resident to be evaluated according to their updated IDCP interventions on 1/5/12. The specific inappropriate sexual behaviors manifested by Resident #5 on 3/2 and 3/4/12 were not documented on the IDCP, and the nursing interventions remained the same on how to supervise the resident after Resident #5 was documented as being sexually preoccupied on the 4/11/12 IPN. The facility was unable to provide psychiatric and/or psychology consultations completed after 1/5/12 when Resident #5 was moved to a secured unit. There was no documentation of a psychiatric consultation until 3/13/12 and psychology consultation until 3/21/12 after two other incidents of being sexually inappropriate was documented on the IPN on 3/2 and 3/4/12 aside from the 1/5/12 incident. A review of the progress notes by a psychiatrist dated 3/13/13, documented ..."called to evaluate pt who is grabbing female residents in a sexual manner." The psychiatrist further documented that on examination, Resident #5 had no eye contact, irritable mood, and impaired memory. He was diagnosed with [REDACTED]. A psychology consultation dated 3/21/12, documented Resident #5 with history of inappropriate sexual behavior. Targeted behaviors included; depressed mood and acting out behavior. Recommendations included to socialize with peers who can hold a conversation. During an interview by the surveyor on 5/22/12 at 10:47 AM with the RN/ADON who was covering as unit manager on Resident #5's unit during the surveyor's visit, revealed that she started working in the facility towards the end of March. She was unaware that Resident #5 had any sexual of inappropriate behavior, and did not think he was capable of anything like that until his incident from 5/3/12. The ADON further stated that Resident #5 was strange, stared, but did not touch, and had a wife who visited him. Further interview with the ADON on 5/22/12 at 3:10 PM , revealed that the one psychiatric consultation for Resident #5 while in the locked unit was from 3/13/12 which she found in the resident's chart. The ADON also looked in Resident #5's chart for any psychiatry and/or psychology consultation done between 1/5/12 to 3/13/12, and did not find any. During an interview by the surveyor on 5/22/12 at 1:42 PM with the 3-11 shift Certified Nursing Assistant (CNA) who witnessed the 5/3/12 incident, corroborated what was documented on the AAS-45. She further stated that Resident #5 was "pumping" his penis in Resident #6's mouth; he stopped when he saw her, and sat on the bed with his pants and diapers off. According to the CNA, Resident #5 had a history of [REDACTED]. The CNA stated that Resident #6 is confused, could not talk, did not know what was happening, and had bleeding from her mouth. According to the CNA, Resident #5 was not in any special kind of monitoring when the 5/3/12 incident occurred. During an interview by the surveyor on 5/22/12 at 3:35 PM with the 3-11 shift male CNA assigned to Resident #5 on 5/3/12, revealed that he saw him last at approximately 7:00 PM lying in his bed with his street clothes still on. The male CNA denied going in his room to care for the resident at that time. Approximately 30 minutes to an hour later, the male CNA was told by another CNA that Resident #5 "assaulted" Resident #6 in her room. According to the male CNA, the resident was already in his room when he came to see him, had 1 to 2 spots of blood on his gown, and denied anything happened. The RN who worked and received the report about the 5/3/12 resident to resident incident was unavailable for interview. A post survey interview conducted by the surveyor on 5/24/12 at 12:20 PM with the 7-3 shift Licensed practical Nurse (LPN) who documented on the IPN about the 3/2/12 inappropriate touching, resident to resident incident about Resident #5. During the interview, the LPN revealed that the nursing supervisor reported to her that staff saw Resident #5 inappropriately touching a female resident whom she named (unsampled resident) in the dayroom. She further stated that the supervisor instructed her to write an incident report which she did and the CNA also wrote a statement. She could not recall if the physician called back, and could not recall about the slapping. According to the LPN, both residents sustained no injuries. The LPN denied being aware of Resident #5's history of inappropriate sexual behavior, and revealed that the unsampled resident has a history of kissing men. The facility could not provide the surveyor an incident report/investigation, and could not identify the female resident involved in the 3/2/12 incident. Further interview with the LPN about facility practice when incidents occur, revealed that they would write an incident report, give the report to the supervisor, and either the supervisor or the ADON would update the nursing care plan and follow up. She further stated that the supervisor and the ADON at the time of the incident both no longer work for the facility. During an interview by the surveyor on 5/22/12 at 2:55 PM and 3:05 PM with the Quality Assurance/RN (QA/RN), revealed that she was not in the facility when the 3/2/12 incident occurred, and became aware that there was no incident/report investigation for the 3/2/12 incident documented. She further stated that she spoke with the Social Worker at that time who verified that they did not have an incident report, and both residents were seen by their physician. The QA/RN also stated that she did not think that the resident to resident incident on 3/2/12 was reported to the State. Further interview with the QA/RN, revealed that there should have been an incident report/investigation when the resident to resident occurred on 3/2/12 in order to determine the cause and to prevent the same incident from reoccurring or happening again. The QA/RN further stated that the care plan should be updated after each incident. During an interview by the surveyor and the ADON on 5/22/12 at 2:50 PM, revealed that they both started in the facility on April 2012. Both DON and ADON revealed that there should have been incident reports/ investigation about the 3/2 and 3/4/12 incidents documented on Resident #5's IPN. 2. According to his face sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data set (MDS), an assessment tool dated 4/6/12, reflected the resident with moderately impaired cognitive ability and independent with transfers and ambulation. An IDCP dated 2/11 to 4/12 identified Resident #1 on [MEDICAL CONDITION] drugs including [MEDICATION NAME], and [MEDICATION NAME], and targeted behaviors included; pushing, altercation with other residents, walking up and down the hallway, agitation, and resistive to care. The goal from 1/12 for his behavior was for Resident #1 to not display physical aggression over the next 90 days, and an updated goal on [MEDICAL CONDITION] medications which included [MEDICATION NAME] as mood stabilizer dated 4/6/12 was for Resident #1 to remain free of drug related side effects x 3 months. Interventions included to administer medications as ordered, monthly psychiatric summary to quantify behavior for possible gradual drug reduction (GDR), monitor side effects of drugs, and offer redirection and reassurance when appropriate. Further review of the IDCP dated 2/11 to 4/12, revealed that on 10/30/11, Resident #1 was noted with agitation and punched a Certified Nursing Assistant (CNA) on the face. On 11/13/11, it was documented ..."altercation with peer. Hit another resident in the nose over taking a pen from the center court." An interdisciplinary care plan progress notes (CPPN) dated 11/14/11, documented that the IDCP team met about Resident #1's physical altercation from 11/13/11. Interventions included, a follow up with a psychiatrist, redirection, and... "continue every 30 minute monitoring." Further review of the CPPN, documented that on 1/30/12, the IDCP discontinued the every 30 minute monitoring. There was no documentation on the IDCP interventions for Resident #1 dated 11/11 to 4/12 when the every 30 minute monitoring was to be implemented from 11/11 and when it was discontinued on 1/30/12. A psychiatric consultation dated 11/15/11, documented about Resident #1's hitting behavior. It was further documented that Resident #1 had poor judgment and insight, and the plan was to increase the [MEDICATION NAME] to 500 mg. A physician's orders [REDACTED].=125 mg by mouth at bedtime, and [MEDICATION NAME] 100 mg, intramuscular every 4 weeks for [MEDICAL CONDITION]. A review of the 4/12 MAR, reflected that the [MEDICATION NAME] that was prescribed for Resident #1 to be rendered at bedtime for mood stability was being circled with nurse's initials consistently between 4/16 to 4/26/12 with no indication in the back of the MAR indicated [REDACTED]. Resident #1 was sent to the hospital on [DATE] for hitting Resident #2, and has not returned. A review of the interdisciplinary progress notes (IPN), dated 4/16/12 to 4/27/12, had no documentation about the medications that were circled on the 4/12 MAR. for Resident #1. It was documented on the IPN dated 4/27/12 at 3:00 PM, at around 11:30 AM that Resident #1 was holding and turning a paper in his hands. Resident #2 reached his hand out for the paper of Resident #1, who swung and elbowed Resident #2 ..."very hard in the face...". Resident #2 was injured and was sent to the emergency room (ER), and Resident #1 was sent to the hospital for evaluation. A Reportable Event Record/Report (AAS-45) dated 4/30/12, sent by the facility to the Department of Health and Senior Services (DHSS), documented that on 4/27/12 at 12:25 PM Resident #1 and Resident #2 were both ambulating around their unit when Resident #1 who was holding a piece of paper hit Resident #2's nose with his right elbow when Resident #2 tried to take the piece of paper from his hand while he stood next to him. Both were separated, and sent to the emergency room (ER) for evaluation. An incident report for Resident #1 dated 4/30/12 attached to the AAS-45, concluded that Resident #1 was sent out for psychiatric evaluation after the incident, and was admitted for treatment. A review of the monthly psych summary for 4/12 dated 5/3/12 by a Registered Nurse, reflected that the resident's targeted behaviors were medication refusals and hitting. The RN documented that Resident #1 refused his medications and on one occasion hit another resident causing injury. Resident #1 was sent to the emergency room , and was transferred to a psychiatric facility for [MEDICAL CONDITION] and Disorganized Thinking. Further review of the monthly psych summary for 4/12, reflected that Resident #1 had 3 episodes of medication refusals on 4/12, and 1 hitting episode on 4/12. Resident #1's last psychiatric consultation was on 12/19/11. The monthly psych summary did not coincide with the 4/12 MAR, and did not document about the reasons why the [MEDICATION NAME] was circled and/or not administered to Resident #1 between 4/16 to 4/26/12, and what was done. During an interview by the surveyor on 5/8/12 at 10:50 AM about Resident #1 and Resident #2's incident from 4/27/12 with the RN/unit manager (RN/UM) who has worked in the facility for one and a half years, revealed that the incident happened by the nursing station with staff present and while she was in the chart area. She also stated watching the video of the incident from their facility camera as part of their investigation. According to the RN/UM, Resident #1 was looking at his paper while standing by the nursing station and Resident #2 also was standing close behind him looking at his paper when Resident #1 elbowed Resident #2 who lost his balance. She further stated that it was the first incident between the two residents. Resident #2 has no history of hitting, and Resident #1 was monitored every 30 minutes due to history of hitting others in the past. The surveyor requested documentation of the every 30 minute monitoring at the time of the incident for Resident #1. The RN/UM who stated that Resident #1 was on every 30 minute monitoring, was unable to provide documentation of the every 30 minute monitoring performed for Resident #1 on the day prior to the hitting incident from 4/27/12. Further interview by the surveyor on 5/8/12 at 1:15 PM with the RN/UM, revealed that the every 30 minute monitoring that was initiated on Resident #1 in 11/11 was discontinued on 1/30/12 as documented on the CPPN provided. When asked by the surveyor why the every 30 minute intervention was not documented on Resident #1's IDCP when it was initiated and discontinued, the RN revealed that it should have been updated "automatic" by the Social Worker who was responsible with updating resident's behavior. When asked by the surveyor about the circled initials on Resident #1's 4/12 MAR from 4/16 to 4/26/12 for his [MEDICATION NAME], the RN/UM stated that she was unaware of the resident's refusals from the 3-11 shift. The RN/UM further stated that it was their practice that she should have been notified after 3 days of the resident not getting his prescribed medication, and if she was, she would have called the physician and the psychiatrist. When the RN/UM was further questioned by the surveyor about their practice on monthly psych summary and MAR indicated [REDACTED]. According to the RN, there should be documentation on the back of the MAR indicated [REDACTED]. Resident #2 was observed by the surveyor sitting in his room at 11:30 AM, calm, was non-conversant, and was unable to relay about the incident from 4/27/12. During an interview by the surveyor on 5/8/12 at 1:40 PM with the Director of Nursing (DON), who has been in the facility for three weeks, revealed that they have no policy on medication refusals, although it was their practice to notify the physician after 3 episodes of refusals, and to "absolutely" document about the medication refusals and physician notification on the medical record. The DON further stated that what to do when resident refuses their medication was a problem she identified when she began as DON in the facility including documentation, and she plans on addressing these issues. A review of the facility's undated policy and procedure on interdisciplinary care plan (IDCP) team, documented that the IDCP team shall meet to assess each resident's needs and develop an individualized care plan that is coordinated among all relevant disciplines. By doing so, IDCP shall be completed and maintained on a regular basis. Procedure included that an interdisciplinary team meeting/ resident care conference shall be held each day. All resident shall be reviewed quarterly or as needed to report any changes in level of functioning and/or effects, and /or needs for interventions by any or all disciplines. Team members shall identify the resident's problems, needs, and appropriate methods of interventions as well as a measurable task oriented short term goal which is to fall hot to exceed three months. Careful attention must be given to proper endorsement of dates. The month and year must be documented as each "problem/need" area is addressed, as it is reviewed, and as each objective and/or goal is achieved. A review of the facility's undated policy and procedure on interdisciplinary care plan procedure reflected that it is the nurse's responsibility to review IDCP quarterly and update when there is a change in patient's condition. The Immediate Jeopardy was lifted on 5/22/12 during the surveyor's second day of visit, based on the plan of correction submitted on the same day at 5:10 PM by the Administrator which included the following: 1. Resident #5 was sent to the hospital on [DATE] for psychiatric evaluation, was admitted to a psychiatric facility, and has not returned. 2. In-services of all licensed nursing staff on how to properly complete an incident/accident report was completed in 5/12. 3. A new Minimum Data Set (MDS)/RN has been employed to ensure care plans are updated timely, accurately, and that individualized nursing interventions are included and staff is informed of the changes and updates. 4. New Nursing and Administrative management had been recently hired and are working towards furthering "staff education and competence". 5. Facility psychiatrist has agreed to come twice a week to visit, and any residents exhibiting an acute issue will be seen as soon as possible. 6. In-service education training will be provided to all management personnel to review required items for reportable incidents to the State. 7. A behavioral 24 hour report will be developed and staff in-serviced to ensure that any potential behavioral incident will be captured, identified, corrected, and care planned appropriately. 8. A bi weekly behavioral team review committee has been established. This is attended by all necessary staff, psychiatrist and psychological team members. 9. The QA/RN has been assigned to review all incidents and accident reports, to include care plan updates with specific interventions. The QA/RN has also been assigned to ensure that the facility follows policy and procedure for abuse and neglect, accident/incident, and state [MEDICATION NAME] correctly through her reviews of the above. 10. Subsequently, on 5/25/12 the (DHSS) received and accepted additional information for the plan of correction consisting of the requested psychiatric consultation from 1/12 and the 3/2/12 incident report for Resident #5. NJAC 8:39-27.1 (b) 8:39- 11.2 (e) 2

C# NJ & NJ Based on observation, interviews, review of medical records, and other facility documentation, it was determined that the facility failed to provide necessary care and services, and/or failed to appropriately and/or adequately intervene when a prescribed medication for mood stabilization, [MEDICATION NAME] was not administered for 11 days (4/16/12 to 4/26/12) for 1 of 7 sampled residents (Resident #1), who had a history of [REDACTED]. Resident #1 physically assaulted Resident #2 on 4/27/12. Subsequently, Resident #2, who was at risk for falls, lost his balance, fell hitting his face on the floor. Resident #2 sustained a 2.0 cm laceration/bleeding over his left eyebrow, required a hospital visit, received 4 stitches to his left eyebrow, was placed on antibiotic treatment, monitored for pain and was followed up by an Orthopedic physician for a fractured nasal (nose) bone. The physician was notified, and ordered to send Resident #1 out for psychiatric evaluation at the hospital. Resident #1 was subsequently admitted to a psychiatric hospital for treatment. The deficient practice is evidenced by the following: A review of Resident #1 and Resident #2's medical records by the surveyor on 5/8/12 revealed the following: 1. According to his face sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data set (MDS), an assessment tool dated 4/6/12, reflected the resident with moderately impaired cognitive ability and independent with transfers and ambulation. An IDCP dated 2/11 to 4/12 identified Resident #1 on [MEDICAL CONDITION] drugs including [MEDICATION NAME], and [MEDICATION NAME], and targeted behaviors included; pushing, altercation with other residents, walking up and down the hallway, agitation, and resistive to care. The goal from 1/12 for his behavior was for Resident #1 to not display physical aggression over the next 90 days, and an updated goal on [MEDICAL CONDITION] medications which included [MEDICATION NAME] as mood stabilizer dated 4/6/12 was for Resident #1 to remain free of drug related side effects x 3 months. Interventions included to administer medications as ordered, monthly psychiatric summary to quantify behavior for possible gradual drug reduction (GDR), monitor side effects of drugs, and offer redirection and reassurance when appropriate. Further review of the IDCP dated 2/11 to 4/12, revealed that on 10/30/11, Resident #1 was noted with agitation and punched a Certified Nursing Assistant (CNA) on the face. On 11/13/11, it was further documented "... altercation with peer. Hit another resident in the nose over taking a pen from the center court." An interdisciplinary care plan progress notes (CPPN) dated 11/14/11, documented that the IDCP team met about Resident #1's physical altercation from 11/13/11. Interventions included, a follow up with a psychiatrist, redirection, and "... continue every 30 minute monitoring." Further review of the CPPN, documented that on 1/30/12, the IDCP discontinued the every 30 minute monitoring. There was no documentation on the IDCP interventions from 2/11 to 4/12 that Resident #1 had been on every 30 minute monitoring. A psychiatric consultation dated 11/15/11, documented about Resident #1's hitting behavior. It was further documented that Resident #1 had poor judgment and insight, and the plan was to increase the [MEDICATION NAME] to 500 mg. A physician's orders [REDACTED].=125 mg by mouth at bedtime, and [MEDICATION NAME] 100 mg, intramuscular every 4 weeks for [MEDICAL CONDITION]. A review of the 4/12 MAR, reflected that the [MEDICATION NAME] that was prescribed for Resident #1 to be rendered at bedtime for mood stability was being circled with nurse's initials consistently between 4/16 to 4/26/12 with no documentation on the back of the MAR indicated [REDACTED] Resident #1 was sent to the hospital on [DATE] for hitting Resident #2, and has not returned since. A review of the interdisciplinary progress notes (IPN), dated 4/16/12 to 4/27/12, had no documentation about the medications that were circled on the 4/12 MAR. for Resident #1. It was further documented on the IPN dated 4/27/12 at 3:00 PM, at around 11:30 AM that Resident #1 was holding and turning a paper in his hands. Resident #2 reached his hand out for the paper of Resident #1, who swung and elbowed Resident #2 ..."very hard in the face...". Resident #2 was injured and was sent to the emergency room (ER), and Resident #1 was sent to the hospital for evaluation. A Reportable Event Record/Report (AAS-45) dated 4/30/12, sent by the facility to the Department of Health and Senior Services (DHSS), documented that on 4/27/12 at 12:25 PM Resident #1 and Resident #2 were both ambulating around their unit when Resident #1 who was holding a piece of paper hit Resident #2's nose with his right elbow when Resident #2 tried to take the piece of paper from his hand while he stood next to him. Both were separated, and sent to the emergency room (ER) for evaluation. An incident report for Resident #1 dated 4/30/12 attached to the AAS-45, concluded that Resident #1 was sent out for psychiatric evaluation after the incident, and was admitted for treatment. A review of the monthly psych summary for 4/12 dated 5/3/12 by a Registered Nurse, reflected that the resident's targeted behaviors were medication refusals and hitting. The RN documented that Resident #1 refused his medications and on one occasion hit another resident causing injury. Resident #1 was sent to the emergency room , and was transferred to a psychiatric facility for [MEDICAL CONDITION] and Disorganized Thinking. Further review of the monthly psych summary for 4/12, reflected that Resident #1 had 3 episodes of medication refusals on 4/12, and 1 hitting episode on 4/12. Resident #1's last psychiatric consultation was on 12/19/11. The monthly psych summary did not coincide with the 4/12 MAR, and did not document about the reasons why the [MEDICATION NAME] was circled and/or not administered to Resident #1 between 4/16 to 4/26/12, and what was done. During an interview by the surveyor on 5/8/12 at 10:50 AM about Resident #1 and Resident #2's incident from 4/27/12 with the RN/unit manager (RN/UM) who has worked in the facility for one and a half years, revealed that the incident happened by the nursing station with staff present and while she was in the chart area. She also stated watching the video of the incident from their facility camera as part of their investigation. According to the RN/UM, Resident #1 was looking at his paper while standing by the nursing station and Resident #2 also was standing close behind him looking at his paper when Resident #1 elbowed Resident #2 who lost his balance. The surveyor requested for the every 30 minute monitoring at the time of the incident for Resident #1. The RN/UM who stated that Resident #1 was on every 30 minute monitoring, was unable to provide documentation of the every 30 minute monitoring performed for Resident #1 on the day prior to the hitting incident from 4/27/12. Further interview by the surveyor on 5/8/12 at 1:15 PM with the RN/UM, revealed that the every 30 minute monitoring that was initiated on Resident #1 in 11/11 was discontinued on 1/30/12 as documented on the CPPN provided. When asked by the surveyor why the every 30 minute intervention was not documented on Resident #1's IDCP when it was initiated and discontinued, the RN revealed that it should have been updated "automatic" by the Social Worker who was responsible with updating resident's behavior. When asked by the surveyor about the circled initials on Resident #1's 4/12 MAR from 4/16 to 4/26/12 for his [MEDICATION NAME], the RN/UM stated that she was unaware of the resident's refusals from the 3-11 shift. The RN/UM further stated that it was their practice that she should have been notified after 3 days of the resident not getting his prescribed medication, and if she was, she would have called the physician and the psychiatrist. When the RN/UM was further interviewed by the surveyor about their practice on monthly psych summary and MAR indicated [REDACTED]. According to the RN, there should be documentation on the back of the MAR indicated [REDACTED]. Resident #2 was observed by the surveyor sitting in his room at 11:30 AM, calm, was non-conversant, and was unable to relay about the incident from 4/27/12. During an interview by the surveyor on 5/8/12 at 1:40 PM with the Director of Nursing (DON), who has been in the facility for three weeks, revealed that they have no policy on medication refusals, although it was their practice to notify the physician after 3 episodes of refusals, and to "absolutely" document about the medication refusals and physician notification on the medical record. The DON further stated that what to do when resident refuses their medication was a problem she identified when she began as DON in the facility including documentation, and she plans on addressing these issues. During a post survey interview by the surveyor on 5/30/12 at 2:30 PM via telephone with the 3-11 Licensed Practical Nurse (LPN), regularly assigned on resident #1's unit, revealed that she was Resident #1's medication nurse on 4/12 during 3-11 shift, and verified that her circled initials from the 4/12 MAR from the 16th to the 26th were due to Resident #1 refusing his medications. She further stated that she honestly did not know about their policy of notifying their supervisor of consistent medication refusals, and that she had to document the reason on the back of the MAR. According to the LPN, she was recently counseled by the new DON and her supervisor about the [MEDICATION NAME] refusal and what she has to do if any resident refuses to take their medication/s after 2-3 days including notifying her supervisor, the physician or the psychiatrist depending on what medication. She further stated that she now knows to document on the back of the MAR, and to document medication refusals and/or notifications in the nurse's notes. The LPN stated that ..."it will not happen again". 2. According to his face sheet, Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE], reflected Resident #2 with poor short and long term memory with impaired decision making skills, and was independent with transfers and walking. An IDCP dated 3/12 to 4/12, reflected that Resident #2 was at risk for falls due to use of [MEDICAL CONDITION] medications. Further review of the IDCP, reflected that on 4/27/12, Resident #2 was hit by Resident #1, fell , and sustained a facial laceration and a fractured nasal bone. Interventions included; first aid to affected/nasal area, ice pack applied to decrease the bleeding and swelling; transferred to the hospital for evaluation and was monitored for pain upon return from the hospital; started on Keflex (antibiotic), and was scheduled for "ENT" (eye, nose, throat) consultation for facial suture removal. A 5/7/12 ENT consultation due to a nasal fracture from 4/27/12, documented Resident #2 with history of nasal fracture. Resident #2 was diagnosed with [REDACTED]. An incident report investigation dated 4/30/12 for Resident #2, reflected that on 4/27/12, as he tried to take a piece of paper from resident #1's hand while they were both ambulating by the nursing station in their unit, Resident #1 reacted by hitting Resident #2's nose with his right elbow and sustained a 2.0 cm laceration/bleeding over his left eyebrow and a swollen nose. Resident #2 was sent to the hospital for an evaluation on the same day and was diagnosed with [REDACTED]. He was returned to the facility with recommendations including ENT consult, pain management/monitoring, and antibiotic therapy. Resident #2 was observed by the surveyor during the initial survey visit to the facility on [DATE] at 10:45 AM in the hallway ambulating, and at 11:30 AM in his room sitting, but was unable to interview due to his cognition, was not talking, and only stared at the surveyor. During an interview by the surveyor on 5/8/12 at 10:50 AM with the RN/UM, revealed that Resident #2 is self ambulatory, and "selectively mute...". She further stated that Resident #2 had no history of hitting, and had no other incidents with Resident #1 in the past. The facility's policy and procedure on General Dose Preparation and Medication Administration dated 5/1/10, documented that after medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following; Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, if medications are refused) on appropriate forms. NJAC 8:39-27.1 (a) 8:39-27.1 (b)

C# NJ & NJ Cross Reference F309 Based on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to assure that medications were administered and/or appropriately documented according to physician's orders [REDACTED].#1). Resident #1 who had a history of [REDACTED]. Resident #2 lost his balance, fell face down on the floor, sustained a 2.0 cm laceration/bleeding over his left eyebrow, and a swollen nose. Resident #2 required a hospital visit, received 4 stitches to his left eyebrow, was placed on antibiotic treatment, seen by an Orthopedist for a fractured nasal bone and was monitored for pain. This deficient practice is evidenced by the following: Reference: New Jersey State Nurse Practice Act Title 45 Chapter 11 45-23 definition: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. According to his face sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data set (MDS), an assessment tool dated 4/6/12, reflected the resident with moderately impaired cognitive ability and independent with transfers and ambulation. An IDCP dated 2/11 to 4/12 identified Resident #1 on [MEDICAL CONDITION] drugs including [MEDICATION NAME], and [MEDICATION NAME], and targeted behaviors included; pushing, altercation with other residents, walking up and down the hallway, agitation, and resistive to care. The goal from 1/12 for his behavior was for Resident #1 to not display physical aggression over the next 90 days, and an updated goal on [MEDICAL CONDITION] medications which included [MEDICATION NAME] as mood stabilizer dated 4/6/12 was for Resident #1 to remain free of drug related side effects x 3 months. Interventions included to administer medications as ordered, monthly psychiatric summary to quantify behavior for possible gradual drug reduction (GDR), monitor side effects of drugs, and offer redirection and reassurance when appropriate. Further review of the IDCP dated 2/11 to 4/12, revealed that on 10/30/11, Resident #1 was noted with agitation and punched a Certified Nursing Assistant (CNA) on the face. On 11/13/11, it was further documented "... altercation with peer. Hit another resident in the nose over taking a pen from the center court." An interdisciplinary care plan progress notes (CPPN) dated 11/14/11, documented that the IDCP team met about Resident #1's physical altercation from 11/13/11. Interventions included; a follow up with a psychiatrist, redirection, and "... continue every 30 minute monitoring." Further review of the CPPN, documented that on 1/30/12, the IDCP discontinued the every 30 minute monitoring. A psychiatric consultation dated 11/15/11, documented about Resident #1's hitting behavior. It was further documented that Resident #1 had poor judgment and insight, and the plan was to increase the [MEDICATION NAME] to 500 mg. A physician's orders [REDACTED].=125 mg by mouth at bedtime, and [MEDICATION NAME] 100 mg, intramuscular every 4 weeks for [MEDICAL CONDITION]. A review of the 4/12 MAR, reflected that the [MEDICATION NAME] that was prescribed for Resident #1 to be rendered at bedtime for mood stability was being circled with nurse's initials consistently between 4/16 to 4/26/12 with no documentation on the back of the MAR indicated [REDACTED]. Resident #1 was sent to the hospital on [DATE] for hitting Resident #2, and has not returned since. A review of the interdisciplinary progress notes (IPN), dated 4/16/12 to 4/27/12, had no documentation about the medications that were circled on the 4/12 MAR for Resident #1. It was further documented on the IPN dated 4/27/12 at 3:00 PM, at around 11:30 AM that Resident #1 was holding and turning a paper in his hands. Resident #2 reached his hand out for the paper of Resident #1, who swung and elbowed Resident #2 ..."very hard in the face...". Resident #2 was injured and was sent to the emergency room (ER), and Resident #1 was sent to the hospital for evaluation. A Reportable Event Record/Report (AAS-45) dated 4/30/12, sent by the facility to the Department of Health and Senior Services (DHSS), documented that on 4/27/12 at 12:25 PM Resident #1 and Resident #2 were both ambulating around their unit when Resident #1 who was holding a piece of paper hit Resident #2's nose with his right elbow when Resident #2 tried to take the piece of paper from his hand while he stood next to him. Both were separated, and sent to the emergency room (ER) for evaluation. An incident report for Resident #1 dated 4/30/12 attached to the AAS-45, concluded that Resident #1 was sent out for psychiatric evaluation after the incident, and was admitted for treatment. A review of the monthly psych summary for 4/12 dated 5/3/12 by a Registered Nurse, reflected that the resident's targeted behaviors were medication refusals and hitting. The RN documented that Resident #1 refused his medications and on one occasion hit another resident causing injury. Resident #1 was sent to the emergency room , and was transferred to a psychiatric facility for [MEDICAL CONDITION] and Disorganized Thinking. Further review of the monthly psych summary for 4/12, reflected that Resident #1 had 3 episodes of medication refusals on 4/12, and 1 hitting episode on 4/12. Resident #1's last psychiatric consultation was on 12/19/11. The monthly psych summary did not coincide with the 4/12 MAR, and did not document about the reasons why the [MEDICATION NAME] was circled and/or not administered to Resident #1 between 4/16 to 4/26/12, and what was done. During an interview by the surveyor on 5/8/12 at 10:50 AM about Resident #1 and Resident #2's incident from 4/27/12 with the RN/unit manager (RN/UM) who has worked in the facility for one and a half years, revealed that the incident happened by the nursing station with staff present and while she was in the chart area. She also stated watching the video of the incident from their facility camera as part of their investigation. According to the RN/UM, Resident #1 was looking at his paper while standing by the nursing station and Resident #2 also was standing close behind him looking at his paper when Resident #1 elbowed Resident #2 who lost his balance. She further stated that it was the first incident between the two residents. Resident #2 has no history of hitting, and Resident #1 was monitored every 30 minutes due to history of hitting others in the past. Further interview by the surveyor with the RN/UM about the circled initials on Resident #1's 4/12 MAR from 4/16 to 4/26/12 for his [MEDICATION NAME], the RN/UM stated that she was unaware of the resident's refusals from the 3-11 shift. The RN/UM further stated that it was their practice that she should have been notified after 3 days of the resident not getting his prescribed medication, and if she was, she would have called the physician and the psychiatrist. When the RN/UM was interviewed further by the surveyor about their practice on monthly psych summary and MAR indicated [REDACTED]. According to the RN, there should be documentation on the back of the MAR indicated [REDACTED]. Resident #2 was observed by the surveyor sitting in his room at 11:30 AM, calm, was non-conversant, and was unable to relay about the incident from 4/27/12. During an interview by the surveyor on 5/8/12 at 1:40 PM with the Director of Nursing (DON), who has been in the facility for three weeks, revealed that they have no policy on medication refusals, although it was their practice to notify the physician after 3 episodes of refusals, and to "absolutely" document about the medication refusals and physician notification on the medical record. The DON further stated that what to do when resident refuses their medication was a problem she identified when she began as DON in the facility including documentation, and she plans on addressing these issues. The facility's policy and procedure on General Dose Preparation and Medication Administration dated 5/1/10, documented that after medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following; Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, if medications are refused) on appropriate forms. There was no evidence that this facility policy was consistently followed by staff. NJAC 8:39-27.1 (b)

Complaint # NJ 1765 Based on observation, interview and medical record review it was determined that the facility failed to supervise, monitor, provide effective interventions and coordinate investigative information in order to protect residents from accidents, incidents and injuries. These deficient practices involved 13 of 23 residents, Residents # 1, 2, 4, 5, 7, 8, 9, 19, 22, 23, 26, 33, and 34. These 13 residents include witnesses to events, aggressors and victims. This resulted in harm for Resident # 2 , who suffered multiple bruising and lacerations from resident to resident altercation with Resident #1 and was sent to the hospital for these injuries; Resident #4 who suffered a fractured nose from an altercation with Resident #5; Resident #26 who experienced a possible unwanted sexual encounter with Resident #7; and Resident #8 who suffered a fracture of the vertebral process and lacerations requiring sutures after a series of falls. These deficient practices were evidenced by the following: 1. The following deficient practice involves Residents #1, 2 and 31 who all resided in the same room. Resident #1 was the aggressor, Resident #2 was the victim and Resident #31 was a witness to an incident that occurred on 11/28/11. During the 11/29/11 initial unit tour at 9:30 a.m., the surveyor observed Resident #1 walking in the hallway with a staff member at his side. At 10 a.m., the surveyor observed the same resident being transported out of the facility by stretcher. The Quality Assurance Registered Nurse (QARNE) told the surveyor that Resident #1 had assaulted Resident #2 in the evening on 11/28/11. She further stated Resident #1 was being sent out to the hospital emergency department for crisis intervention. The surveyor and the QARNE went to Resident #2's room a short time later at 10:05 a.m. and observed Resident #2 who was in bed. The resident's room was at the far end of the hallway. The room had 3 beds. Resident #2 was in the bed next to the door. Resident #31 was in the middle bed and Resident #1's bed was the third bed next to the window. Resident #2 was wearing a disposable diaper, socks, and 1 shoe. The resident did not have a sheet or blanket covering him and the resident's door was open. The resident awoke easily and did not respond verbally to the surveyor or the ARNE. The surveyor asked the ARNE to perform a skin check in the surveyor's presence. The following wounds were observed by the surveyor as identified on Resident #2 by the ARNE: multiple right inner thigh bruises, a bruised and swollen right knee with a scab in the center, multiple left front thigh bruises, a left knee bruise, a laceration on the left forehead at the hairline, and multiple bruises covering the left scapula. The ARNE stated that on 11/28/11 during evening care, the Certified Nursing Assistant (CNA) observed an injury on the forehead of Resident #2. The CNA told the unit nurse. Resident #2 was sent out to the hospital for evaluation. The physician ordered Resident #1 sent out the following morning on 11/29/11, since he was sleeping soundly at that point. The QARN told the surveyor she would complete her investigation and provide it to the surveyor. The surveyor reviewed the medical records of Residents #1 and #2 on 11/29/11. Resident #1 was recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was prescribed an antipsychotic medication, Seroquel 25 mg. every 12 hours and an antianxiety medication Ativan, 1 mg. at 9:30 p.m. A review of Resident #1's hospital records prior to admission to the facility revealed that the resident exhibited behaviors of wandering into other patient's rooms during his hospital stay. The resident was discharged from the hospital to an assisted living facility where he resided for short period before admission to this nursing facility. The 11/8/11 admission Minimum Data Set (MD'S), an assessment tool, reflected that the resident had severely impaired cognition and required supervision with ambulation. The resident was also assessed to have depression. The 11/11/11 Therapeutic Recreation Comprehensive Initial Assessment assessed Resident #1 to be forgetful and confused and having the intention to exit the building. Resident #1's initial care plan, dated 11/2/11, identified the following problem areas: 1) compromised short and long term memory as manifested by confusion and disorientation,wanders about the unit, disoriented to time and place and 2) at risk for drug related side effects due to use of antipsychotic and antianxiety medications. The behaviors these medications were intended to treat were listed as aggression, delusions, agitation and nervousness. The Approach/Interventions the staff were to utilize to help alleviate these behaviors were: monitor the resident's location "at start and end of unit," involve in "enjoyable" activities, redirect or relocate to prevent further altercations, discourage negative and unacceptable behavior. The interventions listed within the care plans were non-specific and not individualized as to who would monitor and when they would monitor the resident. The resident's preference of enjoyable activities was not documented, and methods of discouraging negative behavior was not offered. A review of Interdisciplinary Progress Notes (IPN) revealed that Resident #1 was admitted [DATE] at 5:05 p.m. At 6:45 p.m. the nurse documented that Resident #1 was wandering with belongings, "refused to allow staff to obtain belongings and put in closet. Kept exit seeking with belongings in hands, stating I got to get out of here." On 11/2/11 the 7-3 shift nurse documented that the resident wandered into a female resident's room unannounced. On 11/5/11, the 3-11 shift nurse documented that Resident #1 was noted to be pacing back and forth on the unit and wandering into other resident's rooms. On 11/7/11 at 12:15 p.m. the nurse documented that Resident #1 became agitated, "combative to nursing staff and to other residents", hitting his fist on the medication cart, "threatening a nurse holding her arms in an aggressive anger (sic) outburst. Security was called and the resident was redirected to the back of the unit/patio. A CNA stayed with the resident on the patio area. The psychiatrist was called and he ordered that the resident be transferred to the hospital for a psychiatric evaluation. The resident left the facility at 3:35 p.m. At 9:15 p.m., Resident #1 returned from the hospital with recommendations to increase the dosage of Seroquel. The primary physician was notified of this recommendation and did not agree to the increase of Seroquel. The nurse documented that the physician wanted to wait until he saw the patient the following day. No new interventions were added to the behavioral care plan when the resident returned from the hospital. On 11/8/11 at 6 a.m., the nurse documented that Resident #1 was wandering around, not following simple commands and going into other residents' rooms. The nurse added, "Resident also break sink bathroom (resident room number), no injury noted." A psychiatric evaluation was done at the facility on 11/8/11. The psychiatrist reported that the hospital psychiatrist recommended to increase the Seroquel. This was not done due to a request made by Resident #1's family that the resident not be placed on an antipsychotic. The psychiatrist's report indicated that "the patient is having intermittent episodes of agitation and aggressive behavior, the last episode was less than 24 hours ago. . . He is ambulatory and with good muscular strength in both upper limbs and lower limbs." The psychiatrist's treatment plan was as follows: "discontinue Seroquel as the patient's family requested to stop all antipsychotic medications although patient is stable today, he could benefit from continuing the medication," and continue the antianxiety, Ativan 1 mg. at hour of sleep. The 11/14/11 "4 th Day Post Admission Summary" described Resident #1's behaviors of pacing the unit with his belongings and looking for the exit. It was also documented that the resident was "Noted with tendency to hit nursing staff." On 11/18/11 at 3:45 p.m., the nurse documented that the resident was observed pacing and wandering in and out of others rooms, taking their belongings. At 5:15 p.m., he was "standing in front of the exit door shaking and trying to get out. At 8:30 p.m. the resident's family had visited and called for a CNA to come to the room. The resident had removed a light bulb from a fixture and had given it to the family. The resident was kneeling on the floor feeling the baseboard and stated he was fixing it. At 10 p.m.,after seeing the resident's behavior that evening, a resident's family member requested that the resident be put back on the antipsychotic medication. On 11/20/11 at 11:45 p.m. the nurse documented that Resident #1 had wandered into another resident's room and was in the process of disrobing, proceeded to completely undress and sat on the window bed. When questioned by the nurse the resident stated, "This is my room, I'm going to sleep." The nurse indicated that the resident was resistant at first but agreed to be shown his room. There was no documentation in the note to address if another resident was in that bed when Resident #1 sat down on the bed; and if so, the response of that resident was not documented. On 11/21/11, the psychiatrist was updated by phone on the resident's increased agitation. The physician ordered to resume Seroquel 25 mg. twice daily. On 11/22/11 at 12 a.m. the Psychoactive Monitoring Form revealed an entry which indicated that Resident #1 was wandering to other resident's rooms; difficult to re-direct, resisting care and very combative. On 11/22/11 at 3:00 p.m., the IPN indicated that Resident #1 was noted to be agitated and aggressive towards staff. The security guard was called and the resident struck the guard. Despite attempts at redirection, the resident remained agitated and combative. The resident was again sent out to the hospital emergency department. The nurse documented on the Universal Transfer Form on 11/22/11 at 3:30 p.m. the reason for transfer was: "Agitated, aggressive, hitting other residents and the staff, causing harm to others and self, very combative." The resident was returned at 9:45 p.m. with recommendations to follow up with primary psychiatrist. The behavior care plan was updated on 11/22/11 with the following intervention: "Will continue to monitor and continue psych recommendation." The care plan did not include specific interventions as to how the resident was to be monitored. On 11/23/11 the psychiatrist evaluated the resident indicating that Seroquel was started again on 11/21/11 and may need to be increased. Other recommendations were to continue redirecting and monitoring. On 11/24/11 at 10 a.m. the nurse documented, "Resident noted with aggression and agitation. Carrying out the stuffs(sic) on a box, possibly to harm other residents. Interventions not effective. As needed Ativan 1 mg by mouth given." An IPN written by a nurse and dated 11/24/11 documented that Resident #1 was wandering in and out of resident rooms, taking others' belongings and "taking call lights (cords) out of sockets, becoming agitated when attempting to remove from him, allowed to calm and followed, when call light laid down then removed." On 11/27/11 the nurse documented in the Psychoactive Monitoring Form at 3:30 p.m. that the resident paced and wandered into resident rooms, taking call bell cords from rooms. At 8:15 p.m., Resident #1 grabbed at a female resident stating she had his million dollars and he wanted it back. An orderly attempted to redirected the resident without success and the resident struck out at the orderly. An as needed dose of Ativan was given. The care plan was revised on 11/27/11 with the intervention "will continue to monitor and continue psych recommendation." Again, there were no specific interventions on how to monitor the resident to protect himself and other residents from harm. On 11/28/11 at 10:30 p.m., the nurse documented in the Psyoactive Monitoring Form that Resident #1 was placed on 1:1 observation following an "alleged incident" with Resident #2. The resident remained on one to one observation until transferred out of the facility. On 11/29/11 at 9:35 a.m., Resident #1 was transferred out of the facility. The nurse documented at 9 p.m., that Resident #1 was transferred from the acute care hospital to a psychiatric hospital. The surveyor reviewed the medical records of Resident #2 on 12/5/11. Resident #2 was admitted to the facility in 2002 with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment dated [DATE] indicated that Resident #2 had no mood or behavioral concerns, had short and long term memory impairment, responded adequately to simple, direct communication, and was able to make concrete requests. Additionally, under the area of Balance During Transition and Walking, Section G0300, Resident #2 was assessed to require human assistance to stabilize and move from a seated to standing position and transfer from surface to surface, i.e. chair to bed. On 12/5/11 at 10 a.m., the QARN gave the surveyor the completed Resident Incident Investigation concerning the 11/28/11 incident. The resident to resident incident was described as follows in the report. On 11/28/11 at approximately 8:15 p.m. the CNA found Resident #2 "with bruises all over his body." A review of the body diagram noting the location of injuries revealed that the nurse had marked approximately 4 straight lines on the Resident #2's left shoulder area with a description of "multiple purplish/red longated discoloration." In addition, there were markings on the hands, left inner arm, right inner thigh, and bilateral knees. The nurse's statement in the Incident and Accident Report revealed the following: " pt noted with multiple purplish longated (sic), discoloration on left side of back, also on bilateral legs and thighs, both hands and forehead noted with red and purple discolorations." Resident #2 was asked by the nurse how he got bruised. He stated: "The guy by the window (referring to Resident #1) took the cord that you use to call for emergencies and kept hitting me." When asked when? He stated," 3 meals back when I was in bed." When the nurse asked Resident #31, Resident #2's other roommate in the middle bed, what happened to Resident #2, he responded, "Yes. last night, this guy, pointing to Resident #1 in the window bed, took a cord and kept hitting him." The nurse documented in the report that when the Supervisor went to see Resident #1 in the room, Resident #2 warned the nurse, "You better be careful." The statement from the CNA who discovered the bruises, dated 11/28/11 at 8:15 p.m., was obtained. The CNA stated," I was told by the resident (Resident #2) that he was hit by Resident #1 with the call light last night and when I was putting him to bed then saw the bruise all on his body and reported it to the nurse." The reporting 3-11 shift CNA did not say that they saw the bruising first but rather that it was Resident #2 that alerted him first and then the CNA saw the bruising while putting him to bed. Another CNA's statement dated 11/28/11 untimed, revealed that the CNA was called to the room by the nurse to see Resident #2. The CNA stated, "Patient had bruises on his legs arms and head. When we asked the patient who did this to him, patient said, The guy by the window." On 11/29/11 on the 11-7 shift the security guard documented the following: Subject: "Fight in 1 South Wing"; Description of incident: " The nurse from 1 South (RN Supervisor) told me as she was walking out, that there was a fight in 1 South, but it's over now, Resident #2 is going to the hospital and the other resident, Resident #1, is sleeping now, she asked me to monitor the 1 South wing and my nursing staff will do the same." A review of the statements provided by the QARN did not include a statement from the RN supervisor at the time of the reported incident. Statements were obtained from the nursing staff from the previous 24 hours. All the statements concluded that no staff member saw anything out of the ordinary. On 12/5/11 at 10:10 a.m., the surveyor observed the resident to be seated next to the nurses station with a towel over his head. On 12/5/11 at 2:20 p.m., the surveyor spoke with Resident #2. The surveyor asked the resident how he got the bruises. He said, "I don't want to talk about it anymore." The resident was pleasant and continued to speak with the surveyor when the topic was changed. Further review of the medical record revealed that on 11/28/11 at 3:30 p.m. the nurse who reported the 11/28/11 8:15 p.m. incident documented that Resident #2 was, " Noted in room, with towel draped over head, as he wears often." A review of Resident #2's care plan dated 3/28/11 lists under the problem area of Alteration in Mood and Behavior describes the habit of "puts towels on head and refuses personal care." On 12/7/11 at 11 a.m., the QARN provided the surveyor with documentation of an interview with Resident #2 and the social worker (SW) dated 11/29/11. At first when the SW asked Resident #2 what happened he stated he didn't know and continued with a flight of ideas. When the SW asked the resident who hit him he stated, " A man hit me...yes..." On 11/29/11 at 12:20 p.m., Resident #2 was transferred to the hospital emergency department where he "presented with grand mal seizure activity (new onset). An MRI of the brain with negative. Resident #2 was sent back to the facility on seizure precautions. Resident #31, was the roommate of Residents #1 and #2 and a witness to the incident. He was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The resident's 10/29/11 significant improvement MDS indicated the resident had moderately impaired cognition, had clear comprehension, clear speech, and had no behavioral concerns. The activities comprehensive update dated 10/30/11 indicated that Resident #31 is alert and oriented times two and verbally responsive with clear speech. On 12/5/11 at 2:30 p.m., the surveyor approached Resident #31 and asked what had happened in his room on the evening of 11/28/11. He did not answer the surveyor and looked away. On 12/5/11 at 11 a.m. the QARN provided the surveyor with the facility's summary/conclusion of the 11/28/11 incident which included several possibilities to account for the reported incident. One conclusion indicated that the facility did not think that the appearance and location of the bruises were consistent with someone who was beaten with a call cord because they appeared rounded versus linear when assessed by the QARN on 11/29/11 at 9:30 a.m. However, the reporting nurse did document and describe in the incident report that the bruises were "longated." The facility also proposed that the bruising occurred from Coumadin (anticoagulant) treatment rather that caused by being whipped with a cord. The facility did not consider whether the Coumadin treatment may have exacerbated traumatic bruising. A third possibility according to the facility was that the Resident #2 had a seizure and fell to his knees and sustained bruising while trying to get back to bed. However the facility's assessment on the MDS contradicts this conclusion. The MDS the facility referred to describes Resident #2 as needing one person physical assistance for transfers and bed mobility and was not steady when moving from seated to standing position and that the resident was only able to stabilize with human assistance. The facility did not conclude that Resident #1 did actually strike Resident #2 in spite of the fact that Resident #1 had a well documented history from various staff members since his 11/1/11 admission of being delusional, going into other residents rooms, difficulty redirecting, had assaulted both staff and residents, had to be sent out to the hospital on 11/7 and 11/22 for unmanageable behaviors, on 11/24 and 11/27 had been seen by several staff members wandering with call bell cords in his hands, and on the morning after the alleged assault the facility sent Resident #1 to the Crisis Center. On 12/8/11 at 11 a.m., in response to the surveyor's concerns, the Chief Operating Officer stated that the Resident #1 had no history of any resident to resident abuse. However, on 11/22/11 at 3:30 p.m., the 7-3 shift unit nurse documented on the Universal Transfer Form that Resident #1 was "hitting other residents and the staff." The 7-3 shift nurse did not report who these resident/s were and the facility did not investigate the involvement of other residents. 2. On 11/29/11 at 11:30 a.m. during the initial tour, the surveyor observed a resident pacing the hallway and rummaging through a housekeeping cart that was left unattended in the hallway. The nurse identified him as Resident #5 and indicated that he was a wanderer. Resident #5 had [DIAGNOSES REDACTED]. On 11/31/11 at 9:30 a.m., the surveyor observed Resident #5 pacing the hallway. That same day at 11:30 a.m., the surveyor reviewed Resident #5's medical record. The Quarterly MDS dated [DATE] and 10/16/11 assessed Resident #5 as being alert, verbally responsive, with periods of agitation and anxiousness. The Quarterly Assessment Notes dated 10/16/11 further indicated, "Continues to ambulate with steady gait walks on and around the unit picking up and hoarding any items that he sees and taking belongings from peers or staff." A review of Resident #5's Care Plan initiated April 2011 identified his problem behaviors as hallucination, delusions, inappropriate behavior such as pushing, hoarding, taking belongings from peers, going to other residents room. A review of Resident #5's care plan for mood and behavior included the following interventions: Psychiatry Consult, administer psych meds, discourage negative behavior, 1:1 counseling if receptive continue to redirect. On 11/30/11 at 12:30 p.m., the surveyor reviewed an IDCP Progress Notes which revealed that Resident #5 had an altercation with a resident on 6/23/11. A review of the investigation indicated that Resident #5 punched Resident #32 in the eye on the evening of 6/22/11. The facility was unaware of the incident until 6/23/11 at 6:00 a.m., when a Certified Nursing Assistant (CNA) found Resident #32 in bed with a swollen left eye. Resident #32 identified Resident #5 as the perpetrator. On 12/7/11 at 12 p.m. the surveyor interviewed Resident #32 who said that Resident #5 punched him in the eyes. Resident #32 also stated, "He hit me for absolutely no reason." Another IDCP Care Plan Progress Notes dated 7/22/11 revealed that on 6/30/11 at 8 a.m., Resident #5 assaulted a CNA without provocation. Resident #5's medications were reviewed, and Resident #5 was told by the team never to assault anybody again. On 11/13/11 at 6:40 a.m., an orderly observed Resident #5 punch a female resident, Resident #4, in the face and broke her nose. This occurred in the common center area. On 11/30/11 at 11:45 a.m., the facility provided the surveyor with their investigation of the 11/13/11 incident. The facility indicated Resident #5 had no prior altercations with Resident #4, but has had prior altercations with other residents. Under the comment section there was a note dated 11/16/11, " No prior behavior interventions on Resident #5 resulting in physical assault on Res. (Resident) Resident suffered Fx (fracture) nasal bone." The facility failed to provide adequate supervision of the unit and implement interventions to provide a secure environment and prevent protect residents at risk for assault. The surveyor reviewed Resident #5's Care Plan to determine what interventions were instituted following the physical altercation of 11/13/11. There were no measurable objectives in the care plan to indicate how other residents will be protected from Resident #5's behavior. Throughout the survey, the surveyor observed Resident #5 wandering on the unit. On 12/5/11 at 10:30 and 11:15 a.m., Resident #5 entered the chart room, dropped some papers on the desk and left. The chart room is the first room at the beginning of the unit. On 12/6/11 at 1:30 p.m., he entered the chart room, rummaged through some documents on the secretary's desk and left. On 12/8/11, at 1:50 p.m. while 2 surveyors were in the chart room, he entered the room uninvited, picked up some papers from the desk and left. The facility was aware of Resident #5 behavior of wandering, and at risk for further altercation with other residents. However, the facility failed to revise Resident #5's care plan and implement effective interventions to provide adequate supervision to prevent recurrence of resident to resident altercations. The facility indicated on 12/5/11 that Resident #5 was placed on every 30 minutes observation following the incident of 11/13/11. On 12/8/11 at 2:30 p.m., when asked by the surveyor, the facility could not provide any documentation to verify that Resident #5 was currently on every 30 minutes observations. There was no written documentation on the 24 hour report of Resident #5 being on 30 minutes observation. Resident #4 had [DIAGNOSES REDACTED]. During the initial tour on 11/29/11 at 10 a.m., the nurse identified Resident #4 as being argumentative and confused at times. The surveyor observed Resident #4 ambulating on the unit without difficulty. On 11/29/11 at 11a.m., Resident #4 approached the surveyor, and reported that another resident assaulted her without provocation. At 11:30 a.m., the nurse confirmed the allegation and identified the other resident as Resident #5. On 12/1/11 at 9:45 a.m., the surveyor reviewed Resident #4's clinical record. According to nursing documentation's dated from April 2011 to September 2011, Resident #4 was involved in several altercations with various residents while residing at the facility. In some instances Resident #4 was the aggressor. On 2/1/11 at 7:05 p.m., another resident scratched Resident #4's face without provocation. On 6/16/11 at 1:20 p.m., another resident struck Resident #4 in the chest. According to a witness statement the incident occurred in the elevator and was unprovoked. On 6/22/11 at 5:35 p.m., Resident #4 sustained some scratches to her right arm while interrupting a fight. On 7/21/11 at 7:30 a.m. and on 8/17/11 at 7:00 p.m., Resident #4 had an altercation with another resident. On Resident #4 was involved in another altercation. On 11/13/11 at 6:40 a.m., Resident #4 sustained a broken nose during the altercation with Resident #5. On 12/1/11 at 12:30 p.m., further review of the clinical record revealed an IPN dated 11/14/11 at 10:15 a.m. in which the nurse documented, " Resident #4 told Resident #5 to place pen back at center core, Resident #5 threw pen at orderly and hit Resident #4 in the face." Resident #4 continued to be at risk for resident to resident altercations including from Resident #5 who continued to wander throughout the unit. 3. Resident #8 had [DIAGNOSES REDACTED]. During the initial tour on 11/29/11 at 12:30 p.m., the nurse identified Resident #8 as being at risk for falls. On 11/30/11 at 9:55 a.m., the surveyor observed Resident #8 seated in a wheelchair unattended in her room. On 11/30/11 at 10 a.m., Resident #8 self transferred to another chair, her alarm sounded at 10:05 a.m. and a CNA entered there room and assisted Resident #8 back to her wheelchair. The CNA told the resident to stay in her wheelchair. On 12/1/11 at 11:30 a.m., the surveyor reviewed Resident #8' s clinical record. The MDS dated [DATE] and 9/30/11 documented that Resident #8 had short and long term memory problem. On the fall assessment risk dated 12/23/10 Resident #8 scored 10. On the fall risk assessment of 3/21/11 and 9/1/11 Resident #8 received a score of 10 and 14. A score of 10 and higher indicated that a resident is at high risk for falling. Further review of the record revealed that between 2/22/11 and 9/17/11 Resident #8 sustained 8 falls at the facility. A review of a form titled, " Resident/Guest Incident and Accident Report dated 2/22/11 at 1:30 p.m., indicated, "Received sitting on floor in her room." The intervention added was for maintenance to check lock on wheelchair and reminded resident to lock her wheelchair. On 5/1/11 at 6:45 a.m., the resident was found by the nurse from the East Wing by the center core on the floor on her knees next to her wheelchair. On 5/13/11 at 3:00 a.m., the Accident report indicated that ," Staff reported while making rounds found lying on floor. Resident lying on back near entrance door and bathroom ... Laceration to forehead with bleeding, pressure dressing applied." The facility did not know how long Resident #8 had been on the floor. The alarm did not sound. Resident #8 was sent to the hospital and returned the same day with staples on the laceration site. On 6/1/11 at 2:30 a.m., Resident #8 sustained another fall without injury. On 7/9/11 at 7:30 p.m., Resident #8 fell in her room. Resident #8 sustained a laceration to her right eyebrow. Resident #8 was hospitalized from [DATE] to 7/13/11 with [DIAGNOSES REDACTED]. The surveyor asked for the hospital record for review several times, but was not provided with the documentation. The nurse documented in the IPN of 7/27/11 "Yelling continuously, placing self on floor." The surveyor reviewed the documentation with the ADON which stated, "Resident #8 was putting herself on the floor, no incident report was completed." On 7/28/11 at 1:40 a.m., Resident #8 fell in her room, hit her head on the side of the bed and sustained a laceration on top of head, bump on eyebrow and left eye. The resident was admitted to the hospital and diagnosed with [REDACTED]. According to documentation in Resident #8's care plan, Resident #8 required 48 staples to close the scalp laceration. On 9/17/11 at 4:40 a.m., Resident #8 fell in the bathroom and sustained a laceration on her upper lip. Resident #8 was sent to the hospital and diagnosed with [REDACTED]. There was no documentation on the incident report to evaluate the effectiveness of the self releasing lap belt as a fall intervention. On 12/6/11 at 1:30 p.m., the surveyor reviewed Resident #8's care plan initiated 6/11 and noted that a chair alarm was added after the fall of 5/13/11. None of the falls incidents reports indicated that the alarm sounded and alerted the staff of the falls. Other interventions such as self releasing lap belt, floor mat, bed alarm bed in lowest position were not added until 7/28/11, after Resident #8 sustained falls with injuries. On 12/6/11 at 10:30 a.m., the surveyor interviewed the nurse on the unit. The nurse indicated that Resident #8 was at high risk for fall due to her unsteady gait and her behavior. He added that Resident #8 needed constant supervision. At 12:10 p.m. on 12/6/11, the surveyor interviewed the CNA assigned to Resident #8 that day. The CNA told the surveyor that Resident #8 was difficult to redirect and that staff should keep an eye on her at all times. While the facility had identified Resident #8 at high risk for falls, and noted this on the care plan there was no evidence that the facility provided for the safety of Resident #8 when the facility was aware of the resident's self injurious behavior The facility failed to update Resident #8's Care Plan and implement new interventions when existing ones were not effective to prevent falls with injuries. 4. The following deficient practice involves Residents #7, 23 and 26. Resident #7 was a wandering resident; Resident #26 may have been the victim of a possible assault; and Resident #23 was, at the time of the alleged incident, the roommate of Resi

Based on observation, interview, and record review, it was determined that the facility failed to follow their abuse policy by: 1. Not conducting complete investigations of reported physical abuse and failed to clarify conflicting documentation concerning resident behavior. In this instance Resident #2 was assaulted by roommate Resident #1 and the assault was witnessed by the third roommate Resident #31; 2. Not conducting a complete investigation of a possible sexual abuse committed by Resident #7 against Resident #26 as reported by the roommate, Resident #23. The facility failed to clarify conflicting documentation regarding Resident #7's behavior, failed to make a determination if the encounter was consensual and failed to report to the State Agency; and 3. Not coordinating investigations done by security and nursing in order to determine how an elopement, Resident #9, occurred and prevent a reoccurrence, and failed to report this incident to the State Agency as is the facility's policy. These deficient practices involved 7 of 14 residents (Residents #1, #2, #7, #9, #23, #26, and #31) reviewed by the surveyors for possible abuse issues and was evidenced by the following: 1. At 11/29/11 at 10 a.m. the surveyor observed Resident #1 being sent out to a Crisis Center for behavior issues. This was the third discharge to the hospital to address Resident #1's behavior issues, since the resident's facility admission date of [DATE]. The other hospitalization s occurred on 11/7 and 11/22. On 11/29/11 at 9:30 a.m., the surveyor was informed that a Certified Nursing Assistant, (CNA) had observed an injury to Resident #2, the roommate of Resident #1. The surveyor was further informed that Resident #2 had been sent out to the hospital at 12:20 a.m. on 11/29/11 for an injury. On 11/29/11 at 10:05 a.m., the surveyor and the Quality Assurance Registered Nurse (QARN) went to see Resident #2, Resident #1's roommate. The QARNE and the surveyor observed numerous injuries on Resident #2. The surveyor requested to see the facility's investigation of the incident when it was completed. All 3 residents, #1, #2, and #31 lived in the same room. Consistent statements from roommates Residents #2 and #31 to at least 2 staff members during the facility's investigation of Resident #2's injuries revealed that both these residents told the staff that Resident #1 had beaten Resident #2 with a call cord. The visible physical evidence on Resident #2 was consistent with injuries that would have been inflicted with a call cord. Resident #31 even warned the nurse to be careful of Resident #1. There are multiple instances documented in the 1 month that Resident #1 has been in the facility from various staff that Resident #1 was delusional, difficult to redirect, frequently entered other residents' rooms and had assaulted both staff and residents. Documentation from various staff also notes that, on 11/24 and 11/27, Resident #1 was seen carrying call cords he had taken from other resident rooms. In their investigation of the incident the facility concluded, in spite of the information gathered as listed above, that the bruising was from anticoagulant therapy or a fall. The facility did not conclude that Resident #2 was beaten with a call cord as both he and his roommate stated. For further information on this incident refer to F 323. 2. The surveyor reviewed Resident #7's clinical record on 11/29/11 at 12:30 p.m. An Interdisciplinary( IDCP) Care Plan Progress Note dated 11/4/11 documented, " Resident was alleged to be engaged in episodic visits at late nights hours 2-3-4 o'clock having sexual activity (oral sex) with resident (Resident #26) in S(south) 3 .... " Further review of the clinical record indicated that another resident (#23) who was the roommate of Resident #26, the possible victim of inappropriate sexual behavior, had witnessed the incident and reported it. Resident #26 never reported that the sexual encounters had occurred. That same day, 11/29/11, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding the allegation. The ADON indicated he was made aware of the allegation on 11/4/11 first by a Certified Nursing Assistant (CNA), then later by the mother of the roommate, Resident #23, who witnessed the incident. The ADON further stated that he did not document his conversation with the mother. The ADON went on to state that the same day the IDCP team met and made the decision to transfer Resident #7 to another unit. The surveyor asked the ADON to provide the investigation for the alleged abuse. The ADON revealed to the surveyor that the alleged abuse was not investigated nor reported. On 11/30/11 at 1:15 p.m., the surveyor attempted to interview Resident #7 regarding the alleged sexual encounters. Resident #7 refused to answer any questions. On 11/30/11 at 2:00 p.m., the survey Team Leader made facility staff aware of the concern with the alleged sexual abuse and asked the facility to provide the report regarding the above incident. The facility indicated there was no documentation in the chart regarding the possible abuse. The facility further stated that Resident #7 was on Q (every) 30 minutes observation following his transfer to the South Unit on 10/31/11, and will provide any additional information on 12/5/11 that would show Resident #7 did not have the opportunity to wander to another resident room and engaged in any sexual activity. On 12/5/11 the facility provided some documents for review. A review of the 30 minutes observation sheet provided by the facility on 12/5/11 indicated that Resident #7 slept all night during the night of 11/1/11, 11/2/11 and 11/3/11. There was no documentation for 11/4/11. There was no documentation on the 30 minutes observation sheet regarding any wandering behavior. On 12/8/11 at 2:30 p.m., during the pre-exit conference, the facility maintained that Resident #7 had no wandering behavior. On 12/8/11 at 2:45 p.m., the surveyor showed the facility the IDCP Notes dated 10/29/11 to 11/3/11 and the 24 hour report which documented that Resident #7 was up all night, difficult to redirect, wandering into another resident's room. This documentation contradicts the facility's statements to the surveyor. The facility did not have any comment regarding the discrepancy. The facility failed to follow their own policy which stated that all allegations of abuse will be investigated and reported within 24 hours to the administrator. The other involved resident was Resident #26. Resident #26 was identified by the facility as being a male resident currently residing on the North Unit since 11/4/11, the date the sexual activity was first documented. Prior to being transferred to the North Unit, Resident #26 resided on the South Unit and shared a room with Resident #23. The Minimum Data Set (MDS), an assessment tool, identified Resident #26 as being cognitively impaired. On 12/1/11 at 11:30 a.m. the surveyor interviewed Resident #23, who told the surveyor that he witnessed Resident #7 engaged in inappropriate sexual activities with Resident #26 several times. Resident #23 went on to state that he chased Resident #7 out of the room, but that he returned within 1 hour. Resident #23 said he reported the activity to a female Latino staff who told him that she did not care and that since, nothing was done to stop the activities; he reported it again to his mother on 11/4/11 at 8:00 a.m. There is no documentation indicating that Resident #23 advised staff that the sexual activity was occurring. At 12:30 p.m. on 12/1/11 the surveyor interviewed Resident #23 again in the presence of the assistant Director of Nursing. Resident #23 recounted the same story. The ADON confirmed that was the same story that Resident #23 reported to the team 3 weeks ago during the IDCP meeting. On 12/1/11 the surveyor reviewed Resident #26's clinical record. An IDCP Care Plan Progress Notes dated 11/4/11 timed 10 a.m. read, " Team met to discuss allegations by roommate .... that Resident was engaged in oral sexual activity with another resident from south wing. On interview Resident #26 admitted that there were occasions of sexual encounters with another visiting resident." Resident #26 identified this other resident as Resident #7. Resident #26 also stated that Resident #7 "bothered my thing." Resident #26 further stated that he was "not going to continue this act .... " Resident #26 admitted to some sexual encounters with Resident #7. Resident #26's roommate witnessed the sexual encounters and reported it. The facility indicated that the incident was reported to the ADON and the Social Worker on 11/4/11. However, the facility failed to investigate the allegation of inappropriate sexual behavior to determine if it was consensual. The facility also failed to report the incident to the State Agencies as outlined by their abuse policy. The surveyors attempted several times to interview Resident #7 and #26 and neither resident would speak to the surveyors concerning the sexual activity. For further information concerning this incident refer to F323. 3) Resident #9 had [DIAGNOSES REDACTED]. A review of the resident's record on 11/29/11 at 12:30 p.m. revealed a nurse's note of 5/23/11 at 6:30 p.m. indicating that the resident had an incident of leaving the facility. The nurse's note also indicated that the resident was visualized by a security guard at a stop sign within the Lincoln Park Care Center (LPCC) property. On 12/5/11 at 2:28 p.m., the ADON gave the surveyor the Investigation Report of 5/23/11. This report indicated that the resident went out during smoking time and was found walking outside the building close to the stop sign. The facility provided the survey team with an investigative report and statements from employees. The facility was unaware that the resident was out of the building until an employee saw him by a stop sign by the road. On 12/8/11 at 10:30 a.m. the Chief Operating Officer (COO) told the survey team that she watched the facility security tape and the security guard had left the employee gate open. The COO said that the resident had left the facility through the employee gate. The COO also gave the team a statement from the Director of Security that said that the security guard who was assigned to secure the employee entrance on the 3-11 shift on 5/23/11, had left the employee entrance gate open allowing Resident #9 to walk out of the open gate. The statement also said that the security guard was suspended pending investigation and as part of the investigation, the Director of Security reviewed the video tape revealing the above. The security guard was terminated on 5/26/11. This statement was not attached to the investigation report given to the surveyor. This information was different from the information that had been previously given and told to the surveyor by the ADON. This information is crucial to the investigation of how Resident #9 was able to get out of a secure building and it was not incorporated into the investigation. Although the facility was aware of the resident's elopement from a locked, fenced and supervised area they failed to report it to the Department of Health and Senior Services as per the regulations. By not incorporating the investigation conducted separately by security the facility also failed to conduct a complete, thorough investigation which is necessary to prevent another occurrence. For further information on this incident refer to F323 N.J.A.C.8:39-4.1(5)