Every finding on record at River Front Rehabilitation and Healthcare Center

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer three of eight residents (Residents (R) 80, R17, and R86) reviewed for pneumonia vaccinations, and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards out of 61 residents sampled. This practice had the potential to increase the risk for residents to contract pneumonia. In addition, the facility policy did not reflect current CDC recommendations. 1. Review of R80's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident on 02/21/22. The resident was over the age of 65 at the time of his/her admission. Review of R80's EMR titled Immunization located under the Immun (Immunization) tab, indicated that the resident received the Pneumovax 23 vaccine on 09/05/23. There was no evidence in the clinical record that the resident and/or his/her representative were given the opportunity to receive the PCV20 or the PCV21. 2. Review of R17's EMR titled admission Record located under the Profile tab, indicated the facility admitted the resident on 11/13/19. The resident turned [AGE] years of age while living at the facility.Review of R17's EMR titled Immunization located under the Immun tab, indicated that the resident received the Pneumovax23 vaccine on 09/05/23. There was no evidence in the clinical record that the resident and/or his/her representative were given the opportunity to receive the PCV20 or the PCV21. 3. Review of R86's EMR titled admission Record located under the Profile tab, indicated that the facility admitted the resident on 02/26/21. The resident turned [AGE] years of age while living at the facility. Review of R86's EMR titled Immunization located under the Immun tab, indicated that the resident received the Pneumovax23 vaccine on 10/04/23. There was no evidence in the clinical record that the resident and/or his/her representative were given the opportunity to receive the PCV20 of the PCV21. During an interview on 01/15/26 at 11:16 AM, the Regional Nurse Consultant and the Infection Preventionist (IP) went through the EMRs for R20, R17, and R86 and both verified that the three residents had received only the Pneumovax23 and did not receive the PCV13 vaccine. Review of the CDC website titled PneumoRecs VaxAdvisor App (Application) for Vaccine Providers dated 01/15/25 indicated . Administer PCV15, PCV20, or PCV21 for all adults 50 years or older . Who have never received any pneumococcal conjugate vaccine . Whose previous vaccination history is unknown . Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both . PCV13 [but not PCV15, PCV20, or PCV21] at any age and . PPSV23 at or after the age of [AGE] years old. NJAC 8:39-(i)

Based on interviews, record reviews, and review of the facility's policy, the facility failed to ensure one of one resident (Residents (R) 17), out of a survey sample of 61, was afforded the right to participate in their care planning process. This failure placed the residents at risk of not being aware of the goals and outcomes of their care and for their care plan not to be person centered.Findings include:Review of R17's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident on 11/13/19.Review of R17's EMR titled social services Progress Notes dated 05/23/25, located under the Prog (Progress) Notes tab, revealed that the resident attended a care conference. There was no further evidence in the clinical record that indicated the resident was invited to subsequent care conferences after this date.Review of a document provided by the facility titled IDT [Interdisciplinary Team] Meeting Information, dated 08/20/25, failed to show that R17 was invited to his/her care conference. Review of R17's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 11/07/25, located under the MDS tab, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed the resident was cognitively intact. Review of a document provided by the facility titled IDT Meeting Information, dated 11/20/25, failed to show that R17 was invited to his/her care conference.During an interview on 01/12/26 at 9:41 AM, R17 stated that he/she had not been invited to care plan meetings for a while.During an interview on 01/14/26 at 9:08 AM, the Social Services Director (SSD) stated there was a period of time that the EMR was not working, and the facility had used paper copies of the care conferences. During an interview on 01/14/26 at 12:22 PM, the SSD provided the documents for the IDT meetings. The SSD stated that he/she would notify the residents verbally, if the residents were their own responsible party, to invite them to their care conferences. SSD confirmed there was no evidence on the IDT Meeting documents that showed R17 was invited to his/her care conference or that the resident participated in his/her care conference. The regional nurse consultant was also present during this interview. Review of a facility policy titled Care Plans, Comprehensive Person-Centered, dated 09/25, indicated . Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to.participate in the planning process.participate in establishing the expected goals and outcomes of care. participate in determining the type, amount, frequency and duration of care. NJAC 8:39-4.1(a)3NJAC 8:39-11.2(e)

Based on observation, record review, interview, and review of the facility's abuse policy, the facility failed to ensure one of 42 sampled residents (Resident # 62) was free from resident-to-resident abuse from Resident # 52. This resulted in harm when Resident # 52 hit Resident # 62 causing a swollen lip and two teeth being knocked out. Findings include: 1.Review of the admission Record located under the Profile tab in the Electronic Medical Record (EMR) identified Resident # 62 was admitted on [DATE], with diagnoses that included muscle wasting and atrophy; other specified mental disorder due to known physiological condition; generalized anxiety disorder; and major depressive disorder.Review of the Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/07/25, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating Resident # 62 was moderately cognitively impaired.2.Review of the admission Record located under the Profile tab in the EMR identified Resident # 52 was admitted on [DATE], with diagnoses that included schizoaffective disorder, bipolar type; recurrent depressive disorder; and anxiety disorder.Review of the Quarterly MDS located under the MDS tab in the EMR with an ARD of 12/05/25, revealed a BIMS score of two out of 15 which indicated Resident # 52 was significantly cognitively impaired.Review of the Facility Reported Incident Investigation provided by the facility and dated 11/20/25, revealed a Certified Nursing Assistant (CNA)11 witnessed Resident # 52 and Resident # 62 seated at the nurses' station talking. Resident # 62 touched Resident # 52's shoulder which prompted Resident # 52 to stand and strike Resident # 62 in the face. Resident # 62 suffered a swollen upper lip and had two front teeth knocked out. The residents were immediately separated. One to one supervision was implemented for Resident # 52 prior to being transferred to the CRISIS emergency room for an evaluation. Upon return, Resident # 52 remained on one-to-one monitoring until it was removed on 01/12/26.During an interview on 01/13/26 at 1:03 PM, Resident # 62 stated they remembered the incident and that he/she lost teeth. Resident # 62 denied being afraid of any resident including the assailant stating, Everyone here, in my nursing home, are my friends, they love me and take care of me.During an interview on 01/14/26 at 3:22 PM, Resident # 52 stated they had not had any incidents with other residents, I haven't hit anyone. Resident # 52 denied striking Resident # 62 in the face.During an interview on 01/14/26 at 3:11 PM, CNA # 11 (witness) stated, Resident # 52 and Resident # 62 usually sat together at the nurses station talking. Resident # 52 said he/she thought Resident # 62 hit him/her so he/she hit Resident # 62 back.During an interview on 01/13/26 at 1:14 PM, Licensed Practical Nurse (LPN #4), stated that Resident # 52 was generally calm, had no previous behaviors, and We just keep his/her routine the same and he/she does well. During an interview on 01/13/26 at 3:23 PM, the Social Services Director (SSD #1) stated that neither resident had behavior concerns prior to the incident. During an interview on 01/15/26 at 11:00 AM, the Psychiatric Nurse Practitioner (PNP #1) stated they had kept Resident # 52 on the one-to-one supervision to ensure he/she did not become aggressive with a resident again. Resident # 52 was removed from one-to-one supervision on 01/12/26.During an interview on 01/14/26 at 8:47 AM, the Physician's Assistant (PA #1), revealed he/she was the PA for both residents. Resident # 52 had no prior behaviors and has had none since the stated incident. Resident # 62 was assessed the next day, by PA #1, and had no recollection of the incident, denied being afraid of anyone, and denied having any pain.Review of the facility's Abuse Prevention and Reporting policy and procedure, with a revision date of 05/20/23, and a review date of 09/14/23, revealed Residents of [name redacted] will be protected from abuse, neglect, mistreatment, or misappropriation of property in accordance with State and Federal Regulations. NJAC 8:39-4.1(a)

Based on observation, record review, and interview, the facility failed to ensure that one of one resident (Resident (R) 41) reviewed for vision out of a total sample of 61 residents had an appointment made for cataract removal. This failure had the potential for the resident's vision to decline. Findings include:Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/25, located in the EMR under the MDS tab revealed R41 was admitted to the facility on [DATE]. The Brief Interview for Mental Status (BIMS) revealed a score of 14 out of 15 indicating R41 was cognitively intact. Review of R41's Physician Orders located in the EMR under the Orders tab revealed R41 was seen on 05/27/25, by an Optometrist and an order was written to schedule R41 for Cataract surgery at an outside facility.Review of R41's Progress Notes located in the EMR under the Progress Notes tab revealed the Unit Secretary had documented a phone call on 06/01/25, to an outside facility to schedule a cataract removal surgery for R41. The appointment was denied due to R41's weight of 374 pounds (lbs.). There was no evidence of any other attempts to locate another outside facility that could accommodate R41's cataract surgery.During an interview on 01/12/26 at 1:30 PM, R41 reported he/she could not see, and needed to see the Doctor. During an interview on 01/12/26 at 2:40 PM with Licensed Practical Nurse (LPN) revealed I have been calling other facilities, ever since he/she was denied at the one facility and no one will accept him/her. When asked about documentation, he/she stated, I don't actually make the calls the Unit Secretary does. During an interview on 01/12/26 at 4:40 PM with the Director of Nursing (DON) revealed he/she was unaware an appointment was needed for R41.The Unit Secretary was on vacation during the survey and unable to be contacted. NJAC 8:39-27.1(a)

Complaint # : 185875 Based on observations, interviews, record reviews, and policy reviews, the facility failed to ensure that resident rights were respected for residents who smoke and/or desire to go outside the facility. Findings include:1. Review of the 01/2025 policy titled Smoking Policy - Residents revealed This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation 1. Prior to, and upon admission, residents are informed of the facility's smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences.2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building.Electronic cigarettes are permitted in designated areas only. Smoking is not allowed inside the facility under any circumstances.3. Oxygen use is prohibited in smoking areas.4. Metal containers, with self-closing cover devices, are available in smoking areas.5. Ashtrays are emptied only into designated receptacles.6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes:a. current level of tobacco consumption;b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.);c. desire to quit smoking; andd. ability to smoke safely with or without supervision (per a completed Say' Smoking Evaluation).e. Smoking Agreement between the facility and the resident. During the Resident Group Interview on 09/03/25 at 1:00 PM with 11 residents (Resident (R) 12, R17, R18, R19, R20, R21, R22, R23, R24, R25, and R26) who were identified as alert and oriented, it was stated that no one is allowed to go outside unless you're a smoker and that is only three times a day for twenty minutes. The residents said non-smokers can go outside twice a day during an activity for thirty minutes. All other times, the door to the enclosed patio is locked and has to have a code. a. Review of R21's admission Record, located under the Profile tab in the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses that included anxiety disorder and depression. Review of the 05/08/25 Smoking Evaluation, provided by the Administrator, revealed R21 preferred to smoke in the morning, afternoon, and evening. R21 was assessed to require no supervision. A care plan, dated 06/25/25, noted the resident liked to smoke and would be monitored for compliance. b. Review of R23's admission Record, located under the Profile tab in the EMR revealed the resident was admitted on [DATE] with diagnoses that included muscle wasting and atrophy and major depressive disorder. Review of the 02/10/25 Smoking Evaluation, provided by the Administrator, revealed R23 preferred to smoke in the morning, afternoon, and evening. R23 was assessed to require no supervision. A care plan, dated 06/16/25, noted the resident liked to smoke and would be monitored for compliance. c. Review of R32's admission Record, located under the Profile tab in the EMR revealed the resident was admitted on [DATE] and had diagnoses including peripheral vascular disease and adjustment disorder with depressed mood. Review of the 01/21/25 Smoking Evaluation, provided by the Administrator, revealed R32 preferred to smoke in the morning, afternoon, and evening. R32 was assessed to require no supervision. A care plan, dated 11/16/22, noted the resident liked to smoke and would be monitored for compliance. d. Review of R33's admission Record, located under the Profile tab in the EMR revealed the resident was admitted on [DATE] with diagnoses that included diffuse traumatic brain injury, depression, and anxiety disorder. Review of the 12/02/24 Smoking Evaluation, provided by the Administrator, revealed R33 liked to smoke in the morning and afternoon. R33 was assessed to require a smoking apron and someone to light and extinguish his cigarettes. Observation of the smoke break on 09/04/25 at 4:00 PM revealed two staff from the Activity Department were responsible for handing the residents their cigarette and lighting it. The residents were permitted two cigarettes, in twenty minutes. At the twenty minute timer, the Activity Director clapped her hands and stated, That's it, everybody inside. During an interview on 09/04/25 at 4:05 PM, R32 stated, It would be nice to have three cigarettes. We only get two. I tried to ask for more [cigarette] but they don't pay attention. One more [cigarette] at 7:30 PM or 8:00 PM would be great. During an interview on 09/04/25 at 4:07 PM, R33 stated, I would like more[cigarettes], but they don't let us. During an interview on 09/04/25 at 4:09 PM, R21 stated, I would like more than three smoke breaks, more than twenty minutes. We can only have two cigarettes in twenty minutes. It's like you have to rush just to smoke, it's not relaxing at all. I would like to have a cigarette before I go to bed to be calm and relaxed. During an interview on 09/04/25 at 4:12 PM, R23 stated, I would like more[cigarettes], more time, not to be so fast. During an interview on 09/04/25 at 4:21 PM, the Pavillion 1 Unit Manager (PAV1UM) said there is always two activity staff on the patio and a nurse to help monitor. During an interview on 09/04/25 at 4:15 PM, Recreation Aide (RA) 1 and RA3 said they had to have a nurse during the smoke breaks because If they fall down, we can't pick them up.When asked about the non-smoking residents, RA1 and RA3 said They only come out twice a day to use the patio, with staff, at 11:30 AM and 2:30 PM. When asked why the residents could not go out onto the enclosed patio at other times, RA1 and RA3 said I don't know. During an interview on 09/04/25 at 4:28 PM, the Director of Nurses (DON) stated, I have to defer to activities because they have the key to this door (exiting out onto the designated smoking area), when asked if an alert an oriented resident wanted to go onto the patio, by themselves, are they allowed to go? The DON stated, They can ask staff, or they can go out with the activity staff. During an interview on 09/04/25 at 4:40 PM with the Administrator, DON, and Regional Nurse Consultant, the Administrator said the residents were not able to go onto the enclosed patio except during the designated time as it was a safety concern. When asked to explain safety concern, the Administrator stated, Well, someone might fall, we need to protect them. When asked about residents who did not smoke and if there was a desire to go outside, were they allowed? The Administrator said, Well they can go out during the outside activity. Review of the September 2025 Activity Calendar revealed none of the activities were identified to be conducted outside. 2. Review of the facility's Facility Responsibilities Policy reviewed 02/2025, indicated, 1. Resident Rights. The resident has a right to a dignified existence, self-determination, and communication and access to persons and services inside and outside the facility; and a. The facility must treat each resident with respect and dignity; and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Observations of 17 residents smoking in the facility's smoking area on 09/04/25 between 1:00 PM and 1:21 PM revealed the residents were supervised by activity staff, the smoke time allowed was 20 minutes, and each resident was allowed only two cigarettes during the 20 minute smoke time.a. Review of R18's admission Record, dated 09/05/25 and found in EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included hypertensive heart disease. Review of R18's annual MDS assessment with an Assessment Reference Date (ARD) of 06/27/25 and found in the EMR under the MDS tab, indicated a BIM) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R18's Smoking/Nicotine Devices Assessment, dated 09/04/25 and found in the EMR under the Assessment Tab, revealed R18 was a smoker and revealed R18 preferred to smoke in the morning, afternoon and evening. During an interview conducted with R18 on 09/04/25 at 4:00 PM, R18 stated that she/he was allowed to smoke three times per day at 9:30 AM, 1:30 PM, and 4:00 PM, that each smoke time was supervised by staff and was in the outside area next to the first floor dining/activity room, that the smoke time allowed was 20 minutes, and that each resident was allowed only two cigarettes during each smoke break. R18 would like to be able to smoke more than two cigarettes at a time if she/he chose to and would like to be able to smoke after dinner and/or before bed. R18 stated there were not offered smoke times after 4:00 PM because the activities staff was responsible for supervising smoking and activities staff left for the day, each day, at 5:00 PM. R18 stated the smoking area was locked after the activities staff left for the day and residents did not have access to the area after that time. b. Review of R26's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included osteomyelitis and history of falls. Review of R26's admission MDS assessment with an ARD of 08/18/25 and found in the EMR under the MDS tab, indicated a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. Review of R26's Smoking/Nicotine Devices Assessment, dated 08/13/25 and found in the EMR under the Assessment Tab, revealed R26 was a smoker and revealed R26 preferred to smoke in the morning, afternoon, evening and at night. During an interview with R26 on 09/02/25 at 4:15 PM, R29 confirmed residents could smoke three times per day for 20 minutes each time and were allowed to have only two cigarettes at each smoke time. R29 stated she/he would like to smoke after dinner, but was not allowed to. R29 further stated she/he had cravings for cigarettes at night because the time between the 4:00 PM smoke time and the 9:00 AM smoke time each following morning was too long. c. Review of R27's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included paraplegia secondary to a spinal cord injury. Review of R27's admission MDS assessment with an ARD of 07/15/25 and found in the EMR under the MDS tab, indicated a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. Review of R27's Smoking/Nicotine Devices Assessment, dated 06/04/25 and found in the EMR under the Assessment Tab, revealed R27 was a smoker and revealed R27 preferred to smoke in the morning, afternoon, and evening. During an interview with R27 on 09/04/25 at 4:30 PM, R27 stated, Why can't we (residents) be outside? Why can't we go outside at leisure? R27 confirmed she/he was only able to go outside to smoke three times daily for 20 minutes and stated she/he would like to be able to go outside at leisure but was not allowed to go outside at any other time than the three 20 minute smoke times. R27 stated, I might not even want three cigarettes during the day.maybe I just want to go outside. d. Review of R28's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included history of traumatic brain injury. Review of R28's admission MDS) assessment with an Assessment Reference Date (ARD) of 07/08/25 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (which indicated the resident was cognitively intact.Review of R28's Smoking/Nicotine Devices Assessment, dated 07/02/25 and found in the EMR under the Assessment Tab, revealed R28 was a smoker and revealed R28 preferred to smoke in the morning, afternoon, and evening. During an interview conducted with R28 on 09/04/25 at 4:00 PM, R28 confirmed she/he was allowed to smoke three times per day, the smoke time allowed was 20 minutes, and she/he was allowed only two cigarettes during each smoke break. R28 stated she/he would like to be able to smoke more than two cigarettes at a time and she/he would like to be able to smoke after dinner and/or before bed. R28 stated there were not offered smoke times after 4:00 PM, and so smoking in the evening/at night was not an option. e. Review of R29's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included osteoarthritis and chronic viral hepatitis. Review of R29's quarterly MDS) assessment with an ARD of 08/08/25 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R29's Smoking/Nicotine Devices Assessment, dated 12/02/24 and found in the EMR under the Assessment Tab, revealed R29 was a smoker and revealed R28 preferred to smoke in the morning and the afternoon. During an interview with R29 on 09/02/25 at 4:10 PM, R29 confirmed residents could smoke three times per day for 20 minutes each time and were allowed to have only two cigarettes at each smoke time. R29 stated she/he would like to smoke after dinner, but was not allowed to. R29 further stated she/he did not understand why residents were only allowed to have two of their cigarettes at each smoke break since the cigarettes were the property of each resident. NJAC 8:39-27.1 (a)

Complaint #: 185875 and 182189Based on observation, interviews, record review, and policy review, the facility failed to ensure the residents' environment remained clean, comfortable, and homelike for three of the three floors (first, second, and third floors). Specifically, the facility failed to provide overall facility cleanliness; clean and repair resident wheelchairs, electric wheelchairs, and geri chairs; repair scraped and scuffed air conditioning units; clean ceiling vents; clean and repair rusty and dirty door jams; provide ceiling vent covers in the shower rooms; and provide window screens that were without rips and tears. Findings include:Review of the facility's 11/2024 Maintenance Rounds Policy and Procedure, provided by the MD, read It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. l. The Director of Maintenance Services will perform routine inspections of the physical plant using the Maintenance Checklist. 2. The Administrator, or designee, will perform random inspections of the physical plant using the Maintenance Checklist. 3. All opportunities will be corrected immediately by maintenance personnel. 4. The facility shall establish quality/compliance thresholds as a benchmark for QA (Quality Assurance) purposes. 5. Data recorded of the Maintenance Checklist will be compared to established thresholds, and action plans will be generated as needed. 6. All Maintenance Checklists will be filed in the Director of Maintenance's office and retained for a minimum of three years. Review of the facility's 11/2024 Cleaning and Disinfection of Environmental Surfaces Policy and Procedure, provided by the ED revealed Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSTIA [OSHA] (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. Review of the 11/2024 facility Cleaning and Disinfecting Residents' Rooms Policy and Procedure, provided by the ED, revealed The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. 1. Observations of the third floor on 09/04/25 at 11:33 AM, revealed the following:The Pavillion 3 Unit Manager (PAVIIIUM) said there were 57 residents on the third floor.a. Observations of the two hallways noted broken room number signs outside resident rooms; unidentified spills, drips, and general unclean walls.b. The floor in R11's room was very sticky. The resident's family member (FM1) said, It's often like that, I just try to ignore it.c. There was an approximately 6-inch diameter hole in the wall near the air conditioning unit. The window screen had holes along the bottom of the screen which could allow pests inside. The overbed table had the edging falling off three of the four sides. The dresser doors and end table doors were broken and hanging.d. Two Geri chairs, an electric wheelchair, and a wheelchair had armrests which were worn, torn, and generally dirty.e. The end cap on the radiator across from room [ROOM NUMBER] was missing.f. R34's Geri chair had no padding on the entire length of the right arm. The wood and screws were exposed. The seat of the Geri chair was observed to have a large patch of xx missing, approximately 7x8 inches. When asked about the chair, the Activity Director (AD), providing drinks and snacks to the residents, stated, (R34) picks it. The AD was not able to state if any alternatives to picking at the arm rest or seat had been implemented for R34. Observations of the second floor on 09/04/25 at 12:16 PM, revealed the following:a. The shower table was dirty on the edges and had a mesh tube running the length of the table that was noted to have a heavy build up of dark dirt and grime.b. There was no ceiling vent cover above the shower table.c. The air conditioning unit, in R14's room, was noted to have a rusty grate and emitted little cool air. Two individual fans were noted to have a buildup of dust and dirt on the blades and covers.During a Group Interview on 09/03/25 at 1:00 PM with eleven alert and oriented residents (Resident (R) 12, R17, R18, R19, R20, R21, R22, R23, R24, R25, and R26), the following verbalizations were made:a. The equipment, including wheelchairs and shower chairs, is dirty.b. Resident bathrooms and walls need to be cleaned.c. Shower room walls and curtains need to be cleaned.d. There are many flies in the facility and ants near the nurses' stations. On 09/05/25 at 9:27 AM, a tour of the facility was conducted with two surveyors, the Maintenance Director (MD), Environmental Director (ED), Regional [NAME] President of Environmental Services, and the Administrator to identify the above concerns to the management staff. Following the facility tour on 09/05/25 at 10:20 AM, the ED stated, When I came, 10 months ago, there was no system in place to clean rooms, floors, halls, etc. The discoloration on the walls is most likely splatter from spraying bleach. Following the facility tour on 09/05/25 at 10:30 AM, the MD stated, This is my fourth week in the facility, I appreciate the extra eyes. We can get this all fixed in time. Review of the undated Hallway Duty List, provided by the ED, noted areas to be cleaned as well as resident rooms, however no specifics were identified as to what that involved. An undated Curtain Wash Schedule was provided for resident rooms only. An undated Shower Room Cleaning form listed the following to be completed every two to five days: Clean shower bed, clean shower chair, wipe handrails, clean walls, wash shower curtains, check sharps box, pull trash, and scrub floors. Review of the Wheelchair Cleaning Log from 01/25 - 08/25 noted wheelchairs were cleaned every three months. Review of the Maintenance TELS log, provided by the MD, noted facility checks to be completed, none of which was listed above. 2. During an initial tour conducted of the facility on 09/02/25 from 11:00 AM - 11:30 AM, the following concerns were noted related to the facility physical environment: Walls in common areas such as hallways and day areas and in resident rooms on all three floors/units in the facility were scuffed, dirty (with brown stains and light colored streaks).Floors in resident rooms and the common hallways on all three units were extremely sticky and the floors were grimy and dirty in corners and against baseboards throughout the units.Door frames at resident room and common room entries were dirty, stained and peeling on all three floors/units.Door numbers were partially or completely missing for many of the resident and common rooms throughout the facility.Trash a debris was observed on floors throughout all three floors/units, but particularly on the second and third floor units.The was a strong urine odor on the second and third floors/units at the lower number end of each hall.Heating/air conditioning registers in resident rooms and common areas on the second and third floor units were dirty and many were broken. During a group interview with 11 residents, including the Resident Council President and Resident Council [NAME] Present, conducted on 09/02/25 at 1:00 PM, the group reported facility bathrooms (in resident rooms) were nasty (dirty), the facility walls were very dirty and needed to be cleaned, the toilet in the hallway bathroom on the second floor had been broken and unusable for four days, shower rooms throughout the facility were dirty, floors throughout the facility were always sticky, and window screens throughout the facility were broken. During a tour conducted with the Maintenance Director, the Director of Housekeeping and Laundry, the [NAME] President of Environmental Services, and the Administrator on 09/05/25 from 10:30 AM - 11:20 AM, all four staff members confirmed the above documented environmental concerns. NJAC 8:39 -31.8(10)NJAC 8:39 -31.4(a)(f)

Complaint # : 178254 and 179036 Based on observations, record review, and interviews, the facility failed to ensure the ceiling vents, ice machine vent, and equipment were kept clean and/or in good repair. The failure had the potential to affect 149 of 153 residents who received meals prepared in the facility kitchen. Findings include:During an inspection of the kitchen on 09/04/25 at 8:45 AM, along with the Dietary Director (DD), the following was observed:a. Three of the insulated food carts were checked for door closure. Two failed to latch and a third cart had no latch on one of the doors.b. The ceiling vent located at the end of the prep table, next to the oven/stove, had a heavy buildup of a black substance.c. The ceiling vent above the prep table had a heavy buildup of a black substance.d. The vent on the outside of the ice machine had a black substance that came off one. The vent on outside of ice machine had black substance that came off on my finger when touched.f. The tray line table, equipped with rollers to allow the trays to move easily, had missing rollers. The table was observed to have a piece of cardboard taped to the sides of the table with duct tape. The duct tape was identified to be tattered and rolled on the edges, making it an uncleanable surface.g. The prep table, located behind the plate warmer, was observed with significant rust on the legs, shelf, and edges of the table.h. A portable stand fan, located next to the oven, was observed blowing on prep table, The fan had no front cover, the blades were exposed, and had a build up of dust and grime. During an interview on 09/04/25 at 8:58 AM, the DD stated, That's a good question, when asked whose responsibility it was to clean the vents. During a tray line observation on 09/04/25 at 12:00 PM, the above conditions were identified to the Regional Food Service Director (RFSD). The RFSD was unable to clarify who was responsible for cleaning the vents, fixing the rollers on the tray table, removing the rust from the prep tables, cleaning the fan and putting a front on the fan to cover the blades. Review of a cleaning schedule, dated Week of 8/25-8/30, provided by the RFSD and the DD on 09/05/25 at 12:02 PM, revealed there were no cleaning job for the vents, ice machine, or the floor fan. The RFSD said they were going to have the Maintenance Director (MD) fix the latches on the insulated food carts. There was no evidence that the insulated food carts had been identified to require repairs prior to 09/05/25. A Policy and Procedure for kitchen cleaning was not provided prior to the exit on 09/05/25 at 3:30 PM. NJAC 8:39-17.2(g)

Complaint # : 185875 Based on record review, observations, staff interviews, and review of facility policy, the facility failed to ensure an effective pest control program within the facility. Flies were observed in multiple areas of the building during the complaint investigation process. This failure created the potential for cross contamination related to the fly infestation. A total of 34 residents were reviewed in the sample. Findings include:Review of the facility's Pest Control Policy dated 11/2024 revealed, Our facility shall maintain an effective pest control program. 1. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Review of the facility's pest control logs, dated 06/01/25 through 09/05/25, revealed multiple entries indicating flies and/or cockroaches/water bugs had been reported on all three of the facility units during that time period. During the initial tour of the facility on 09/02/25 from 11:00 AM - 11:30 AM, at least 15 flies were observed flying about on the third floor unit, a very large dead roach was observed laying upside down in the entry to room [ROOM NUMBER] on the second floor unit, at least 10 flies were observed flying about on the second floor unit, and four flies were observed flying about on the first floor unit.During a tour of the facility on 09/03/25 from 10:10 AM - 10:45 AM, two flies were observed flying about and around the non-interviewable resident in room [ROOM NUMBER]-B.During a tour of the facility with the Maintenance Director (MD), the Director of Housekeeping and Laundry, the [NAME] President of Environmental Services and the Administrator on 09/05/25 from 10:30 AM - 11:20 AM, multiple flies were observed flying about on all three floors of the facility.During the group interview conducted with 11 residents, including the Resident Council President and Resident Council [NAME] President, on 09/03/25 at 1:00 PM, the group unanimously indicated flies were an ongoing problem in the building and the residents stated they also frequently saw large black water bugs in the facility in common areas as well as their individual rooms. One resident stated she/he had just seen a large black water bug in his room the previous night. Three residents confirmed they had seen flies in the building on the day of the interview. The residents further indicated ants were sometimes a problem on the second floor unit around the nurse's desk. All of the residents confirmed the pests were bothersome to them.During an interview with Certified Nursing Assistants (CNA)3 and CNA4 on 09/03/25 at 4:45 PM, both confirmed they had recently seen ants around the second floor nurse's desk. During an interview with the Director of Housekeeping and Laundry and the [NAME] President of Environmental Services on 09/05/25 at 1:33 PM, both confirmed the observation of multiple flies on all three units of the facility during the tour conducted on 09/05/25. The Director of Housekeeping and Laundry confirmed he had received recent reports of flies in the facility and stated he was aware of sightings of water bugs in the facility. He stated all facility staff was expected to document sightings of pests in the pest control books kept on each unit and he stated the pest control company was in the facility every Friday. He stated the pest control company provided pest control based on reports of pests received during the week prior to each visit.During an interview with the Administrator on 09/05/05 at 2:00 PM, she stated her expectation was the facility should be free of pests. N.J.A.C. S 8:39-31.5

Complaint # 2587860 and 187900Based on review of facility policy, record review, and interviews, the facility failed to ensure timely reporting of allegations of potential exploitation and/or abuse to the State Agency for four Sampled Residents (Resident (R ) R1, R2, R15 and R16) out of a total sample of 34 residents. This failure created the potential for this and other residents to experience further exploitation and/or abuse. Findings include:Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy dated most recently reviewed in 09/2024 read, in pertinent part, It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion misappropriation of resident property, or exploitation; and G. Reporting and Response: The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property , are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. 1. Review of R1's admission Record, dated 09/05/25 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included dementia and history of falls. Review of R1's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/06/25 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of four out of 15 (which indicated the resident was severely cognitively impaired). The document indicated Family Member (FM1) was the resident's Responsible Party (RP). Review of R1's Progress Notes, dated 07/02/25 and found in the EMR under the Notes Tab, 30 Day discharge: Resident (R1) and family served 30-day discharge notice due to non-payment. Letter mailed via mail and certified mail to (Resident and FM2's address). Letter also mailed to Ombudsman, DOH (Department of Health) and Provider. Resident to be discharged on 07/31/25. Review of R1's Progress Notes, dated 07/18/25 and found in the EMR under the Notes Tab, Administrator and Business Office Manager met with (Resident's Family Member (FM2)), to discuss (R1's) discharge from the facility. It was once again explained to (FM2) that due to non-payment of monies due to facility (R1) received a 30-day discharge notice. It was reiterated that the Facility has tried to work with the family on several occasions, but family continues to refuse to disclose where assets were spent and have not paid off remaining balance. (FM2) was unable to provide answers to those questions and stated that he would try to provide us with additional information at the beginning of the following week. (FM2) was reminded that there is less than 2 weeks remaining before his grandmother is scheduled to be discharged . Review of R1's Progress Notes, dated 07/31/25 and found in the EMR under the Notes Tab, revealed Administrator and BOM (Business Office Manager) met today with FM1, FM2, as well as representatives from the State of NJ (New Jersey) Ombudsman's Office. Attorney for the Ombudsman's Office joined via telephone. All issues and barriers for discharge were discussed. The meeting concluded with 3 choices for the family. 1) pay the facility monies owed as well as the difference between the resident's income and facility rates and the resident can stay. 2)Find another safe accepting facility for the resident to discharge to. 3)Take the resident home. (FM1) stated that she will be in touch with the facility early next week (Monday or Tuesday) to let them know her final decision. Review of R1's Progress Notes, dated 08/06/25 and found in the EMR under the Notes Tab, revealed, Facility has not yet heard from the family about (FM1) their final decision as far as resident discharge status. Administrator and BOM left message for (Ombudsman) to inform them that the facility has not yet heard back from the family and asked for guidance from Ombudsman on how to proceed. Review of R1's progress notes revealed R1's RP (FM1) refused to provide information to show where R1's assets were as of the 09/05/25 complaint investigation exit date. Entries dated 07/15/25, 07/21/25, 07/22/25, 07/28/25 and 07/30/25, revealed FM1 abruptly ended the call or hung up on facility staff members who were attempting to reach out to FM1 on those dates to discuss R1's care and ability to remain in the facility. Review of R1's Progress Notes, dated 08/26/25 and found in the EMR under the Notes Tab, revealed, Social service director (SSD) and Social Worker (SW) issued (a second) 30-day discharge notice to resident on unit. Witnessed by UM (Unit Manager) as well. Review of R1's Progress Notes, dated 09/04/25 and found in the EMR under the Notes Tab, revealed, At approximately 12:35pm Administrator called NJ DOH, NJ LTC Ombudsman and local Pennsauken police to report possible financial exploitation of (R1's) by her family. Review of the Facility's reportable incident records revealed the concerns related to R1's family potential exploiting her by mismanaging her money/assets were not reported as potential abuse to the State Agency (SA) or the local police department (PD) until 09/04/25 when the surveyors were conducting the complaint investigation. R1 was not able to be interviewed due to her poor cognition. During an interview with the Administrator on 09/03/25 at 3:17 PM, she confirmed she had been aware of concerns related to R1's family potentially misappropriating her funds/exploiting her since sometime in June of 2025. She confirmed no reporting of potential exploitation/misappropriation of funds had ever been done (to the SA or the local police). The Administrator stated multiple attempts had been made to determine where R1's financial assets were so that the resident's care could be paid for with no success. During an interview with the Business Office Manager (BOM), the [NAME] President of Clinical, the Regional Nurse Consultant, and the Administrator on 09/04/25 at 11:40 AM, the BOM confirmed the facility had been aware there were funds R1 owed prior to Medicaid covering her care and services. The facility received notice from Medicaid that there had been a financial penalty applied in that amount due to the resident having excess funds/assets above what allowed to qualify for Medicaid benefits. The BOM confirmed contact had been attempted/made with FM1 and FM2 multiple times since the end of June 2025 to try to determine where those funds were, and confirmed the family members had not been cooperative with locating/providing those funds to ensure R1's care could continue to be paid for. The BOM confirmed the resident had been issued 30-day involuntary discharge notices related to non-payment on 07/02/25 and then again on 08/26/25 due to failure to pay. She confirmed FM1 was responsible for managing R1's finances as R1 was not able to make her own decisions due to dementia. The [NAME] President of Clinical and the Regional Nurse Consultant indicated they understood the potential exploitation/financial abuse of R1 by FM1 should have been identified and reported by the facility prior to 09/04/25 when the surveyors brought the concerns to their attention. They indicated the potential abuse/exploitation would be reported immediately. 2. Review of R2's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included dementia, cerebral ischemia and chronic obstructive pulmonary disease. Review of R2's quarterly MDS assessment with an ARD of 07/18/25 and found in the EMR under the MDS tab, indicated a BIMS score of zero out of 15 which indicated the resident was severely cognitively impaired. Review of R2's Progress Notes, dated 06/29/25 at 10:00 AM, entered into the resident's record on 06/30/25 at 3:34 PM, and found in the EMR under the Notes Tab, indicated Aide (Certified Nursing Assistant (CNA6) stated that the resident refused care and out of nowhere the resident started swinging his backscratcher at her. Writer went to resident's room to speak with resident, resident denied that he tried to hit Aide. PT (patient) teaching was giving for refusal of care. Review of R2's Progress Notes, dated 06/30/25 11:47 AM and found in the EMR under the Notes Tab, indicated Resident noted with bruising and discoloration to right hand, area cleansed with soap and water and applied an ice pack to area. Full ROM (Range of Motion) to both hands noted with no facial grimacing when touched or using affected hand. Referred to be seen by wound care. NP (Nurse Practitioner) made aware, Daughter made aware. Review of the facility's investigation documentation related to R2's bruise of unknown origin revealed the incident was not reported as potential abuse to the State Agency (SA) until 07/01/25 at 11:13 AM (almost 24 hours after the injury of unknown origin was initially identified). During an interview with the Administrator 09/03/25, she confirmed the above stated injury of unknown origin was not reported to the SA until 07/01/25. During an interview with the BOM, the [NAME] President of Clinical, the Regional Nurse Consultant, and the Administrator on 09/04/25 at 11:40 AM, the Clinical President of Clinical and the Regional Nurse Consultant confirmed R2's injury of unknown origin was expected to have been reported to the SA within two hours of identifying the injury and confirmed the report submitted to the SA by the facility on 07/01/25 was submitted late. 3. Review of R15's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included schizoaffective disorder and chronic kidney disease. Review of R15's admission MDS assessment with an ARD of 09/04/25 and found in the EMR under the MDS tab, indicated a BIMS score of three out of 15 which indicated the resident was severely cognitively impaired. Review of R15's Progress Notes, dated 09/01/25 at 9:15 PM and found in the EMR under the Notes Tab, indicated This writer was made aware that two resident was arguing. This writer went to investigate and notice (R16) and (R15) facing each other. This writer immediately separated both resident (for) safety. Resident was assessed and found to have no injuries (R15) was brought back to his room and place on 1:1[one to one monitoring]. The resident was also reminded of his room change from 130A to 324B. Family, DON, and MD (Medical Doctor) made aware. Review of R16's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included vascular dementia and anoxic brain damage. Review of R16's quarterly MDS assessment with an ARD of 07/11/25 and found in the EMR under the MDS tab, indicated a BIMS score of five out of 15, which indicated the resident was severely cognitively impaired. Review of R16's Progress Notes, dated 09/01/25 at 9:49 PM and found in the EMR under the Notes Tab, indicated DON made aware by supervisor that resident had a verbal altercation with another resident (R15). Residents immediately separated and patient placed on a 1:1. Review of the facility's investigation documentation related to the above allegation of potential resident to resident verbal abuse revealed the incident was reported to the SA on 09/02/25 at 9:30 AM (almost 12 hours after the incident occurred). During an interview with the Administrator 09/03/25, she confirmed that the above stated resident to resident altercation was not reported to the SA until 09/02/25. During an interview with the Business Office Manager (BOM), the [NAME] President of Clinical, the Regional Nurse Consultant, and the Administrator on 09/04/25 at 11:40 AM, the Clinical President of Clinical and the Regional Nurse Consultant confirmed R15 and R16's verbal altercations was expected to have been reported to the SA within two hours of observation of the incident and confirmed the report submitted to the SA by the facility on 09/02/25 was submitted late. NJAC 8:39-9.4(f)

Complaint # : 2587860 and 187900 Based on review of facility policy, record review, and interviews, the facility failed to ensure a thorough investigation was completed related to allegations of potential exploitation and/or abuse two sampled residents (Resident (R) R1and R2) out of a total sample of 34 residents. This failure created the potential for these and other residents to experience further exploitation and/or abuse.Findings include: Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy dated most recently reviewed in 09/2024 read, in pertinent part, It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion misappropriation of resident property, or exploitation; and E. Investigation: When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with assistance of appropriate personnel. The investigation will include: i. Who was involved ii. Residents' Statements iii. Resident roommate statements (if applicable) iv. Involved staff and witness statements of events v. A description of the resident's behavior and environment at the time of the incident vi. Injuries present including a resident assessment vii. Observation of resident and staff behaviors during the investigation viii. Environmental considerations; and Investigation of injuries of unknown origin of suspicious injuries must be immediately investigated to rule out abuse. 1. Review of R1's admission Record, dated 09/05/25 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included dementia and history of falls. Review of R1's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/06/254 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of four out of 15 (which indicated the resident was severely cognitively impaired). The document indicated Family Member (FM1) was the resident's Responsible Party (RP). Review of R1's Progress Notes, dated 07/02/25 and found in the EMR under the Notes Tab, 30 Day discharge: Resident (R1) and family served 30-day discharge notice due to non-payment. Letter mailed via mail and certified mail to (Resident and FM1's address). Letter also mailed to Ombudsman, DOH (Department of Health) and Provider. Resident to be discharged on 7/31/25. Review of R1's progress notes revealed R1's RP (FM1) refused to provide information to show where R1's assets were as of the 09/05/25 complaint investigation exit date. Entries dated 07/15/25, 07/21/25, 07/22/25, 07/28/25 and 07/30/25, revealed FM1 abruptly ended the call or hung up on facility staff members who were attempting to reach out to FM1 on those dates to discuss R1's care and ability to remain in the facility. Review of R1's Progress Notes, dated 09/04/25 and found in the EMR under the Notes Tab, revealed, At approximately 12:35pm Administrator called NJ DOH, NJ LTC Ombudsman and local Pennsauken police to report possible financial exploitation of (R1's) by her family. Review of the facility's records revealed an investigation of potential abuse/exploitation related to the concerns about R1's family potentially exploiting her by mismanaging her money/assets was not initiated until 09/04/25 when the surveyors requested information related to an investigation into the concerns. During an interview with the Administrator on 09/03/25 at 3:17 PM, she confirmed she had been aware of concerns related to R1's family potentially misappropriating her funds/exploiting her since sometime in June of 2025. She confirmed an investigation into the potential exploitation of R1 by her family members had never been initiated. During an interview with the Business Office Manager (BOM), the [NAME] President of Clinical, the Regional Nurse Consultant, and the Administrator on 09/04/25 at 11:40 AM, The [NAME] President of Clinical and the Regional Nurse Consultant indicated they understood the potential exploitation/financial abuse of R1 by FM1 should have been identified and investigated by the facility prior to 09/04/25 when the surveyors brought the concerns to their attention. 2. Review of R2's admission Record, dated 09/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included dementia, cerebral ischemia and Chronic Obstructive Pulmonary Disease. Review of R2's quarterly MDS assessment with an ARD of 07/18/25 and found in the EMR under the MDS tab, indicated a BIMS score of zero out of 15 which indicated the resident was severely cognitively impaired. Review of R2's Progress Notes, dated 06/29/25 10:00 AM, entered into the resident's record on 06/30/25 at 3:34 PM, and found in the EMR under the Notes Tab, indicated Aide (Certified Nursing Assistant (CNA6) stated that the resident refused care and out of nowhere the resident started swinging his backscratcher at her. Writer went to resident's room to speak with resident, resident denied that he tried to hit Aide. PT (patient) teaching was giving for refusal of care. Review of R2's Progress Notes, dated 06/30/25 11:47 AM and found in the EMR under the Notes Tab, indicated Resident noted with bruising and discoloration to right hand, area cleansed with soap and water and applied an ice pack to area. Full ROM (Range of Motion) to both hands noted with no facial grimacing when touched or using affected hand . Review of the facility's investigation documentation, dated 6/29/25, related to R2's bruise of unknown origin revealed the incident was not fully investigated per the facility's abuse policy/requirements. The investigation did not include interviews with staff members present on the day of the event, during which it was reported R2 attempted to strike CNA6 with his/her reacher and CNA6 pulled the reacher from his/her hand to ensure abuse of R1 by CNA6 did not occur during that incident, resulting in the bruising to R1's hand. During an interview with the Administrator 09/03/25, she confirmed interviews had not been conducted with staff present on the day of the event that occurred between CNA6 and R1 to ensure no abuse of R2 by CNA6 had been perpetrated. The Administrator stated that the CNA was suspended. During an interview with the Business Office Manager (BOM), the [NAME] President of Clinical, the Regional Nurse Consultant, and the Administrator on 09/04/25 at 11:40 AM, the Clinical President of Clinical and the Regional Nurse Consultant confirmed R2's injury of unknown origin was expected to have been thoroughly investigated, including interviews with any staff who was present at the time of/may have had direct knowledge about the events which might have caused the injury to R2. NJAC 8:39-27.1(a)

Complaint # 179036Based on record review, interviews, and policy review, the facility failed to develop a comprehensive care plan for one of two residents (Resident (R) 8) sampled for the use of a Life Vest, (a wearable defibrillator). Findings include: Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R8 was initially admitted on [DATE] and discharged to home on [DATE]. R8 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertensive heart disease with heart failure, chronic atrial fibrillation, unspecified, and chronic diastolic (congestive) heart failure. Review of the Physician Orders located under the Orders tab in the EMR revealed R8 received an order for a Life Vest on 09/19/24. The order noted Change life vest battery every day shift. Life vest manufacturer [NAME] 1-8005433267serial # 58020305. Check [NAME] monitor for function and placement. Review of the 09/19/24 Comprehensive Care Plan located under the Care Plan tab in the EMR revealed The resident has altered cardiovascular status r/t (related to) CHF (congestive heart failure), afib (atrial fibrillation) use of life vest. The goal was identified as The resident will be free from complications of cardiac problems through the review date. The interventions listed Assess for shortness of breath and cyanosis every (specify). Encourage low fat, low salt intake. The care plan failed to address the cleanliness of the Life Vest, personal hygiene when utilizing a Life Vest, responding to alarms, and when to notify the resident's physician in the comprehensive care plan for R8 who utilized a Life Vest, a wearable defibrillator. Review of the Treatment Administration Records (TAR) for the months of 09/24, 10/24, 11/24, and 12/24, located under the Orders tab in the EMR, revealed the nursing staff were changing the battery every day and monitoring the [NAME] for function and placement every shift. During an interview with the Minimum Data Set Coordinator (MDSC) on 09/05/25 at 2:16 PM, the MDSC stated, We all work on the care plans, but I did not complete (R8's). During an interview with the Director of Nurses (DON) on 09/05/25 at 2:16 PM, the DON stated, I was not employed at that time, I cannot answer. During an interview on 09/05/25 at 2:30 PM, the Pavilion I Unit Manager (PAV1UM) stated, I do the care plans. I remember (R8). I don't know why (R8's) care plan did not address the specifics of the Life Vest. We changed the battery every day. Review of the Life Vest Policy and Procedure, dated 11/2024, provided by the Regional Nurse Consultant revealed Nursing home staff must provide safe and competent care for residents utilizing the LifeVest wearable defibrillator. This includes ensuring proper use, monitoring, and maintenance of the device, as well as providing education to staff and residents to prevent complications and ensure effective operation.Daily Care/Device Inspection identified Check the LifeVest daily for proper positioning, cleanliness, and secure fit. Inspect electrode pads and battery connections to ensure the device is functioning. Assist residents in maintaining hygiene without compromising the LifeVest's functionality. When removed for bathing, ensure the device is promptly re-worn as instructed by the manufacturer.Ensure spare, fully charged batteries are available. Replace the battery per the manufacturer's instructions to avoid interruptions in monitoring. Responding to Alarms/Non-Emergency Alarms: If the LifeVest issues a non-emergency alert (e.g., low battery, poor connection), address the issue following the manufacturer's troubleshooting steps. Document any actions taken and notify, the resident's physician if necessary. Emergency Alarms (Shock Delivery): If the LifeVest delivers a shock:l. Monitor the resident's condition immediately. 2. Call 9l1 and notify the physician for further assessment. 3. Record the event in the residents' medical chart, including the time, observed symptoms, and response to the shock. NJAC 8:39-27.1(a)

Complaint #: NJ180849 Based on observations, interviews, and review of other facility documentation on 2/10/2025, it was determined that the facility failed to maintain a clean and homelike environment for the residents. This deficient practice was identified for 2 of 3 units, (Pavilion 2 and Pavilion 3) and was evidenced by the following: During a tour of the 2nd floor unit (Pavilion 2) on 2/10/2025 at 10:08 AM, the surveyor observed the following: 1.) Inside resident room [ROOM NUMBER], a brown stain on the ceiling tile and a build-up of dust and unknown debris in the heater vent. 2.) Inside resident room [ROOM NUMBER], four small holes in the wall behind the television for Bed-B and chipped paint on the walls. 3.) Inside resident room [ROOM NUMBER], two holes in the wall next to the bathroom door, a build-up of unknown debris in the heater vent, and chipped paint on the heater. 4.) Inside resident room [ROOM NUMBER], two holes in the wall behind the television for Bed B, a build-up of unknown debris in the heater vent, a build-up of dirt around the heater knobs, and tape around the heater. 5.) Inside resident room [ROOM NUMBER], a build-up of unknown debris in the heater vent and chipped paint on the heater. During a tour of the 3rd floor unit (Pavilion 3) on 2/10/24 at 10:40 AM, the surveyor observed the following: 1.) Inside resident room [ROOM NUMBER], a build-up of unknown debris in the heater vent. 2.) Inside resident room [ROOM NUMBER], a build-up of unknown debris in the heater vent, chipped paint on the heater, the electrical outlet cover had rust on it, multiple circular rust spots on the bathroom floor, and a hole on the right side of the toilet behind the toilet seat. During an interview with the surveyor on 2/10/2025 at 1:37 PM, the Director of Maintenance (DM) stated that the maintenance staff was responsible for fixing stains on the ceiling tile, cleaning the heaters and the heater vents, painting, and repairing holes. The DM stated that environmental rounds were conducted weekly on a different floor by himself, the Housekeeping Director (HD), Nursing staff, and the Licensed Nursing Home Administrator (LNHA). He further stated that anything that needed repair would have been noticed during environmental rounds and put into the facility's work order system. The DM stated that he had not been made aware of the stain on the ceiling tile, holes in the walls, the build-up of dust and unknown debris in the heater vents, the chipped paint on the heater, and the hole on the toilet prior to the tour with the surveyor. The DM confirmed that the above findings did not create a homelike environment for the residents. On 2/10/2025 at 2:03 PM, the LNHA in the presence of the DM, the HD, and the surveyor acknowledged the above findings. On 2/10/2025 at 3:22 PM, the surveyor asked the LNHA for evidence that the environmental rounds were being conducted weekly. The LNHA stated that the only evidence that environmental rounds were conducted was the facility's work order sheets. During exit conference on 2/10/2025 at 4:08 PM, the facility was unable to provide the surveyor with evidence that the weekly environment rounds had been completed. A review of the facility's policy titled Maintenance Services and Work Orders last revised on 10/1/2024 revealed, 1. The Maintenance Department will operate the facility in compliance with current federal, state and local laws, regulations and guidelines that may include, maintaining: the building in good repair and free from hazards. 3.The Maintenance Department will provide and document routine and emergency maintenance services to all areas of the facility. NJAC 8:39-31.4 (a) (b)

Complaint # NJ 158956, 166158, 170632 Based on interview, and review of other facility documentation, it was determined the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: A review of the provided Facility assessment dated [DATE] included .our approach to ensure adequate staff based on our resident population and their needs for care . for Certified Nurse Aides 1:8 Residents for days, 1:10 evenings, 1:14 nights, one Restorative Aide day shift weekdays and one Restorative Aide Day shift weekends. During resident Council meeting on 08/08/2024 at 11:00 AM, a resident stated nights are short staffed, and wait time is long. Only two were on 2nd floor last night. 2 of 5 residents stated they have waited 4 to 5 hours for an aide. A review of New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the following weeks weeks revealed the facility was deficient in CNA staffing for residents as follows: 1. For the 2 weeks of staffing prior to survey from 07/21/2/2024 to 08/03/2024, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts and deficient in total staff for residents on 1 of 14 overnight shifts as follows: The facility provided less than half the required CNA staffing for resident care on 4 day shifts. -07/21/24 had 14 CNAs for 168 residents on the day shift, required at least 21 CNAs. -07/22/24 had 16 CNAs for 168 residents on the day shift, required at least 21 CNAs. -07/23/24 had 16 CNAs for 168 residents on the day shift, required at least 21 CNAs. -07/24/24 had 12 CNAs for 168 residents on the day shift, required at least 21 CNAs. -07/25/24 had 16 CNAs for 170 residents on the day shift, required at least 21 CNAs. -07/26/24 had 15 CNAs for 170 residents on the day shift, required at least 21 CNAs. -07/27/24 had 13 CNAs for 170 residents on the day shift, required at least 21 CNAs. -07/28/24 had 12 CNAs for 173 residents on the day shift, required at least 22 CNAs. -07/29/24 had 13 CNAs for 171 residents on the day shift, required at least 21 CNAs. -07/29/24 had 10 total staff for 171 residents on the overnight shift, required at least 12 total staff. -07/30/24 had 15 CNAs for 168 residents on the day shift, required at least 21 CNAs. -07/31/24 had 16 CNAs for 165 residents on the day shift, required at least 21 CNAs. -08/01/24 had 13 CNAs for 164 residents on the day shift, required at least 20 CNAs. -08/02/24 had 13 CNAs for 164 residents on the day shift, required at least 20 CNAs. -08/03/24 had 11 CNAs for 163 residents on the day shift, required at least 20 CNAs. 2. For the week of Complaint staffing from 07/30/2023 to 08/05/2023, the facility was deficient in CNA staffing for residents on 5 of 7 day shifts as follows: -07/30/23 had 5 CNAs for 163 residents on the day shift, required at least 20 CNAs. -07/31/23 had 16 CNAs for 163 residents on the day shift, required at least 20 CNAs. -08/01/23 had 19 CNAs for 163 residents on the day shift, required at least 20 CNAs. -08/04/23 had 18 CNAs for 159 residents on the day shift, required at least 20 CNAs. -08/05/23 had 18 CNAs for 159 residents on the day shift, required at least 20 CNAs. 3. For the week of Complaint staffing from 08/13/2023 to 08/19/2023, the facility was deficient in CNA staffing for residents on 2 of 7 day shifts as follows: -08/13/23 had 13 CNAs for 160 residents on the day shift, required at least 20 CNAs. -08/18/23 had 17 CNAs for 159 residents on the day shift, required at least 20 CNAs. 4. For the week of Complaint staffing from 08/27/2023 to 09/02/2023, the facility was deficient in CNA staffing for residents on 3 of 7 day shifts as follows: -08/27/23 had 9 CNAs for 157 residents on the day shift, required at least 20 CNAs. -08/28/23 had 16 CNAs for 157 residents on the day shift, required at least 20 CNAs. -09/01/23 had 18 CNAs for155 residents on the day shift, required at least 19 CNAs. 5. For the week of Complaint staffing from 12/31/2023 to 01/06/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in total staff for residents on 2 of 7 evening shifts as follows: -12/31/23 had 10 CNAs for 155 residents on the day shift, required at least 19 CNAs. -01/01/24 had 11 CNAs for 155 residents on the day shift, required at least 19 CNAs. -01/01/24 had 14 total staff for 155 residents on the evening shift, required at least 15 total staff. -01/02/24 had 14 CNAs for 155 residents on the day shift, required at least 19 CNAs. -01/03/24 had 16 CNAs for 155 residents on the day shift, required at least 19 CNAs. -01/04/24 had 17 CNAs for 155 residents on the day shift, required at least 19 CNAs. -01/05/24 had 11 CNAs for 155 residents on the day shift, required at least 19 CNAs. -01/06/24 had 12 CNAs for 155 residents on the day shift, required at least 19 CNAs. -01/06/24 had 14 total staff for 155 residents on the evening shift, required at last 15 total staff. 6. For the week of Complaint staffing from 01/21/2024 to 01/27/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts, and deficient in total staff for residents on 2 of 7 evening shifts as follows: -01/21/24 had 10 CNAs for 162 residents on the day shift, required at least 20 CNAs. -01/21/24 had 15 total staff for 162 residents on the evening shift, required at least 16 total staff. -01/22/24 had 7 CNAs for 162 residents on the day shift, required at least 20 CNAs. -01/23/24 had 14 CNAs for 161 residents on the day shift, required at least 20 CNAs. -01/24/24 had 15 CNAs for 161 residents on the day shift, required at least 20 CNAs. -01/25/24 had 16 CNAs for 161 residents on the day shift, required at least 20 CNAs. -01/26/24 had 16 CNAs for 161 residents on the day shift, required at least 20 CNAs. -01/26/24 had 15 total staff for 161 residents on the evening shift, required at least 16 total staff. -01/27/24 had 16 CNAs for 158 residents on the day shift, required at least 20 CNAs. 7. For the week of Complaint staffing from 05/25/2024 to 06/01/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in total staff for residents on 1 of 7 overnight shifts as follows: -05/26/24 had 18 CNAs for 166 residents on the day shift, required at least 21 CNAs. -05/27/24 had 12 CNAs for 165 residents on the day shift, required at least 21 CNAs. -05/27/24 had 9 total staff for 165 residents on the overnight shift, required at least 12 total staff. -05/28/24 had 16 CNAs for 165 residents on the day shift, required at least 21 CNAs. -05/29/24 had 16 CNAs for 165 residents on the day shift, required at least 21 CNAs. -05/30/24 had 15 CNAs for 165 residents on the day shift, required at least 21 CNAs. -05/31/24 had 16 CNAs for 165 residents on the day shift, required at least 21 CNAs. -06/01/24 had 15 CNAs for 165 residents on the day shift, required at least 21 CNAs. On 8/14/24 at 10:34 AM, the surveyor interviewed the facility Staffing Coordinator (SC) who stated she was aware of the staffing requirements for Certified Nurse Aides in New Jersey. The SC stated one CNA to 10 residents on dayshift, one CNA to 10 residents on the evening shift and one CNA to 20 residents on the night shift. The SC stated she did her best and believed they were meeting the minimum staffing requirements a majority of the time. During an interview with the Director of Nursing (DON) on 08/13/2024 at 02:44 PM, the surveyor reviewed the Facility Assessment and asked the DON what was the facility's staffing pattern for nurses? The DON explained the following: PAV (Pavilion) 1 DAY 2 nurses EVE 2 nurses NIGHT 2 nurse PAV 2 DAY 2 nurses EVE 2 nurse NIGHT 1 nurse PAV 3 DAY 2 nurses EVE 2 nurses NIGHT 1 nurse.

Based on observation, interview, review of the medical record, and review of pertinent facility records it was determined that the facility failed to follow through on recommendations made by the consultant pharmacist (CP) during their monthly medication regimen review (MRR) in a consistent and timely manner. This deficient practice was identified for 2 of 5 residents reviewed for unnecessary medications, (Resident #55 and Resident #89) and was evidenced by the following: The surveyor reviewed the facility policy on 08/13/2024 at 10:45 AM, titled Medication Regimen Review Policy NO: ROP-32, Reviewed: 6/2/2024. The following was revealed under POLICY: It is the facilities policy to provide a Medication regimen review (MRR) for all residents admitted to the nursing facility. The following was revealed under Policy Explanation and Compliance Guidelines: 1. Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. 4. The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and the reports must be acted upon. c. The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. 7. Upon completion of the MRR, the facility designee and/or physician, will respond to the recommendations in a timely manner. 10. Each resident's drug regimen remains free of unnecessary drugs. An unnecessary drug is any drug when used: a. In excessive doses, including duplicate therapy. b. For excessive duration. c. Without adequate monitoring. d. Without adequate indications for its use. e. In the presence of adverse consequences which indicate the dose should be reduced or discontinued. 1.On 08/06/2024 at 08:43 AM Resident #55 was observed lying in bed and asleep. Resident #55 did not respond to the surveyor voice. A review of the Electronic Medical Record on 08/06/2024 at 12:01 PM revealed the following: According to the Admission Record Resident #55 had the following but not limited to diagnoses: Osteoarthritis of left knee, diabetes mellitus, encounter for attention to colostomy, and acquired absence of left toe. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated June 14, 2024, revealed that Resident #55 had a Brief Interview for Mental Status score of 15/15 indicating intact cognition. Section N of the MDS revealed Resident #55 received antidepressant, anticoagulant, opioid and hypoglycemic medications daily. A review of the Order Summary Report revealed that Resident #55, as of 8/14/2024 had the following active order: Dicyclomine HCl (hydrochloric acid) Oral Tablet 20MG (milligram) (Dicyclomine HCl) Give 1 tablet by mouth every 12 hours as needed for Abdominal pain Order Status: Active Order Date: 01/19/2024. A review of the July 2024 and August 2024 Medication Administration Record (MAR) revealed Resident #55 had not received Dicyclomine HCl oral tablet during the month of July or August 2024. A review of the CP MRR Note To Attending Physician/Prescriber MRR Date: 6/24/2024 revealed the following CP recommendation: Recommend discontinuing PRN (as necessary) Dicyclomine. The resident has not used medication > (greater than) 60 days. A review of the Physician/Prescriber Response revealed that the physician/prescriber Agreed: and was signed and dated 7/2/24. A review of the Consultant Pharmacist's Medication Regimen Review document for recommendations created between 6/23/2024 and 6/24/2024 revealed the following recommendation: Recommend discontinuing PRN Dicyclomine. The resident has not used medication for > 60 days. Under the Follow-Through heading the following was documented: Note written to physician 2. On 08/06/2024 at 09:07 AM, Resident #89 was observed lying in bed with the head of the bed elevated. Resident #89 was asleep, and no maladaptive behaviors were exhibited on this observation. A review of the Medical Record on 08/06/2024 at 10:37 AM revealed the following: A review of the Admission Record revealed Resident #89 had the following but not limited to diagnoses: Chronic Obstructive Pulmonary Disease (a type of progressive lung disease), morbid obesity, hypertensive heart disease (high blood pressure), atherosclerotic heart disease, and paranoid schizophrenia. A review of Resident #89's comprehensive MDS, dated [DATE], revealed that Resident #89 had a Brief Interview for Mental Status score of 15/15 indicating intact cognition. Section N of the MDS revealed that Resident #89 received a diuretic (promotes increased production of urine) daily. A review of the Order Summary Report with Active Orders As Of: 08/14/2024, revealed Resident #89 had the following physician/practitioner order: Lasix Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for edema Order Status: Active Order Date: 10/04/2023. A review of Resident #89's comprehensive care plan revealed a care plan Focus: I am on diuretic therapy (Lasix) r/t (related to): HTN (hypertension) Created on: 05/24/2023. The following was revealed under Interventions: Ask physician to review medication for possible dose reduction every three months Created on: 05/24/2023 and Administer medication as ordered and monitor for side effects. Report to MD as appropriate. Created on: 05/24/2023. A review of Resident #89's MAR for 7/1/2024 - 7/31/2024 revealed that Resident #89 received Lasix Oral Tablet 40 MG daily at 0800 (8:00 AM) for the dates of 7/1/2024 through 7/31/2024. A review of Resident #89's 8/1/2024 - 8/31/2024 MAR revealed that Resident #89 received Lasix Oral Tablet 40 MG daily from 8/1/2024 through 8/8/2024 (MAR was provided to surveyor on 8/8/2024). On 08/08/2024 at 11:33 AM the surveyor conducted a review of the CP MRR for the past 6 month period. Review of the Consultant Pharmacist's Medication Regimen Review for recommendations created between 6/23/2024 and 6/24/2024 revealed the following recommendation for Resident #89: Resident has been on Lasix for edema since 10/5/2023. Please re-evaluate continuous need and consider discontinuing. Has the edema resolved? Under the Follow-Through heading the following documentation was observed: Note written to physician. A review of the Note To Attending Physician/Prescriber MRR Date: 6/24/2024 revealed the following: Resident has been on Lasix for edema since 10/5/2023. Please re-evaluate continuous need and consider discontinuing. Has the edema resolved? The following was documented under Physician/Prescriber Response: Agree signed and dated 7/2/24. A review of Resident #89's progress notes dated 7/2/2024 and 7/3/2024 did not reveal any documentation concerning the discontinuation of the Lasix medication. On 08/13/2024 at 08:53 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM #1) who was assigned to the unit that Resident #55 and #89 resided. The surveyor asked LPN/UM #1 to describe the facility process for responding to the CP MRR. LPN/UM #1 told the surveyor The physician recommendations are given to the doctors in a folder monthly. They respond to them and sign them and then they are given back to me. I (UM/LPN #1) take care of the monthly nursing recommendations. It is up to the physicians to handle and agree or disagree with the CP monthly medication regimen reviews. During a follow-up interview with LPN/UM #1 on 08/14/2024 at 09:02 AM, the surveyor asked LPN/UM #1 if she had ever been responsible for discontinuing physician orders recommended by the CP. LPN/UM #1 replied, I've never had to discontinue an order from the physician side. I/we (nursing) are only responsible for nursing recommendations. The physician is responsible for carrying out their own recommendations concerning consultant pharmacy recommendations. On 08/14/2024 at 09:52 AM, the surveyor conducted an interview with the facility Director of Nursing (DON). The surveyor asked the DON what the facility process was concerning the CP MRR. The DON told the surveyor, The physician will discontinue the order, or they will provide nursing with a verbal order to discontinue a CP recommendation if they agree with the recommendation. That applies to physicians and nurse practitioners. For Resident #89 the Lasix order should have been discontinued on 7/2 or 7/3/2024. Concerning Resident #55 Yes, the Dicyclomine should have been discontinued according to the physician checking Agree and signing and dating. I agree that there is a breakdown in the MRR process, and I take that seriously. NJAC 8:39-29.3(a)(1)

Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: The surveyor reviewed a facility policy on 08/05/2024 at 12:02 PM, titled [company name] Dining Services Food Storage, undated. The following was revealed under Canned Fruits: Dented or bulging cans shall be placed on Damaged Goods Shelf and returned for credit. The following was revealed under Canned Vegetables: Dented or bulging cans shall be placed on Damaged Goods Shelf and returned for credit. The surveyor reviewed a facility policy on 08/05/2024 at 12:02 PM, titled [facility name] Dining Services Pots and Pans - Sanitizing Solution, undated. The following was revealed under the heading SANITATION OF EQUIPMENT: NOTE: Allow all items to air dry. Towels shall never be used for drying. When items are dry, store in proper storage area. On 08/11/2024 at 12:26 PM, the facility provided the surveyor with a copy of the facility policy for refrigerators in the pantries, Reviewed 2/2024. The policy revealed the following under the heading POLICY: The facility recognizes the importance of ensuring that all foods are held at a safe temperature to ensure the safety of its residents. All refrigerators on the units will be monitored daily for correct temperatures. The policy did not address the monitoring of freezer temperatures. On 8/5/2024 from 9:26 to 10:05 AM, the surveyors, accompanied by the facility Food Service Director (FSD), observed the following in the kitchen: 1. In the dry storage room a can of mushrooms on a multi-tiered rack had a significant dent on the seam. The FSD removed the can of mushrooms to the designated dented can area with the other dented cans that were removed for dents. 2. A stack of five (5) deep/full pans on a middle rack of the pot and pan storage rack were stored in the inverted position. The surveyor picked up the top pan with their hand and observed a clear, watery substance on the bottom surface of the pan beneath. Further observation revealed that the additional three (3) pans in the stack also were covered with a wet watery substance, a process known as wet nesting (occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow). The FSD removed the stack of five (5) pans from the pot/pan storage rack to be rewashed and sanitized. On 08/08/2024 from 12:57 to 1:17 PM, the surveyors, accompanied by Unit Manager/Licensed Practical Nurse (UN/LPN #1) observed the following on the PAV1 (pavilion 1) pantry: 1. The surveyor reviewed the PAV1 Pantry Food Refrigerator Temperature Log, dated [DATE]. The log revealed that the Refrigerator range for foods was 32-40 degrees Fahrenheit and Freezer: -10 to 0 F. Observation of the interior of the pantry freezer determined there was no internal thermometer in the freezer and no temperatures were recorded for the [DATE] PAV1 Pantry freezer on the temperature log only refrigerator temperatures. On interview the UM/LPN # stated that she was not aware that the freezer required a thermometer and that the temperature needed to be monitored. UM/LPN # told the facility Infection Preventionist who was walking by that the unit needs a thermometer for the PAV 1 freezer in the presence of the surveyor. On 08/08/2024 from 1:20 to 1:30 PM, the surveyor, accompanied by LPN/UM #1 observed the following in the PAV3 (pavilion 3 pantry): 1. The temperature log, as described above for PAV1 had no freezer temperatures recorded for the dates 8/1 thru 8/8/2024. Observation of the freezer revealed no internal thermometer was present to monitor the freezer temperature. On interview LPN/UM #1 stated, I was not aware that we had to do the freezer as well as the refrigerator. It makes perfect sense. I will get a thermometer. NJAC 18:39-17.2(g)

Based on observation and interview, and review of other facility documentation, it was determined that the facility failed to ensure the transport of a non-ambulatory resident was provided in a manner to promote the dignity and respect of the resident. This deficient practice was identified for 1 of 32 residents reviewed for dignity, (Resident #27) and was evidenced by the following: A review of a facility policy titled Resident Rights, Created: 2/2024, revealed the following under Policy Explanation and Compliance Guidelines: 10. All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. 11. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. The following was revealed under the heading Resident rights: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. On 08/05/2024 11:23 AM, during the initial tour of the facility, the surveyor observed Resident #27 seated in a Geri-chair. A female staff was observed to transport Resident #27 from the Pavilion 3 dining/activity room and past the nursing station by pulling the Geri-chair from behind and not pushing Resident #27 facing forward. The surveyor interviewed Licensed Practical Nurse (LPN #2). The surveyor asked LPN #2 how a non-ambulatory resident should be properly transported. LPN #2 responded by stating that she was sorry. A review of the Electroinic Medical Record on 08/06/2024 at 09:26 AM, revealed the following: A review of the Admission Record revealed that Resident #27 was admitted to the facility with the following but not limited to diagnoses: Contracture (unspecified joint), vascular dementia, and major depressive disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated June 28, 2024, revealed Resident #27 had a Brief Interview for Mental Status score of 3/15, which indicated severe cognitive impairment. Section GG revealed that Resident #27 had impairment on side to both the lower and upper extremity. On 08/13/2024 at 02:20 PM, the surveyor conducted an interview with the facility administration which included the Director of Nursing DON), the Licensed Nursing Home Administrator (LNHA), and the [NAME] President of Clinical Services. When asked how to properly transport a non-ambulatory resident, the DON told the surveyors, The resident should be transported from behind so that the staff and resident are moving forward in the same direction to see where you are going and for dignity issues. NJAC 4.1(a)(12)

C/O # NJ 156940 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 2 of 3 units, (Pavilion 2 and Pavilion 3) and was evidenced by the following: 1. On 08/13/2024 at 10:40 AM, a review of a facility policy titled Complete Room Cleaning dated 06/2024, revealed under the purpose section; The complete room cleaning schedule insures {sic} (ensures)that each resident room is discharge-cleaned on a monthly basis. Under the Patient Room section 3. Starting in a clockwise rotation from patient room door; clean polish, scrub, scrape, dust, disinfect, sweep, wipe and mop everything in the room including: . Check all the corners, ceiling and floors, Remove buildup on floor, dust mop and damp mop entire room. Under the Bathrooms section: . Toilet: scrub and disinfect toilet bowl. Use cleanser on interior of bowl only. Remove all stains and buildup. Remove all buildup from the floor around the bowl, door frame, corners and edges. Dust mop the entire floor. Make sure vent in the bathroom is cleaned. Damp mop the entire floor. During the initial tour of the facility on the 2nd floor on 08/05/2024, the surveyor observed the following: + at 11:11 AM, in room [ROOM NUMBER] floor the surveyor feet stuck to floor. + at 11:14 AM room [ROOM NUMBER] had debris on floor. During a subsequent tour of the 2nd floor on 08/07/2024 at 12:12 PM, the surveyor observed the following: + room [ROOM NUMBER] floor with debris, hair knot by wheel at bottom of the bed, floor near door where the jam meets floor with dark spots, + room [ROOM NUMBER] dark marks on floor where the door jam and floor meet. + surveyor shoes stuck to the floors in rooms [ROOM NUMBERS]. + room [ROOM NUMBER] dark marks floor and where the door jam and floor meet. + hair knot observed on the floor outside room [ROOM NUMBER] in hallway. On 08/07/2024 at 12:23 PM, the hallway 2nd floor high hall was observed with various colored debris marks on the floor between rooms [ROOM NUMBERS]. + room [ROOM NUMBER] corner of wall upon entering on left missing baseboard, cracked paint. + corners where door jams meet floor rooms 222, 223, 221, 220 219, 218, 217, 216, all have debris and dark marks. + floor room [ROOM NUMBER] upon entering with dark marks and w/c wheel trails. + medication cart high hall 2nd floor wheels with hair wrapped around wheels. + room [ROOM NUMBER] in the bathroom, floor where the baseboard and floor meet have dark stains, on left side of toilet when looking at it, on the floor is discolored and stains along base of toilet and inside toilet bowl. During an interview with the surveyor on 08/07/2024 at 12:24 PM, a family member said they are supposed to clean the rooms every day. They only mop the floors, don't sweep before mopping. Look at the stuff on the floors. The family member said they only mop floor in bathroom, they don't clean toilet. On 08/12/2024 at 12:00 PM, medication cart high hall 2nd floor wheel stills have hair wrapped on wheels. On 08/12/2024 at 09:06 AM, observed laminate board on door to room [ROOM NUMBER] peeling off. During an interview with the surveyor on 08/13/2024 at 09:44 AM, the Director Environmental Services and Laundry (DEVS) was asked what the process was for cleaning resident rooms. The DEVS responded first they knock on door, empty trash, sweep rooms (dry sweep) with dustpan and broom, wipe on top and bottoms of all surface areas, also clean top of lights. Then they go to the bathroom, clean toilet, sink and mirrors, check make sure toilet paper and paper towels are inside the holder not on back of toilet. They finish with wet mop rooms and bathroom. The DEVS also said they check privacy curtains to make sure they are clean of spills or stains. When asked how often this is done, he said this is done daily. The DEVS said I usually have 2 housekeepers on each floor and 1 porter on day shift. On evening we have 2 floor techs, and they are responsible for day rooms and scrub the hallways, and empty soiled linen and trash. The surveyor asked what about the corners of the room. The DEVS replied that is also part of the daily cleaning. When asked who is responsible to clean the hallways, the DEVS said the evening floor techs. The housekeeper or floor tech are responsible to clean marks off the floors. The DEVS went on to say that hallways are cleaned daily, and twice weekly halls are scheduled to be scrubbed. The surveyor questioned what scrubbed means and he said we run the floor machine is what scrubbing means. The surveyor asked how often room carbs (carbolization which is the process of deep cleaning a room) done. The DEVS replied 1 room on each floor daily including weekends. This includes pulling all dressers, beds away from the wall, cleaning behind everything, top of lights, wipe call bell and phone lines are cleaned, wiping remotes (done daily as well) dust TV, picture frames, bed frames, mattresses, window frames and windowsills and windows. The surveyor asked who is responsible to clean the medication carts. The DEVS responded Housekeeping is responsible to clean the medication carts. We have a spare, we clean that one, nursing then switches cart and then we take the dirty cart and clean it. Yes, that includes wheels and drawers, scrape anything left in there and when it is clean we leave for nursing to switch back. That is done monthly. During an interview with the surveyor on 08/13/2024 at 01:15 PM, the Housekeeping Assistant (HKA #1) said rooms are clean daily. The process is to sweep floor, mop floor, clean toilet, clean sink, dust top of dressers, lights, wipe bed down including mattress every day. When questioned about carbolizations, how often is this done. The Housekeeper replied do one room a day so done monthly. 40039 2. On 08/05/2024 at 10:35 AM Resident #101 was observed lying in bed on the initial tour of the facility. Tube feeding (TF) was observed to be off at this time of observation. The surveyor observed what appeared to be tan/brown tube feed formula to be spilled on the floor and on the base of the IV pole. On 08/07/2024 at 08:26 AM Resident #101 was observed lying in bed with the head of the bed (HOB) slightly elevated. TF is not hung or infusing on this observation. The IV pole base remains covered with an unidentified tan colored substance on the base of the IV pole. On 08/08/2024 at 08:24 AM Resident #101was observed lying in bed with HOB elevated. Enteral pump is turned off and no tube feed is present. Base of IV pole and floor are stained/covered with an unidentified tan/brown substance that resembles an enteral feed, as seen on previous observations. On 08/12/2024 at 11:10 AM Resident #101was observed lying in bed and receiving intravenous fluids. No TF was hung at this time. IV pole base is covered with an unidentified tan/brown substance that is dried onto the base. Appears to be dried tube feed formula that spilled. On 08/13/2024 at 08:35 AM Resident #101 was observed lying in bed with HOB elevated. Tube feeding of Jevity 1.5 (an enteral formula to provide nutrition to residents that are unable to eat by mouth). IV pole base is covered with what appears to be dried enteral feeding. The surveyor conducted an interview with the Housekeeping Assistant assigned to Resident #101's room. When asked who was responsible for cleaning of IV poles the house keeping assistant (HKA #2) stated that housekeeping staff were responsible for the maintenance/cleaning of IV poles in the facility. HKA #2 agreed that the IV pole needed cleaning and agreed that enteral formula had been spilled on the IV pole base. On 08/13/2024 at 09:45 AM the surveyors conducted an interview with the facility Director of Environmental Services and Laundry (DEVS). When asked who was responsible for the cleaning of IV poles the DEVS responded, We are responsible to clean the IV poles. They are scheduled once a week to be cleaned but they can be cleaned daily if need be. On 08/13/2024 at 02:26 PM during an interview with facility administration the DON and LNHA confirmed housekeeping/environmental services was responsible for cleaning IV poles as well as the person making the spill. NJAC 8:39-31.4(a)

Based on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives, timelines, and interventions to meet resident's medical and nursing needs for 1 out of 4 residents investigated for Respiratory Care. A review of a facility policy reviewed on 08/08/2024 at 11:05 AM, titled, Care Plan, dated June 2024, revealed the following statement, It is the policy of [facility name] that all residents admitted to the facility will have adequate person-centered care plans that provide for all their needs in a timely manner. Under Procedures, #1. Baseline Care Plans for all new admissions will be initiated within 48 hours of admission. Under #2. They will include initial goals, MD orders, medications, treatments, dietary orders, therapy orders, social service and PASARR recommendations. The deficient practice was evidenced by the following: On 08/05/2024 at 10:13 AM, the surveyor observed Resident #372 in his/her room, lying in bed with a tracheostomy, (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) with 5 liters of continuous oxygen inhalation therapy infusing. A review of Resident #372's Electronic Medical Record on 08/06/2024 at 09:31 AM, revealed the following: A review of Resident #372's Admission Record revealed that he/she had a diagnosis of Multiple Sclerosis, Paraplegia, Tracheostomy, and Chronic Respiratory Failure with Hypoxia. A review of the resident physician orders revealed orders for the care and treatment of the tracheostomy. A review of Resident #372's most recent comprehensive Minimum Data Set (MDS), an assessment tool to facilitate resident care dated 07/18/2024, under Section O-Special Treatments, Procedures, and Programs, indicated that Resident #372 required Oxygen therapy, Suctioning, and Tracheostomy Care. A review of Resident # 372's care plan did not include the required care and maintenance for the resident's tracheostomy. During an interview with the surveyor on 08/07/2024 at 09:10 AM, Registered Nurse/Unit Manager (RN/UM #1), stated that there was no care plan for the respiratory care for Resident #372. RN/UM #1 added that it was ultimately her responsibility to assure that a care plan was in place. 8:39-11.2 (e)

Based on interview, review of the Electronic Medical Record (EMR), and review of other facility documentation, it was determined that the facility failed to ensure a resident had a Physician Order (PO) for transfer to the hospital. This deficient practice was identified for 2 of 2 residents reviewed for hospitalization s (Resident # 126 and Resident # 137) and was evidenced by the following: On 08/14/2024 at 9:52 AM, a review of the facility's Transfer or Discharge, Emergency policy dated revised June 2024, included, Should it become necessary to make an emergency transfer or discharge to a hospital . Notify the resident's attending physician; place order for transfer per attending physician/NP (nurse practitioner)/PA .(physician assistant) On 08/06/2024 at 11:42 AM, a review of the Electronic Medical Record (EMR) revealed the following: 1. A review of the Admission record revealed Resident #126 was admitted to the facility with diagnoses including but not limited to: Conversion Disorder with Seizures or Convulsions. A review of a facility progress note (PN) dated 11/5/2023 revealed Resident #126 was observed sitting in the chair with both eyes rolled up and unresponsive. 911 was called and Resident #126 left with Emergency Medical Services to the local hospital. A further review of the EMR did not include a physician order to transfer Resident #126 to the hospital. During an interview with the surveyor on 08/14/2024 at 09:10 AM, the Director Of Nursing (DON) said there was no order to transfer Resident #126 to the hospital. The surveyor asked should there have been an order and she replied, Yes. 39460 2. On 8/13/24 at 8:47 AM, the surveyor reviewed the medical record for Resident #137, a hospitalized resident. A review of the Admission Record reflected the resident was admitted to the facility with diagnoses which included injury of the cervical (neck) spinal cord, muscle weakness and difficulty walking. A review of the Progress Notes (PN), Health Status Note, dated 8/3/24 at 8:14 PM, the resident was observed with SOB (shortness of breath) and skin pale in color. The NP (Nurse Practitioner) was contacted and ordered resident to be sent out [to the hospital] via 911. A review of the Medication Review Report for August 2024 did not reveal a physician's order for the resident to be sent to the hospital on 8/3/24. On 8/14/24 at 8:42 AM, the surveyor interviewed the DON who stated there should be a physician's order for a resident to be transferred to the hospital. The DON acknowledged there was no order for Resident #137 to be transferred to the hospital in the resident's medical record. NJAC 8:39-11.2(b); 27.1(a)

Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to follow physician orders specifically to change the piston set (a device intended for medical purposes that consists of a calibrated hollow barrel and a movable plunger) every 24 hours for 1 of 3 residents reviewed for Tube Feeding, (Resident #54). This deficient practice was evidenced by the following: On 08/12/2024 at 12:10 PM, a review of a facility policy titled Enteral Tubes with a last revised date of 06/3/2024, revealed under the Procedure section: 16. Rinse Thoroughly with tap water and place in a labeled dry plastic bag to remain at bedside. *Change syringe and bag every 24 hours. During the initial tour of Pavilion 2 on 08/05/2024 at 10:58 AM, Resident # 54's piston set was observed on the bed side table. The bottled had the residents name and was dated 8/3/24. A review of the Electronic Medical Record on 08/06/2024 at 09:29 AM, revealed the following: Resident #54 was admitted with diagnoses including but not limited to: Multiple Sclerosis, Gastrostomy (G Tube), Dysphagia (difficulty swallowing). A review of the most recent Quarterly Minimum Data Set, an assessment tool, dated 05/24/2024, revealed under section K Resident #54 had a swallowing disorder and had a feeding tube under Nutritional Approaches. A review of the Physician Order Summary included a physician order with a start date of 02/23/2022 to change piston set every shift (Name and date bottle/package) every night shift. A review of the Medication Administration Record for August 2024 revealed the aforementioned order. Under the dates 08/04 and 08/05 signatures that the order was completed were observed. During an interview with the surveyor on 08/12/2024 at 09:23 AM, the Registered Nurse/Unit Manager (RN/UM #1) was asked what was the facility process for the use of piston sets. RN/UM #1 replied they are changed daily in the evening, usually 11-7 shift which is night. They are used to flush water and give hydration through the G tube. It is important to change every 24 hours for infection control. The surveyor asked what was meant by infection control and she said you could be entering bacteria directly into blood stream of the resident. It is also used to check residual as well. The surveyor also asked where this would be documented, and she responded on the TAR (Treatment Administration Record). RN/UM #1 went on to say if there are initials on the TAR it means it was changed and completed. They are signing for that. On 08/12/2024 at 09:32 AM, the surveyor reviewed the evidence of the irrigation set dated 8/3/24 with RN/UM #1 and confirmed that on 08/05 it had not been changed for 2 days even though it was signed out as having been done. During an interview with the surveyor on 08/12/2024 at 11:05 AM, the Director of Nursing (DON) was asked what was the process for the use of piston sets. The DON replied, to provide fluids or nutrition to the patient. They are supposed to be changed every 24 hours. It is an infection control issue. The surveyor questioned what was meant by infection control issue. The DON responded Make sure that anything going right into their (residents) body is safe and not introduce foreign bacteria into GI (gastrointestinal) system. When asked where this would be documented, the DON replied, It should be on the TAR. On 08/12/2024 at 11:09 AM, the surveyor reviewed the evidence with the DON who confirmed it (the piston set) should have been changed. NJAC 8:39-27.1(a)

Complaint #: NJ 2 Based on record review, interviews, observations, and facility policy review, the facility failed to investigate to determine the causative factors of falls to prevent the falls and/or reduce risk for falls for 1 of 3 residents (Resident #5) reviewed for falls. Resident #5 had multiple falls, with one fall that resulted in a fractured left arm. Findings included: 1. The admission history form indicated Resident #5 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], brain cancer, and a previous stroke. The quarterly Minimum Data Set (MDS) assessment, dated 01/01/2021, indicated the resident had significant memory impairment and the Brief Interview for Mental Status (BIMS) score could not be obtained. Resident #5 was completely dependent for all Activities of Daily Living (ADLs). The MDS indicated Resident #5 needed extensive assistance of one person to transfer. A review of the facility's incident reports beginning 06/01/2020 revealed the following falls for Resident #5: - 06/03/2020 at 10:00 AM - 06/03/2020 at 6:45 PM - 06/04/2020 at 8:48 AM - 06/05/2020 at 2:56 PM - 06/23/2020 at 12:08 PM - 06/27/2020 at 3:43 PM - 07/22/2020 at 6:44 AM - 07/29/2020 at 3:45 AM - 08/04/2020 at 10:00 PM - 08/22/2020 at 9:00 AM - 12/08/2020 at 2:31 PM - 12/31/2020 at 2:46 PM The incident report for the fall on 06/03/2020 at 10:00 AM revealed the facility did not complete an investigation of how the fall occurred or how the facility was going to prevent future falls with goals and interventions. The report revealed the resident was found on the floor. The incident report indicated, Resident is high risk for falls secondary to history of multiple falls, history of non-compliance of fall precautions. Resident #5 was not taken to the hospital. There were no new interventions indicated on the incident report or in the medical record. The incident report for the fall on 06/03/2020 at 6:45 PM revealed the nurse was requested, by the certified nursing assistant (CNA), to assist the roommate. The privacy curtain was drawn when the CNA heard a noise. Upon entering the room, the nurse observed Resident #5 on the floor. The nurse immediately assessed Resident #5 and observed mild swelling and discoloration to the forehead and left wrist.The resident was able to perform active range of motion (AROM) and neurologically was within normal limits (WNL). The physician was made aware and ordered a urine culture to rule out a urinary tract infection ([CONDITION(S)]). The facility did not complete an investigation of how the fall occurred or how they were going to prevent future falls. Resident #5 was not taken to the hospital. There were no new interventions indicated on the incident report or in the medical record. The incident report for the fall dated 06/04/2020 at 8:48 AM, revealed Resident #5 was found on the floor next to his/her wheelchair. Resident #5 was found leaning on the dresser. A nursing note indicated, Patient was transferred from floor to wheelchair and continued assessment was completed and pain and discoloration was noted. The nursing note did not reveal where the pain and discoloration were noted. Resident #5 was transferred to the hospital for evaluation. A nursing note on 06/04/2020 at 1:45 PM indicated Resident #5 returned from the hospital with a fractured left arm. The arm was stabilized in a sling. On 01/13/2021 at 10:42 AM, the Rehabilitation Director (RD) was interviewed. The RD stated prior to September of 2020, Resident #5 was in a standard wheelchair that had an anti-tip rollback system, a Velcro seatbelt, a tab alarm, and brake extenders. The RD stated Resident #5 was picked up for physical and occupational therapy following the 06/04/2020 fall and the left wrist fracture. The main goal of therapy was to assist Resident #5 with self-feeding. On 01/13/2021 at 1:30 PM, CNA #12 was interviewed. CNA #12 stated Resident #5 knew how to release the Velcro seatbelt. Resident #5 moved around a lot and they never knew when to expect a fall. CNA #12 did not recall receiving updated information about interventions to keep Resident #5 safe and prevent falls. On 01/13/2021 at 1:38 PM, CNA #16 was interviewed. CNA #16 stated Resident #5 was unpredictable and would fall on any shift. Resident #5 would often bend over, thinking there was something on the floor that needed to be picked up. CNA #16 did not recall receiving updated information about interventions to keep Resident #5 safe and prevent falls. On 01/13/2021 at 2:25 PM, the Infection Preventionist (ICP) nurse was interviewed. At the time of the 06/03/2020 and 06/04/2020 falls, the ICP was the Director of Nursing (DON). The ICP stated during that time, the facility was going through a lot as it related to COVID-19 outbreaks, and they were looking for a unit manager for the unit where Resident #5 resided. She stated that a follow up investigation was completed, but she could not locate it. Since she could not locate the actual investigation, she could not confirm a root cause analysis had been completed. In addition, she was unable to verbalize the causative factors of the resident's multiple falls. She continued by stating that she was normally organized, but during that time she was working nursing shifts on the floor and papers were just stacking up in her office. A review of Resident #5's plan of care (POC) revealed following the fall with a fracture on 06/04/2020, the resident's POC for falls was not updated until 06/29/2020. The facility's Fall Management Program Policy No-NP-292 dated 02/2020, indicated in part: Policy: The facility will provide the highest quality in the safest environment for the residents residing in the facility. The facility has developed a Fall Management Program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. New Jersey Administrative Code S 8:39-27.1(a)

COMPLAINT # NJ 1, NJ 5 Based on interviews, review of medical records (MR) and other facility documentation, it was determined that the facility failed to ensure that 1 of 7 residents (Resident #2) who exhibited signs and symptoms of pain after a fall, was assessed by a Registered Nurse (RN) on the 11PM-7 AM shift when the accident occurred and medicated for pain in a timely manner. On 6/16/2017 at 5:10 a.m., Resident #2 was found on the bathroom (BR) floor, yelling and holding onto his/her left (L) hip from the pain. A review of the MR indicated that pain medication was administered to Resident #2 on 6/16/2017 at 8:30 a.m. however, the resident was in pain since 5:10 a.m. from the fall, three hours later he/she is given pain medication. The resident was subsequently admitted to the hospital for a left [MEDICAL CONDITION]. This deficient practice is evidenced by the following; 1. According to the facility Admission Record, Resident #2 was admitted in 10/2014 and had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 5/2/2017, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. In addition, the MDS indicated the resident sometimes understood others, sometimes made self understood and required assistance with activities of daily living (ADLS). Review of a Care Plan (CP), created on 4/27/2017, indicated the resident was on hospice and interventions included but were not limited to; assess for pain, restlessness, agitation, constipation and other symptoms of discomfort. In addition, the CP included to medicate as ordered, evaluate effectiveness and provide non-pharmacological approaches to aide in decreasing discomfort. Review of a Progress Note (PN) and corresponding Change In Condition Evaluation (CIC), dated 6/16/2017 at 2:43 p.m., indicated the resident had a fall in the morning, complained of L hip pain, an X-RAY was ordered and pain medication was administered as ordered. Additional review of the CIC Evaluation revealed under Summarize your observations and evaluation: Resident was observed moaning and holding (his/her) hip and complaining of pain. However, review of a Risk Management System (RMS)/Incident Report (IR), dated 6/16/2017 at 5:10 a.m., completed by the 11-7 shift LPN #3, indicated the resident was assisted off of the BR floor and into a w/c and placed into bed. The RMS/IR included the following; Root Cause: Patient didn't use the call bell that was with in reach. Corrective Actions: Re-educated the patient on the use of the call bell. Review of a statement, dated 6/16/2017, attached to the RMS/IR by 11-7 shift LPN #3 revealed; Patient (Resident #2) was found on the bathroom floor holding L (left) hip. Assessed the patient for bumps, bruises and skin tears. Assisted the CNA removing the patient off the floor and into the w/c (wheel chair). Patient was placed in the bed and vitals (vital signs) were taking and neurological checks began. Review of a statement by 11-7 shift CNA #4, dated 6/16/2017, revealed; Working in another client herd (heard) a big bang then a loud scream. Left out patient room went into (Resident #2's) room where the screaming was coming from found (Resident #2) on the floor (sic ) left (the) hip. Yelling at the top of (his/her) voice. Run and called for nurse. Assist nurse with care. Review of a Neurological Assessment Flow Sheet, dated 6/16/2017, completed by 7-3 shift, LPN #1 and 11-7 shift, LPN #3 indicated on 6/16/2017 under observations that Resident #2 had L hip pain at 5:25 a.m, 5:55 a.m., 6:25 a.m., 6:55 a.m., 7:55 a.m., 8:55 a.m., 9:55 a.m. and 10:55 a.m. Review of the 6/2017 physician's orders [REDACTED].#2 had an order for [REDACTED]. Review of the 6/2017 Medication Administration Record, [REDACTED]. Review of the 6/2017 Pain Presence Monitoring sheet for Resident #2 revealed no documenting of the residence's pain after the fall on 6/16/2017. The DON provided another unsampled resident's narcotic declining sheet, emailed to the NJDOH on 12/22/2017, which indicated 7-3 shift LPN #1 administered [MEDICATION NAME] 0.25 ml to Resident #2 on 6/16/2017 at 8:30 a.m., (over three hours after the resident fell ) and at 2:00 p.m. Attached to the email was a statement, dated 12/20/2017, by LPN #1 that noted Resident #2 was medicated at those times. However, this confirmed that no pain medication was administered to Resident #2 after the fall by the LPN #3 or RN on the 11-7 shift. Review of an X- RAY report, dated 6/16/2017, at 2:36 p.m., revealed the resident had an Acute lip [MEDICAL CONDITION] . Review of a New Jersey (NJ) Universal Transfer Form, dated 6/16/2017, revealed Resident #2 was transferred to the hospital on [DATE] at 3:00 p.m. for L hip pain and a positive X-RAY. During a telephone interview with the surveyor on 12/11/2017 at 9:40 a.m., 11-7 shift CNA #4 stated that on on 6/16/2017, she was in another resident's room and heard a big bang and a scream. CNA #4 ran to Resident #2's room and saw the resident on the BR floor and immediately ran to get 11-7 LPN #3. CNA #4 stated LPN #3 came in, did an assessment, checked the resident's blood pressure, and asked the resident if he/she was in pain, was able to get up, then LPN #3 and another CNA picked Resident #2 off the floor and transferred the resident to bed. CNA #4 stated, Resident #2 was crying, holding his/her left hip. CNA #4 stated LPN #3 was the only nurse who was in the resident's room from the time he/she responded to the fall and was transferred to bed. Additionally, CNA #4 stated after the resident was transferred to bed, Resident #2 was yelling and holding onto her left hip. During an interview with the surveyors on 12/12/2017, at 12:20 p.m., 7-3 shift, LPN #1 stated she came into work the 7-3 shift on 6/16/2017, and was assigned to Resident #2. LPN #1 stated Resident #2 was in bed, in pain, the physician gave an order not to send the resident to the hospital and was waiting for an X- RAY to be done. LPN #1 stated the prior nurse, 11-7 shift, LPN #3 ordered the X-RAY but did not order it STAT (immediately), so LPN #1 ordered the X-RAY STAT. LPN #1 stated she was very concerned for Resident #2, who had definite signs of pain, with facial grimacing. LPN #1 stated she believed LPN #3 gave the resident pain medication, and LPN #1 stated she also gave the resident pain medication. The surveyor reviewed 6/2017 MAR indicated [REDACTED]. LPN #1 stated After a fall, a RN is to assess the resident but LPN #3 did not call an RN because she felt her assessment was good enough, and the RN supervisor was not aware of Resident #2's fall. LPN #1 stated the RN unit manager arrived around 7/730 a.m. that morning and assessed the resident. During a telephone interview with the surveyor on 12/14/2017 at 2:44 p.m., CNA #5 stated she was assigned to Resident #2 during the 7-3 shift on 6/16/2017. CNA #5 stated Resident #2 was in bed during the shift and showed signs of pain such as holding his/her leg, would scream when moved and CNA #5 stated he/she needed another CNA to assist with care but was only able to provide incontinent care because the resident was in so much pain. CNA #5 stated, you couldn't do too much for (him/her) because (he/she) was in pain, all I could do was wash a little but could not keep moving (Resident #2) back and forth. Additionally, CNA #5 stated, Resident #2 would scream if you touched (him/her), which was different than usual. Review of the hospital emergency room (ER) records, dated 6/16/2017, at 4:40 p.m. indicated the resident had an unwitnessed fall at the facility, and the xrays show left hip fx (fracture), screaming in pain . The ER notes indicated the physician saw the resident at 4:00pm. on 6/16/2017, and included but was not limited to; It appears (Resident #2) got out of bed without assistance to go to the bathroom and had a mechanical fall. When medical staff from the nursing home arrived (he/she) was unable to bear weight on that extremity and was complaining of severe pain, unable to bear weight .Location: Left hip(,)Severity:severe (,) Quality:aching (,) Timing: Continuous Duration:11 hours . Review of the Physical Exam revealed the resident Appears distressed and the resident's left leg was externally rotated mildly shortened. ROM (Range of Motion) limited due to pain . Review of a facility policy, dated 1/1/2004, revised on 11/28/2016, titled, Pain Management included but was not limited to; Patients will be evaluated as part of the nursing assessment process for the presence of pain upon admission/re-admission, quarterly, with change in pain status, and as required by the state thereafter. 5. If PRN (as needed) medications are given, document on the back of the MAR indicated [REDACTED]. 8. Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. Document: 8.1 Effectiveness of PRN medications. 8.2 Ineffectiveness of routine or PRN medications including interventions, follow-up, and physician/APN/PA notification; NJAC 8:39-27.1(a)

Complaint # NJ Based on observation, interviews, review of medical records and other facility documentation, it was determined that the the facility failed to implement the interventions and re-evaluate the expected outcomes that were not effective for Resident #16. The facility failed to consistently monitor the behaviors that triggered incidents and evaluate that the staff implemented the interventions that were identified in the plan of care were being provided to the resident. These deficient practices posed a serious and immediate threat to all residents and was identified as an immediate jeopardy (IJ) situation. The facility's Administrator, and Director of Nursing (DON) were made aware of the Immediate Jeopardy (IJ) situation on 9/20/2017 at 1:35 p.m., which began on 5/7/2017 and was corrected on 9/20/2017 when an acceptable Plan of Correction (P(NAME)) was implemented. The P(NAME) is as follows: Resident #16 has been put on 1:1 to eliminate risk until alternate placement can be found. Care Plan updated to reflect changes. All residents with Care Plans have the potential to not have them updated to include comprehensive, individualized interventions. Staff have been re-educated on the current P&P for abuse prohibition. Review of RMS's r/t resident to resident altercations completed to assure that aggressive behaviors were identified and addressed appropriately. Daily review (5 days a week) of completed RMS's by IDCP team, at morning meeting, to assure that investigations have been completed as per policy. Care Plan completed and note written at that time. Weekly review by CNE with report submitted to QAPI monthly. This deficient practice was identified in 1 of 31 sampled residents (Resident #16) who had a history of [REDACTED]. A review of the Resident #16's MR, indicated Resident #16 had four resident to resident altercations (5/7/2017, 6/3/2017, 8/7/2017 and 9/1/2017) in 2017. Care Plan (CP) interventions included but were not limited to; Attempt to keep (Resident #16) a safe distance away from other residents. History of striking out at others, (Date initiated: 02/27/2014, Revision on 05/08/2017). Re-educate staff to intervene if they see that other residents are getting too close to (Resident #16) and divert them as needed., (Date Initiated: 01/29/2015, Revision on: 05/8/2017). Have other (Residents) keep a safe distance to ensure that (Resident #16) can't reach out and grab them, (Date Initiated: 08/14/2014, Revision on 08/08/2017). Continue to observe resident for behavior, (Date Initiated: 09/01/2017). There was no indication in the MR that specific interventions were followed, and/or effective. Additionally, during interviews with the surveyors, all staff members on Resident #16's unit were not aware to keep Resident #16 a safe distance from other residents. A review of a Certified Nursing Assistant (CNA) Kardex (care plan), reviewed by the surveyor on 9/19/2017, included but was not limited to; Attempt to keep (Resident #16) away from other residents. History of striking out. Have other (Resident #16) keep a safe distance to ensure that (Resident #16) can't reach out and grab them. Observe and monitor (Resident #16) for aggressive/combative behavior towards residents and intervene as necessary. Re-educate staff to intervene if they see that other residents are getting too close to (Resident #16) and divert them as needed. Review of a Progress Note (PN), dated 4/15/2017 at 12:45 p.m., revealed, Since the last evaluation there has been no change in behavior symptoms. Continues to wheel the wheelchair into other patients intentionally. Has to be redirected from staff. A. According to the facility Admission Record, Resident #13 was admitted in 8/2014 with [DIAGNOSES REDACTED]. An MDS, dated [DATE], revealed Resident #13 had short and long term memory impairments, and required extensive assistance with ADLS. Review of a Reportable Event Record/Report (AAS-45) sent to the New Jersey Department of Health (NJDOH), dated 5/8/2017, revealed that on 5/7/2017, Resident #16 had grabbed Resident #13's hair in the dining room (DR) after Resident #13 was cursing and yelling at Resident #16. The residents were separated and there was no injury noted. Review of a Risk Management System (RMS)/Incident Report (IR), dated 5/7/2017 at 1:10 p.m., for Resident #16 indicated Resident #16 pulled Resident #13's hair. Then Resident #13 was yelling and cursing at Resident #16. Under Corrective Actions: Residents immediately separated by staff, checked for injury; MD (physician) and family notified; social services offered; to be seen by psych. An additional RMS for Resident #13, dated 5/7/2017 at 1:10 p.m. indicated, Resident #13 was observed being verbally abusive to Resident #16 who later grabbed/pulled Resident #13's hair. Resident removed from the area. Under Root Cause/conclusion: Verbally abusive to another Resident (#16) and (Resident #13's) hair was pulled by (Resident #16). No apparent injury noted, denied pain or discomfort.Corrective actions: Resident (#13) Not sure if that is who was removed immediately removed from the area. Resident educated on verbal abuse. Social services offered. Review of Resident #13's PN dated, 5/7/2017 timed at 1:09 p.m., indicated, A change in condition had been noted. The symptoms include: Trauma (fall related or other) 05/07/2017 in the afternoon. Review Resident #16's PN dated, 5/7/2017 timed at 3:17 p.m., revealed, A change in condition has been noted. The symptoms include: Other change in condition (Resident #16) grabbed the hair of another resident. Review of a statement written for Resident #27 who observed the incident, by the Social Worker (SW), dated 5/8/17, indicated Resident #16 and Resident #13 were in the DR. Resident #13 called Resident #16 a profanity. Resident #16 backed his/her w/c into Resident #13's table and pulled Resident #13's hair. A CNA was passing lunch trays when Resident #27 yelled out (he's/she's) fighting (Resident #13), then a CNA came over and removed Resident #16's hand from Resident #13's hair. Review of a statement from CNA #13, dated 5/7/2017, indicated a staff member witnessed Resident #16 pulling Resident #13's hair. The staff member separated the two residents and stated Resident #13 was using profanity towards Resident #16 before he/she pulled the resident's hair. Review of the Med Options (Nurse Practitioner Psychiatric) consult titled, Medication Management Assessment, dated 5/7/2017, indicated Resident #16 had [DIAGNOSES REDACTED]. The consult recommendations included but was not limited to; Recommendations/Plan See medication orders. Continue to monitor mood and behavior. Continue to encourage interaction/activity participation. medication orders [REDACTED]. Resident remains stable overall. **Recent incident due to dementia. Review of Resident #13's CP included an intervention, dated 5/10/2017, to Evaluate need for Psych/Behavioral Health consult. Follow up as needed. Review of Resident #16's CP included an intervention, dated 5/10/2017, to obtain a psychiatric evaluation as ordered and follow up as needed with revisions, dated 5/7/2017, to prior interventions. B. According to the facility Admission Record, Resident #29 was admitted in 3/2017 with [DIAGNOSES REDACTED]. An MDS, dated [DATE], revealed Resident #29 had a BIMS of 15 which indicated intact cognition and required supervision with ADLS. Review of a RMS/IR, dated 6/3/2017 at 6:35 p.m., for Resident #16, revealed Resident #16 was sitting in a w/c when Resident #29 walked by with a cane. Resident #16 grabbed Resident #29's cane, Resident #29 tried to take back the cane by pulling on it, but Resident #16 was still holding onto the cane which caused Resident #16 to fall over in the w/c. There were no injuries and Resident #16 was assisted back into the w/c. Under Root Cause/conclusion: Resident (#16) grabbed onto another ambulating resident's cane, when the other resident (#29) pointed it toward him. Corrective actions: keep the other ambulating resident (#29) away from (Resident #16). Both residents were educated on the hazard of their actions. Review of a statement, dated 6/3/2017 at 6:15 p.m., indicated While walking past the nursing station I heard a loud crash. When I turned around I saw (Resident #16's) wheelchair flipped backwards while holding onto another residents cane . Review of a statement, dated 6/3/2017 at 6:15 p.m., revealed that when walking past the nurses station .I heard a big bang and screaming. Saw patient (Resident #16) on the floor with wheelchair positioned as if (he/she) fell backwards. Other resident (Resident #29) was pulling his cane back from (Resident #16). Review of Resident #16's PN, dated 6/3/2017 at 6:31 p.m., indicated a change in condition (CIC) for Resident #16 indicating the resident had a fall. Review of Resident #16's PN, dated 6/12/2017 at 9:34 a.m., indicated the Interdisciplinary Care (IDC) reviewed the fall from 6/3/17 at 6:35 p.m.; This resident grabbed the cane of another resident as (he/she) was walking by. (Resident #16) did not let go of the cane and resident (#16) was pulled out of wheelchair landing on the floor. No apparent injury noted at this time. Resident has psych (psychiatric) history and will be seen on next visit. During an interview with the surveyor on 9/20/2017 at 1:00 p.m., Resident #29 stated when on the second floor while walking with the cane in the hallway, Resident #16 self-propelled the w/c and grabbed the cane. Resident #29 stated he/she got scared, held onto the cane and pulled it away so Resident #16 couldn't get it. Resident #29 stated Resident #16 was very strong. During an interview with the surveyor on 9/20/2017 at 10:44 a.m., the DON stated she reviewed the 6/3/2017 RMS/IR for Resident #16 and considered it a fall, not a resident to resident altercation, however, after reviewing it, it should have been a resident to resident (altercation). Review of the Med Options Medication Management Assessment consult, 6/12/2017, included the same [DIAGNOSES REDACTED]. Resident remains stable overall. Review of Resident #29's CP did not indicate the CP was reviewed or updated after the incident. Review of Resident #16's CP did not indicate the CP was reviewed or updated after the resident to resident incident altercation on 6/3/2017. C. According to the facility Admission Record, Resident #28 was admitted in 1/2014 with [DIAGNOSES REDACTED]. An MDS, dated [DATE], indicated the resident had short and long term memory impairments and required extensive assistance with ADLs. Review of Resident #28's PN dated, 8/7/2017 at 2:30 p.m. revealed the resident was kicked in the right leg by another resident. Review of Resident #16's PN, dated, 8/7/2017 at 2:12 p.m., revealed, A change in condition has been noted. The symptoms include: Behavior symptoms (e.g. agitation, [MEDICAL CONDITION]) on 08/07/2017 in the afternoon . Review of Resident #16's PN, dated 8/8/2017 at 11:22 a.m. and titled Care Plan Evaluation revealed; resident with episode of kicking another resident. Review of an AAS-45 Reportable Event/Record sent to the NJDOH on 8/8/2017 indicated; on 8/7/2017 Resident #28 was sitting in the hallway when Resident #16 went near the resident and swung a foot towards the resident hitting the right lower leg. The residents were separated immediately. Resident #28 was assessed and no injuries were noted. Interventions implemented were to; keep a safe distance from others, follow up by psychiatry, observation of both residents for 72 hours and for social services to follow up. Attached to the Reportable Event AAS-45 included a summary that revealed, On 8/7/2017, (Resident #28), who has dementia with behavior disturbances, was sitting in his/her wheelchair in the hallway outside of room (resident room) when (Resident #16), with hx (history) of aggression towards others, depression, [MEDICAL CONDITION] (and) dementia, wheeled up to (Resident #28), sung (swung) foot hitting (Resident #28) in the right shin. No injury was noted, full assessment was completed and not (sic) redness, selling (sic), or discolorations were found. Residents were immediately separated and (Resident #16) was kept a safe distance from other residents. Psych (Psychiatry) services followed up with (Resident #16), Social service to follow both residents. Staff reinforced to keep resident a safe distance from other residents. Observation of both residents by staff for 72 hours. (Resident #28) was interviewed and was unable to recall incident. (Resident #16) was interviewed and was not able to respond to any questions. Review of the RMS/IR, dated 8/7/2017 at 2:15 p.m. for Resident #28, indicated that the Resident #28 was observed by a CNA being kicked by Resident #16. Under Root cause/conclusion: Resident was kicked in the shin by another resident who has a history of [MEDICAL CONDITION], delusions and aggression towards others, no injury was noted. Corrective Actions: other resident was removed from area; social services to follow; nursing to observe every shift for 72 hours. Review of a statement by CNA #1, dated 8/7/2017, revealed; I was coming out of (room number) after making the beds and caught (Resident #16) kicking (Resident #28) the resident's right leg. I stopped (Resident #16) from kicking (Resident #28) by moving (Resident #16's) wheelchair away from (Resident #28). I brought (Resident #16) to the day room and told my unit manager. During an interview with the surveyor on 9/20/17 at 2:12 p.m. CNA #1 stated; (Resident #16) sometimes strikes at other residents. As per the CNA, the staff did not receive instructions to keep Resident #16 away from other residents. I learned that on my own, that (Resident #16) needs to be kept away from other residents; especially women. (Resident #16) likes to attack women. We can't watch (Resident #16) all day. We put (him/her) on a separate table by (him/her) self, but (Resident #16) moves around freely. We are in and out of the resident rooms and it is hard to watch someone like that. If you noticed just now there was no nurse at the nursing station and no aide either. The resident was in the wheel chair across from the elevator. The surveyor observed Resident #16 was sitting in his/her w/c across from the elevator. There were no staff at the nursing station. Review of the Med Options Medication Management Assessment consult, dated 8/7/2017, indicated the resident had [DIAGNOSES REDACTED]. The consult included but was not limited to; Recommendations/Plan See medication orders. Continue to monitor mood and behavior. Continue to encourage interaction/activity participation. medication orders [REDACTED]. Resident remains stable overall. Review of Resident #28's CP revealed no documented evidence of the incident. Review of Resident #16's CP included an intervention, dated 8/8/2017, Monitor conditions that may contribute to mood state, including: metabolic causes (e.g., [MEDICAL CONDITIONS] disorder, liver disease, [MEDICAL CONDITION], electrolyte imbalance) respiratory problems, [MEDICAL CONDITION], delusions, hallucinations, psychiatric disorder(s), poor nutrition, hearing or vision impairment, new/acute health problem, exacerbation of a chronic condition (e.g.,, [MEDICAL CONDITION], diabetes), constipation, infection, head injury, pain, fever, dehydration or alcohol withdrawal. with a CP revision dated 8/8/2017 Have other (Resident #28) keep a safe distance to ensure that (Resident #16) can't reach out and grab them. D. According to the facility Admission Record, Resident #27 was admitted in 2/2016 with [DIAGNOSES REDACTED]. An MDS, dated [DATE], revealed a BIMS of 15 which indicated intact cognition and required assistance with ADLS. Review of a PN for Resident #27, dated 9/1/2017 at 3:17 p.m., included; A change in condition has been noted. The symptoms include: .punched on left upper arm 09/01/2017 in the morning. Review of a PN for Resident #27, dated 9/1/2017 at 11:17 p.m., included; A penny-sized discoloration on her left lateral arm noted. No complaint of pain on the area. Review of PN for Resident #16, dated 9/1/2017 at 2:34 p.m., revealed a change in condition for Resident #16 indicating the resident was struck in arm. Review of Resident #16's PN, dated 9/8/2017, timed at 10:29 a.m., revealed; IDC (Interdisciplinary Care) team reviewed incident that occurred on 9/1 at 11:40 am where (Resident #16) hit another resident and was in return hit back by resident. No injury noted to either resident. Resident (#16)has had behaviors noted in the past. Followed by psych (psychiatry) .Staff to ensure that (Resident #16) is a safe distance from other residents. Review of an AAS-45 sent to the NJDOH on 9/1/2017 revealed that on 9/1/2017 a confused resident (Resident #16) was described as having been involved in an incident where he/she punched another resident in the arm after he/she had gotten close to him. The residents separated themselves and staff was educated to have residents respect others space and not to strike out at other residents. Review of an RMS/IR, dated 9/1/2017 at 11:40 a.m., for Resident #16 revealed that Resident #27 was hit in the left upper arm by Resident #16. Under Root cause/conclusion: resident gets upset at times and will grab or swing at other residents. Corrective actions: resident will continue (to) be observed andis (and is) followed by psych services. Review of a statement from the Director of Environmental Services, dated 9/1/2017, indicated on 9/1/2017 at 11:00 a.m., Resident #27 was crying and stated Resident #16 punched him/her on the arm and Resident #27 punched back. Review of a statement from Resident #27, dated 9/1/2017, revealed on 9/1/2017, the resident went to the day room to visit a family member and when Resident #27 went around the table, Resident #16 punched the resident in the left arm and Resident #27 punched Resident #16 back. Review of a Statement by RN #1, dated 9/1/2017, indicated Resident #27 was crying and stated Resident #16 punched this resident and Resident #27 returned the punch. RN #1 assessed Resident #27's arm and a small bump was noted under the skin. Resident #16 remained in the day room for lunch supervised by staff and then was brought out to the nursing desk. During an interview with the surveyor on 9/20/17 at 2:45 p.m., Resident #27 stated that a guy (Resident #16) hit me 3 months ago. I was riding by (Resident #16) and I said excuse me, then the resident (#16) put arm up and hit me. I hit (him/her) back. The nurse came and checked me and found a large lump on my arm. (Resident #16) pulled another resident hair. (Resident #16) creeped up to another resident and pulled (his/her) hair in the dining room. I yelled and staff pried (Resident#16's) hands off of the resident's hair. Another time (Resident #16) was hitting roommate with a pillow. (Resident #16) still goes to the dining room; spits on the nurse and the people who are being fed. I try not to get too close. Review of Resident #27's CP included an intervention, dated 9/1/2017, educated on importance of not striking back. Make staff aware when (he/she) wants to visit with (family member) in dining room in presence of other resident. Review of Resident #16's CP included an intervention dated 9/1/2017, continue to observe resident for behavior. During an interview with the surveyor on 9/20/2017 at approximately 11:15 a.m., RN #1, stated Resident #16 was able to self-propel with a w/c and that staff are aware, including activities staff, to observe Resident #16 and to make sure that the resident stays away from other residents. Also, to try not to sit Resident #16 next to other residents. The surveyor reviewed Resident #16's CP interventions and the incidents with the other residents with RN #1. The surveyor asked RN #1 how Resident #16 was able to have contact with the other residents. RN #1 stated, We can't see him every second of every day and We are trying to keep an eye on him the best we can. The surveyor asked RN #1 if Resident #16's interventions were effective. RN #1 stated, Not always. During an interview with the surveyor on 9/19/2017 at 9:10 a.m., LPN #3 stated everyone is aware of Resident #16's behaviors and staff try to keep the resident away from other residents because he/she will try to punch or kick others, is quick to make a fist and shows an increase in aggression towards the female residents. LPN #3 stated, the staff move him away before he reacts. During an observation on 9/19/2017, at 9:15 a.m., CNA #8 was observed transporting Resident #16 in his w/c and placed the resident directly next to a female resident. During an interview with the surveyor on 9/19/2017 at 9:18 a.m., CNA #8 stated Resident #16 tries to back his/her w/c into the other residents, and sometimes tries to hit staff and residents, and stated everyone has to watch him. During an interview with the surveyor on 9/20/2017 at approximately 2:53 p.m., the recreation assistant (RA) for the second floor stated that Resident #16 can self-propel in a w/c and she was never told to keep Resident #16 away from other residents. Additionally, the RA stated that nursing or her boss would notify her of any changes with a resident's behavior. During an interview with the surveyor on 9/20/17 at 2:35 p.m., Unsampled Resident #7 stated, Sometimes (Resident #16) grabs my legs and tries to hit me. The first time he/she tried to hit me with a pillow. (Resident #16) punches other people a lot of the times in the hallway. If the people say something, he/she punches them. I can't protect myself, my body does not move. I call the nurse. I am not scared of him. I do not want a room change. When he/she is in bed, I am ok because he/she does not walk. During an interview with the surveyor on 9/20/17 at 2:25 p.m. CNA #4 stated, No one informed me to keep an eye on any resident. We do not have any resident on increased supervision. I am not aware to keep (Resident #16) away from other residents. The resident moves a lot in the w/c from the DR back out into the hallway. The surveyor interviewed CNA #5 on 9/20/17 at 1:14 p.m. CNA #5 stated, (Resident #16) usually sits in front of the nursing station and/or dining room. The resident is aggressive with other residents at times whereby he/she pulls arms and/or hits. Nurses do not report to us to keep the Resident (#16) away from other residents. Resident #16 is not on increased supervision. The surveyor interviewed CNA #2 on 9/20/17 at 1:25 p.m. CNA #2 stated that Resident #16 was not on increased supervision and she was not aware of any plan to keep this resident(Resident#16) away from other residents. On day 5 of the survey, 9/20/2017 at 10:44 a.m., the DON was asked by the surveyors to provide the behavior monitoring sheets for Resident #16. The DON stated, the staff have not been completing the behavior monitoring as they should, and was not sure what months were in the MR. A review of the Behavior Monitoring and Interventions (BMI) sheets that were received by the surveyor for the months of May 2017 and June 2017 were blank even though the resident had incidents with other residents on 5/7/17 and 6/3/17. The BMI for August 2017, behavior codes for kicking and punching were written in, however, there was no documented evidence to support the staff noted Resident #16's behavior on 8/7/17 of kicking another resident. During a subsequent interview with the surveyor on 9/20/2017 at 10:44 a.m., the DON was asked who monitored the resident after each incident. The DON stated that Resident #16 self-propels around, the staff are supposed to keep him occupied and they try to keep an eye on him, he sits by himself a lot .no one can sit with him one on one. The DON added, He's not appropriate to be here. Review of a facility policy titled, Person-Centered Care Plan dated 11/28/2016, included but was not limited to the following; The Center must develop and implement a baseline person-centered care plan within 48 hours for each patient that included the instructions needed to provide effective and person centered care that meet professional standards of quality of care. The interdisciplinary team, in conjunction with the patient and/or resident representative, as appropriate, will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. 2. A comprehensive person-centered care plan must be developed for each patient and must describe the following: 2.1 Services that are to be furnished .4.1 The care plan must be customized to each individual patient's preferences and needs. 5. Care plan will be: 5.1 Communicated to appropriate staff, patient, HCDM, family; 5.2 Reviewed and revised a minimum of quarterly and as needed to reflect the response to care and changing needs and goals;5.3 Documented on the Care Plan Evaluation Note. NJAC 8:39-27.1(a)

Complaint # NJ , NJ 8, NJ 5, NJ 6 Based on observation, interviews, review of medical records (MR) and other facility documentation, it was determined that the facility failed to provide adequate supervision in a manner that maximized resident safety and minimized the risk for resident to resident mistreatment. The resident (Resident #16) had a known history of resident to resident altercations that involved hitting, kicking and grabbing since 5/7/2017. Also, the facility failed to develop/implement any additional interventions when previous interventions were not effective for Resident #16. The facility failed to consistently monitor the behaviors that triggered incidents and evaluate that the staff implemented the interventions that were identified in the plan of care were effective. The resident was able to self-propel in a wheel chair (w/c), attended functions on and off the unit unsupervised. A review of the Resident #16's MR revealed that the resident had four resident to resident altercations (Residents #13,#27,#28, and #29) on 5/7/2017, 6/3/2017, 8/7/2017, and 9/1/2017 2017. These deficient practices posed a serious and immediate threat to all residents and was identified as an immediate jeopardy (IJ) situation on 9/20/17 at 1:35 p.m. Upon receipt of an acceptable plan of correction (P(NAME)) the deficient practice was corrected on 9/20/17 at 5:01 p.m. The deficient practice was identified for 1 of 31 sampled residents (Resident #16) as evidenced by the following: See Example #1. This deficiency continues at a lower scope and severity of G based on the following; Based on interviews and review of the MR and other facility documentation, it was determined that the facility failed to implement an assistive device, leg rests, on a w/c for Resident #12 who was at risk for falls. Resident #12 was transported in a w/c without leg rests, fell , sustained abrasions to the face which required a treatment ordered by the physician of triple antibiotic ointment to the face for 7 days. In addition, facility staff failed to report an unwitnessed fall (Resident #4) according to facility policy. These deficient practices occurred for 2 of 3 sampled residents reviewed for falls in a sample of 31 and is evidenced by the following; See Example #2. 1. According to the facility Admission Record, Resident #16 was admitted to the facility in 1/10/2013. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 8/1/2017, indicated the resident had long and short term memory impairments and required extensive assistance with activities of daily living (ADLS) including locomotion on and of the unit in a w/c. Review of the Med Options (Nurse Practitioner Psychiatric) consult titled, Medication Management Assessment consult and dated 9/7/2017, included diagnoses, not limited to; Unspecified Psychosis, Major Depressive Disorder and Unspecified Dementia with Behavioral Disturbance. The consult included but was not limited to; Recommendations/Plan .Continue to monitor mood and behavior. Continue to encourage interaction/activity participation .Continue Risperdal, Cymbalta, and Ativan as ordered. Resident remains stable overall. **Sporatic behavior incidents are due to dementia. A Care Plan (CP), initiated on 7/29/2013, and revised on 8/14/2017, included a focus that Resident #16 exhibits or is at risk for distressed mood, psychosocial well-being behavior symptoms related to dementia, delusions, hallucinations, paranoia, labile mood swings, progressive cognitive deterioration, wandering, combative during care: hitting, kicking, biting staff, refusal of medication and care at times. Interventions included but were not limited to; Attempt to keep (Resident #16) a safe distance away from other residents. History of striking out at others, (initiated on 02/27/2014, and revised 05/08/2017). Re-educate staff to intervene if they see that other residents are getting too close to (Resident #16) and divert them as needed (initiated on 01/29/2015, and revised 05/08/2017). Have other (sic) (Resident #16) keep a safe distance to ensure that (Resident #16) can't reach out and grab them, (initiated on 08/14/2014 and revised 08/08/2017). Observe and monitor (Resident #16) for aggressive/combative behavior towards residents and intervene as necessary, (initiated 8/14/2014). Continue to observe resident for behavior (initiated on 09/01/2017). A review of a Certified Nursing Assistant (CNA) Kardex (care plan), reviewed by the surveyor on 9/19/2017, included but was not limited to; Attempt to keep (Resident #16) away from other residents. History of striking out. Have other (Resident #16) keep a safe distance to ensure that (Resident #16) can't reach out and grab them. Observe and monitor (Resident #16) for aggressive/combative behavior towards residents and intervene as necessary. Re-educate staff to intervene if they see that other residents are getting too close to (Resident #16) and divert them as needed. Review of a Progress Note (PN), dated 4/15/2017 at 12:45 p.m., revealed, Since the last evaluation there has been no change in behavior symptoms. Continues to wheel the wheelchair into other patients intentionally. Has to be redirected from staff. A. According to the facility Admission Record, Resident #13 was admitted in 8/2014 with [DIAGNOSES REDACTED]. An MDS, dated [DATE], revealed Resident #13 had short and long term memory impairments, and required extensive assistance with ADLS. Review of a Reportable Event Record/Report (AAS-45) sent to the New Jersey Department of Health (NJDOH), dated 5/8/2017, revealed that on 5/7/2017, Resident #16 had grabbed Resident #13's hair in the dining room (DR) after Resident #13 was cursing and yelling at Resident #16. The residents were separated and there was no injury noted. Review of a Risk Management System (RMS)/Incident Report (IR), dated 5/7/2017 at 1:10 p.m., for Resident #16 indicated Resident #16 pulled Resident #13's hair. Then Resident #13 was yelling and cursing at Resident #16. Under Corrective Actions: Residents immediately separated by staff, checked for injury; MD (physician) and family notified; social services offered; to be seen by psych. An additional RMS for Resident #13, dated 5/7/2017 at 1:10 p.m. indicated, Resident #13 was observed being verbally abusive to Resident #16 who later grabbed/pulled Resident #13's hair. Resident removed from the area. Under Root Cause/conclusion: Verbally abusive to another Resident (#16) and (Resident #13's) hair was pulled by (Resident #16). No apparent injury noted, denied pain or discomfort.Corrective actions: Resident (#13) Not sure if that is who was removed immediately removed from the area. Resident educated on verbal abuse. Social services offered. Review of Resident #13's PN dated, 5/7/2017 timed at 1:09 p.m., indicated, A change in condition had been noted. The symptoms include: Trauma (fall related or other) 05/07/2017 in the afternoon. Review Resident #16's PN dated, 5/7/2017 timed at 3:17 p.m., revealed, A change in condition has been noted. The symptoms include: Other change in condition (Resident #16) grabbed the hair of another resident. Review of a statement written for Resident #27 who observed the incident, by the Social Worker (SW), dated 5/8/17, indicated Resident #16 and Resident #13 were in the DR. Resident #13 called Resident #16 a profanity. Resident #16 backed his/her w/c into Resident #13's table and pulled Resident #13's hair. A CNA was passing lunch trays when Resident #27 yelled out (he's/she's) fighting (Resident #13), then a CNA came over and removed Resident #16's hand from Resident #13's hair. Review of a statement from CNA #13, dated 5/7/2017, indicated a staff member witnessed Resident #16 pulling Resident #13's hair. The staff member separated the two residents and stated Resident #13 was using profanity towards Resident #16 before he/she pulled the resident's hair. Review of the Med Options (Nurse Practitioner Psychiatric) consult titled, Medication Management Assessment, dated 5/7/2017, indicated Resident #16 had [DIAGNOSES REDACTED]. The consult recommendations included but was not limited to; Recommendations/Plan See medication orders. Continue to monitor mood and behavior. Continue to encourage interaction/activity participation. Medication Orders: Continue Risperdal, Cymbalta, and Ativan as ordered. Resident remains stable overall. **Recent incident due to dementia. Review of Resident #13's CP included an intervention, dated 5/10/2017, to Evaluate need for Psych/Behavioral Health consult. Follow up as needed. Review of Resident #16's CP included an intervention, dated 5/10/2017, to obtain a psychiatric evaluation as ordered and follow up as needed with revisions, dated 5/7/2017, to prior interventions. B. According to the facility Admission Record, Resident #29 was admitted in 3/2017 with [DIAGNOSES REDACTED]. An MDS, dated [DATE], revealed Resident #29 had a BIMS of 15 which indicated intact cognition and required supervision with ADLS. Review of a RMS/IR, dated 6/3/2017 at 6:35 p.m., for Resident #16, revealed Resident #16 was sitting in a w/c when Resident #29 walked by with a cane. Resident #16 grabbed Resident #29's cane, Resident #29 tried to take back the cane by pulling on it, but Resident #16 was still holding onto the cane which caused Resident #16 to fall over in the w/c. There were no injuries and Resident #16 was assisted back into the w/c. Under Root Cause/conclusion: Resident (#16) grabbed onto another ambulating resident's cane, when the other resident (#29) pointed it toward him. Corrective actions: keep the other ambulating resident (#29) away from (Resident #16). Both residents were educated on the hazard of their actions. Review of a statement, dated 6/3/2017 at 6:15 p.m., indicated While walking past the nursing station I heard a loud crash. When I turned around I saw (Resident #16's) wheelchair flipped backwards while holding onto another residents cane . Review of a statement, dated 6/3/2017 at 6:15 p.m., revealed that when walking past the nurses station .I heard a big bang and screaming. Saw patient (Resident #16) on the floor with wheelchair positioned as if (he/she) fell backwards. Other resident (Resident #29) was pulling his cane back from (Resident #16). Review of Resident #16's PN, dated 6/3/2017 at 6:31 p.m., indicated a change in condition (CIC) for Resident #16 indicating the resident had a fall. Review of Resident #16's PN, dated 6/12/2017 at 9:34 a.m., indicated the Interdisciplinary Care (IDC) reviewed the fall from 6/3/17 at 6:35p.m.; This resident grabbed the cane of another resident as (he/she) was walking by. (Resident #16) did not let go of the cane and resident (#16) was pulled out of wheelchair landing on the floor. No apparent injury noted at this time. Resident has psych (psychiatric) history and will be seen on next visit. During an interview with the surveyor on 9/20/2017 at 1:00 p.m., Resident #29 stated when on the second floor while walking with the cane in the hallway, Resident #16 self-propelled the w/c and grabbed the cane. Resident #29 stated he/she got scared, held onto the cane and pulled it away so Resident #16 couldn't get it. Resident #29 stated Resident #16 was very strong. During an interview with the surveyor on 9/20/2017 at 10:44 a.m., the DON stated she reviewed the 6/3/2017 RMS/IR for Resident #16 and considered it a fall, not a resident to resident altercation, however, after reviewing it, it should have been a resident to resident (altercation). Review of the Med Options Medication Management Assessment consult, 6/12/2017, included the same [DIAGNOSES REDACTED]. Resident remains stable overall. Review of Resident #29's CP did not indicate the CP was reviewed or updated after the incident. Review of Resident #16's CP did not indicate the CP was reviewed or updated after the resident to resident incident altercation on 6/3/2017. C. According to the facility Admission Record, Resident #28 was admitted in 1/2014 with [DIAGNOSES REDACTED]. An MDS, dated [DATE], indicated the resident had short and long term memory impairments and required extensive assistance with ADLs. Review of Resident #28's PN dated, 8/7/2017 at 2:30 p.m. revealed the resident was kicked in the right leg by another resident. Review of Resident #16's PN, dated, 8/7/2017 at 2:12 p.m., revealed, A change in condition has been noted. The symptoms include: Behavior symptoms (e.g. agitation, psychosis) on 08/07/2017 in the afternoon . Review of Resident #16's PN, dated 8/8/2017 at 11:22 a.m. and titled Care Plan Evaluation revealed; resident with episode of kicking another resident. Review of an AAS-45 Reportable Event/Record sent to the NJDOH on 8/8/2017 indicated; on 8/7/2017 Resident #28 was sitting in the hallway when Resident #16 went near the resident and swung a foot towards the resident hitting the right lower leg. The residents were separated immediately. Resident #28 was assessed and no injuries were noted. Interventions implemented were to; keep a safe distance from others, follow up by psychiatry, observation of both residents for 72 hours and for social services to follow up. Attached to the Reportable Event AAS-45 included a summary that revealed, On 8/7/2017, (Resident #28), who has dementia with behavior disturbances, was sitting in his/her wheelchair in the hallway outside of room (resident room) when (Resident #16), with hx (history) of aggression towards others, depression, psychosis (and) dementia, wheeled up to (Resident #28), sung (swung) foot hitting (Resident #28) in the right shin. No injury was noted, full assessment was completed and not (sic) redness, selling (sic), or discolorations were found. Residents were immediately separated and (Resident #16) was kept a safe distance from other residents. Psych (Psychiatry) services followed up with (Resident #16), Social service to follow both residents. Staff reinforced to keep resident a safe distance from other residents. Observation of both residents by staff for 72 hours. (Resident #28) was interviewed and was unable to recall incident. (Resident #16) was interviewed and was not able to respond to any questions. Review of the RMS/IR, dated 8/7/2017 at 2:15 p.m. for Resident #28, indicated that the Resident #28 was observed by a CNA being kicked by Resident #16. Under Root cause/conclusion: Resident was kicked in the shin by another resident who has a history of psychosis, delusions and aggression towards others, no injury was noted. Corrective Actions: other resident was removed from area; social services to follow; nursing to observe every shift for 72 hours. Review of a statement by CNA #1, dated 8/7/2017, revealed; I was coming out of (room number) after making the beds and caught (Resident #16) kicking (Resident #28) the resident's right leg. I stopped (Resident #16) from kicking (Resident #28) by moving (Resident #16's) wheelchair away from (Resident #28). I brought (Resident #16) to the day room and told my unit manager. During an interview with the surveyor on 9/20/17 at 2:12 p.m. CNA #1 stated; (Resident #16) sometimes strikes at other residents. As per the CNA, the staff did not receive instructions to keep Resident #16 away from other residents. I learned that on my own, that (Resident #16) needs to be kept away from other residents; especially women. (Resident #16) likes to attack women. We can't watch (Resident #16) all day. We put (him/her) on a separate table by (him/her) self, but (Resident #16) moves around freely. We are in and out of the resident rooms and it is hard to watch someone like that. If you noticed just now there was no nurse at the nursing station and no aide either. The resident was in the wheel chair across from the elevator. The surveyor observed Resident #16 was sitting in his/her w/c across from the elevator. There were no staff at the nursing station. Review of the Med Options Medication Management Assessment consult, dated 8/7/2017, indicated the resident had [DIAGNOSES REDACTED]. The consult included but was not limited to; Recommendations/Plan See medication orders. Continue to monitor mood and behavior. Continue to encourage interaction/activity participation. Medication Orders: Continue Risperdal, Cymbalta, and Ativan as ordered. Resident remains stable overall. Review of Resident #28's CP revealed no documented evidence of the incident. Review of Resident #16's CP included an intervention, dated 8/8/2017, Monitor conditions that may contribute to mood state, including: metabolic causes (e.g., delirium, thyroid disorder, liver disease, renal failure, electrolyte imbalance) respiratory problems, CVA, delusions, hallucinations, psychiatric disorder(s), poor nutrition, hearing or vision impairment, new/acute health problem, exacerbation of a chronic condition (e.g.,, CHF, diabetes), constipation, infection, head injury, pain, fever, dehydration or alcohol withdrawal. with a CP revision dated 8/8/2017 Have other (Resident #28) keep a safe distance to ensure that (Resident #16) can't reach out and grab them. D. According to the facility Admission Record, Resident #27 was admitted in 2/2016 with [DIAGNOSES REDACTED]. An MDS, dated [DATE], revealed a BIMS of 15 which indicated intact cognition and required assistance with ADLS. Review of a PN for Resident #27, dated 9/1/2017 at 3:17 p.m., included; A change in condition has been noted. The symptoms include: .punched on left upper arm 09/01/2017 in the morning. Review of a PN for Resident #27, dated 9/1/2017 at 11:17 p.m., included; A penny-sized discoloration on her left lateral arm noted. No complaint of pain on the area. Review of PN for Resident #16, dated 9/1/2017 at 2:34 p.m., revealed a change in condition for Resident #16 indicating the resident was struck in arm. Review of Resident #16's PN, dated 9/8/2017, timed at 10:29 a.m., revealed; IDC (Interdisciplinary Care) team reviewed incident that occurred on 9/1 at 11:40 am where (Resident #16) hit another resident and was in return hit back by resident. No injury noted to either resident. Resident (#16)has had behaviors noted in the past. Followed by psych (psychiatry) .Staff to ensure that (Resident #16) is a safe distance from other residents. Review of an AAS-45 sent to the NJDOH on 9/1/2017 revealed that on 9/1/2017 a confused resident (Resident #16) was described as having been involved in an incident where he/she punched another resident in the arm after he/she had gotten close to him. The residents separated themselves and staff was educated to have residents respect others space and not to strike out at other residents. Review of an RMS/IR, dated 9/1/2017 at 11:40 a.m., for Resident #16 revealed that Resident #27 was hit in the left upper arm by Resident #16. Under Root cause/conclusion: resident gets upset at times and will grab or swing at other residents. Corrective actions: resident will continue (to) be observed andis (and is) followed by psych services. Review of a statement from the Director of Environmental Services, dated 9/1/2017, indicated on 9/1/2017 at 11:00 a.m., Resident #27 was crying and stated Resident #16 punched him/her on the arm and Resident #27 punched back. Review of a statement from Resident #27, dated 9/1/2017, revealed on 9/1/2017, the resident went to the day room to visit a family member and when Resident #27 went around the table, Resident #16 punched the resident in the left arm and Resident #27 punched Resident #16 back. Review of a Statement by RN #1, dated 9/1/2017, indicated Resident #27 was crying and stated Resident #16 punched this resident and Resident #27 returned the punch. RN #1 assessed Resident #27's arm and a small bump was noted under the skin. Resident #16 remained in the day room for lunch supervised by staff and then was brought out to the nursing desk. During an interview with the surveyor on 9/20/17 at 2:45 p.m., Resident #27 stated that a guy (Resident #16) hit me 3 months ago. I was riding by (Resident #16) and I said excuse me, then the resident (#16) put arm up and hit me. I hit (him/her) back. The nurse came and checked me and found a large lump on my arm. (Resident #16) pulled another resident hair. (Resident #16) creeped up to another resident and pulled (his/her) hair in the dining room. I yelled and staff pried (Resident#16's) hands off of the resident's hair. Another time (Resident #16) was hitting roommate with a pillow. (Resident #16) still goes to the dining room; spits on the nurse and the people who are being fed. I try not to get too close. Review of Resident #27's CP included an intervention, dated 9/1/2017, educated on importance of not striking back. Make staff aware when (he/she) wants to visit with (family member) in dining room in presence of other resident. Review of Resident #16's CP included an intervention dated 9/1/2017, continue to observe resident for behavior. During an interview with the surveyor on 9/20/2017 at approximately 11:15 a.m., RN #1, stated Resident #16 was able to self-propel with a w/c and that staff are aware, including activities staff, to observe Resident #16 and to make sure that the resident stays away from other residents. Also, to try not to sit Resident #16 next to other residents. The surveyor reviewed Resident #16's CP interventions and the incidents with the other residents with RN #1. The surveyor asked RN #1 how Resident #16 was able to have contact with the other residents. RN #1 stated, We can't see him every second of every day and We are trying to keep an eye on him the best we can. The surveyor asked RN #1 if Resident #16's interventions were effective. RN #1 stated, Not always. During an interview with the surveyor on 9/19/2017 at 9:10 a.m., LPN #3 stated everyone is aware of Resident #16's behaviors and staff try to keep the resident away from other residents because he/she will try to punch or kick others, is quick to make a fist and shows an increase in aggression towards the female residents. LPN #3 stated, the staff move him away before he reacts. During an observation on 9/19/2017, at 9:15 a.m., CNA #8 was observed transporting Resident #16 in his w/c and placed the resident directly next to a female resident. During an interview with the surveyor on 9/19/2017 at 9:18 a.m., CNA #8 stated Resident #16 tries to back his/her w/c into the other residents, and sometimes tries to hit staff and residents, and stated everyone has to watch him. During an interview with the surveyor on 9/20/2017 at approximately 2:53 p.m., the recreation assistant (RA) for the second floor stated that Resident #16 can self-propel in a w/c and she was never told to keep Resident #16 away from other residents. Additionally, the RA stated that nursing or her boss would notify her of any changes with a resident's behavior. During an interview with the surveyor on 9/20/17 at 2:35 p.m., Unsampled Resident #7 stated, Sometimes (Resident #16) grabs my legs and tries to hit me. The first time he/she tried to hit me with a pillow. (Resident #16) punches other people a lot of the times in the hallway. If the people say something, he/she punches them. I can't protect myself, my body does not move. I call the nurse. I am not scared of him. I do not want a room change. When he/she is in bed, I am ok because he/she does not walk. During an interview with the surveyor on 9/20/17 at 2:25 p.m. CNA #4 stated, No one informed me to keep an eye on any resident. We do not have any resident on increased supervision. I am not aware to keep (Resident #16) away from other residents. The resident moves a lot in the w/c from the DR back out into the hallway. The surveyor interviewed CNA #5 on 9/20/17 at 1:14 p.m. CNA #5 stated, (Resident #16) usually sits in front of the nursing station and/or dining room. The resident is aggressive with other residents at times whereby he/she pulls arms and/or hits. Nurses do not report to us to keep the Resident (#16) away from other residents. This resident(Resident #16) is not on increased supervision. The surveyor interviewed CNA #2 on 9/20/17 at 1:25 p.m. CNA #2 stated that Resident #16 was not on increased supervision and she was not aware of any plan to keep the Resident #16 away from other residents. On day 5 of the survey, 9/20/2017 at 10:44 a.m., the DON was asked by the surveyors to provide the behavior monitoring sheets for Resident #16. The DON stated, the staff have not been completing the behavior monitoring as they should, and was not sure what months were in the MR. A review of the Behavior Monitoring and Interventions (BMI) sheets that were received by the surveyor for the months of May 2017 and June 2017 were blank even though the resident had incidents with other residents on 5/7/17 and 6/3/17. The BMI for August 2017, behavior codes for kicking and punching were written in, however, there was no documented evidence to support the staff noted Resident #16's behavior on 8/7/17 of kicking another resident. During an interview with the surveyor on 9/20/2017 at 9:00 a.m., the DON stated the Social Worker (SW) was looking into another facility for Resident #16 that was more appropriate because the last eight months the resident had been having increased episodes of hitting and slapping and shouldn't be here. During a subsequent interview with the surveyor on 9/20/2017 at 10:44 a.m., the DON was asked who monitored the resident after each incident. The DON stated that Resident #16 self-propels around, the staff are supposed to keep him occupied and they try to keep an eye on him, he sits by himself a lot .no one can sit with him one on one. The DON added, He's not appropriate to be here. The facility's Administrator, and DON were made aware of the Immediate Jeopardy (IJ) situation on 9/20/2017 at 1:35 p.m., which began on 5/7/2017 and was corrected on 9/20/2017 when an acceptable Plan of Correction was implemented. The Plan of Correction is as follows: Resident #16 has been put on 1:1 to eliminate risk until alternate placement can be found. Care Plan updated to reflect changes. All residents with Care Plans have the potential to not have them updated to include comprehensive, individualized interventions. Staff have been re-educated on the current P&P for abuse prohibition. Review of RMS's r/t resident to resident altercations completed to assure that aggressive behaviors were identified and addressed appropriately. Daily review (5 days a week) of completed RMS's by IDCP team, at morning meeting, to assure that investigations have been completed as per policy. Care Plan completed and note written at that time. Weekly review by CNE with report submitted to QAPI monthly. 2. According to the Admission Record, Resident #12 was admitted in 4/2016 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 6/20/2017 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment and needed assistance with all activities of daily living (ADLs). In addition, the MDS revealed the resident used a w/c and was coded as 3:2 for locomotion, on and off the unit, which indicated the staff provided weight bearing support during transfers and one person physical assist. Walking in the corridor or room did not occur. An Interdisciplinary Care Plan (ICP), initiated 4/15/2017, included that the resident was at risk for falls due to impaired mobility, cognitive loss and lack of safety awareness. Interventions included but were not limited to; staff to anticipate resident's needs. An Occupational Therapy (OT) Initial Evaluation, dated 5/9/2017, revealed the resident had minimal verbal response requiring mod (moderate) to max (maximum) assist for all basic self care and transfers . and was a primary w/c user. The OT Evaluation included a measurement of the Current Level of ADLs which indicated the resident was unable to propel in a w/c; Wheelchair: = (equals) 0 = (equals) Unable. Review of a facility Risk Management System (RMS)/Incident Report (IR), dated 8/2/2017 at 11:51 a.m. by Registered Nurse #3, revealed that on 8/2/2017 at 10:15 a.m. on the unit hallway, Resident #12 fell out of the wheelchair on to carpet causing 3 small abrasions to left side of face. Three staff helped assist patient into the wheelchair after assessment was completed. The IR included that the resident leaned forward in the w/c while being transported up the hallway in her w/c and fell out of wheelchair onto the carpet. The corrective actions included to order an OT evaluation for positioning and w/c leg rests were put into place. Review of a Nursing Progress Note (NPN), dated 8/2/2017 at 9:30 p.m. by Licensed Practical Nurse (LPN) #5 revealed; .Abrasion remain to left upper eye and underneath left eye. (physician) in facility to examine resident, ordered TAO (Triple Antibiotic Ointment) treatment to facial abrasions (for) 7 days . Review of a NPN, dated 8/3/2017 at 10:45 p.m., revealed; .Abrasions remain to left upper eye brow and beneath eye .Neurological checks in progress. Review of a NPN, dated 8/4/2017 at 6:24 a.m., revealed; Skin discoloration and swelling noted to (L) (left) orbital eye, with two skin scrapes . Review of a physician progress notes [REDACTED]. Review of a Physician order [REDACTED]. Review of the Treatment Administration Record (TAR) confirmed the aforementioned PO and was initialed/signed as administered according to the PO. Review of a statement from the assigned 7-3 shift, Certified Nurses Aide (CNA) #9, dated 8/2/2017, revealed that CNA #9 was pushing (Resident #12) down the hall and (Resident #12) put her foot down real hard and she went forward to the floor. Review of a statement from 7-3 shift, Licensed Practical Nurse (LPN) #4, dated 8/2/2017, included but was not limited to that she was administering medications when she heard a thump on the floor and observed Resident #12 face down on the floor with rugburn scraps on the right side of her face above her eyebrow and the side of her eye. (CNA #9) stated she was pushing her (Resident #12) down the hall and (Resident #12) was stopping with her feet under the chair and fell on her face. Review of an Individual Performance Improvement Plan for CNA #9, dated 8/2/2017, revealed; Staff member was propelling resident in w/c (wheelchair without) footrests, Residents feet dug into the floor and got caught on rug causing resident to fall out of wheelchair to the floor. resident sustained [REDACTED]. The plan included that CNA #9 was inserviced on resident safety and propelling in a w/c. During an interview with the surveyor on 9/12/2017 at 12:30 p.m. and on 9/20/2017 at 8:45 a.m., Resident #12's assi(TRUNCATED)

COMPLAINT # NJ 7 CROSS REFERENCE F 367 Based on interviews and review of the medical record (MR) and other facility documentation it was determined that the facility staff failed to consistently ensure that the correct diet was served according to the diet recommendations of the Speech Therapist (ST) and nursing standards of practice for 1 of 4 sampled residents (Resident #1). In addition, the facility failed to ensure that medications were administered according to physician orders [REDACTED].#1). On 4/29/2017, Resident #1, who was on a diet of ground meat, pureed vegetables and pureed bread was served a peanut and butter jelly sandwich (PBJ) by Licensed Practical Nurse (LPN) #1. Resident #1 consumed at least half of the sandwich. LPN #1 failed to verify the resident's diet prior to notifying the kitchen staff to send the PBJ sandwich. The kitchen staff failed to verify the diet order and sent the PBJ sandwich. LPN #1, who stated she was aware of the diet, gave it to Resident #1 who had a diet order for pureed bread. In addition, during a Nutritional Assessment on 4/26/2017, the Registered Dietician (RD) failed to address/follow the diet recommendations of the ST and documented and verified that she told Resident #1 that a PBJ sandwich was an item the Resident was able to eat. The facility's failure to administer the correct diet according to the diet recommendations and nursing standards of practice resulted in an IJ to the resident's health and well being and had the potential to affect 3 sampled Residents (Resident #2, #4 and #5) and 46 unsampled residents who were on mechanical altered diets. The IJ began on 4/29/2017 when Resident #1 was served and ate the PBJ sandwich and was identified by the surveyor and relayed to the Administrator and Director of Nursing (DON) on 6/9/2017 at 11:10 a.m. The IJ was lifted on 5/30/2017, day 1 of the survey, when facility staff were in serviced and an acceptable plan of correction (POC) was put in place. This deficient practice is 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: 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. 1. a. CROSS REFERENCE F 367, See Example #1. The IJ to the resident's health and well being began on 4/29/2017 when Resident #1 was served and ate the PBJ sandwich and was identified by the surveyor and relayed to the Administrator and Director of Nursing (DON) on 6/9/2017 at 11:10 a.m. The IJ was lifted on 5/30/2017, day 1 of survey, when facility staff were in serviced and an acceptable plan of correction (POC) put in place as follows: 1. Resident #1 is no longer residing at this facility. The concern noted regarding Resident #1 during survey has been addressed. On May 3, 2017, the nurse involved was re-educated on importance of verifying resident's diet order prior to requesting and/or serving any food or liquid item. 2. All residents on altered diets have the potential to be affected by this practice. All resident's records have been reviewed to ensure that the correct diet is consistently documented throughout POC and Care Plan. 3. On May 30, 2017, all nursing staff were re-educated on proper procedure on the verification of diet order per the physician's orders [REDACTED]. On May 30, 2017, all dietary staff were re-educated on the importance of verifying diet order from nursing for each resident prior to sending to nursing unit, to include upon special request by a nursing staff member. On May 30, 2017, the Registered Dietician was re-educated on ensuring diet ordered is consistent with the recommendation of the Speech Therapist as well as what is ordered by the Attending Physician. The Speech Therapist has been requested to recommend one of the available diets, as per facility policy, not a combination of two different diets. 4. All dietary special requests will be entered into a daily log, to be signed off by the requesting nurse as well as the dietary employee delivering same. This log will be reviewed by nursing administration and dietician at a minimum on a weekly basis, to ensure continued compliance. All discrepancies will be reported and addressed immediately. The findings will be documented and reviewed monthly to the CQI Committee. This deficiency continues at a scope and severity of D. Based on interviews, review of the medical record and other facility documentation, it was determined that facility staff failed to ensure that medication was administered according to physician orders [REDACTED].#1.) Reference: https://medlineplus.gov/druginfo/meds/a 3.html [MEDICATION NAME] ([MEDICATION NAME]) [MEDICATION NAME] is used to relieve pain .[MEDICATION NAME] is in a class of medications called opiate (narcotic) [MEDICATION NAME]. According to the facility Admission Record, Resident #1 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 4/28/2017, revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderately impaired cognition, and that the resident needed some assistance with meals and was on as needed (prn) pain medication Review of a Care Plan (CP), initiated 5/1/2017, included that the resident was at risk for fluctuating mood symptoms related to a [DIAGNOSES REDACTED]. Review of a Physician order [REDACTED]. Review of a 4/2017 Medication Administration Record [REDACTED]., 2 tablets, was signed as given at 6:00 a.m., 10:15 a.m., 1:30 p.m. and 9:30 p.m. However, review of the facility declining inventory sheet for 4/25/2017 revealed that [MEDICATION NAME] was signed out for the resident at 12:45 p.m. and 9:30 p.m. for one tablet, and not the prescribed two tablets. Review of the Skilled Nursing Notes (SNN) dated 4/25/2017 at 11:35 a.m. by Registered Nurse #2 included that the resident was given all medications by the cart nurse and pain medications were given as needed and, Resident voiced no complaints. Additionally, a review of the 4/2017 MAR indicated [REDACTED]. Review of the SNN on 4/25/2017 on the 7-3 shift did not indicate why the medication was not given according to physician orders. Review of an email to the New Jersey Department of Health (NJDOH) on 6/16/2017 from the Administrator included a statement form the nurse who gave the [MEDICATION NAME] on 4/25/2017 at 9:30 p.m. The statement included that she administered one tablet of 2 mg. instead of 2 tablets because she misread the order on the MAR. (The) medicine was effective, there were no further complaints of pain before my shift ended. Review of an additional email, sent to the NJDOH on 6/19/2017, included that the facility was unable to contact the second nurse who administered the 6:00 a.m. dose of [MEDICATION NAME]. During an interview with the surveyor on 6/12/2017 at approximately 1:00 p.m., the DON confirmed that all medications should be given according to physician orders. NJAC; 8:39-27.1 (a) 8:39-17.4 (a) (1) (2)

COMPLAINT # NJ 7 Based on interviews and review of the medical record (MR) and other facility documentation it was determined that the facility staff failed to consistently ensure the safety of 1 of 4 sampled residents (Resident #1) who was on a mechanically altered diet and was served regular textured food. On 4/29/2017, Resident #1, who was on a diet of ground meat, pureed vegetables and pureed bread was given a peanut and butter and jelly sandwich (PBJ) by Licensed Practical Nurse (LPN) #1. LPN #1 failed to verify the resident's diet prior to notifying the kitchen staff to send the PBJ sandwich. The kitchen staff failed to verify the diet, and sent the PBJ sandwich and LPN #1 gave it to Resident #1 who was only to have pureed bread. In addition, during a Nutritional Assessment on 4/26/2017, the Registered Dietician (RD) failed to address/follow the diet recommendations of the Speech Therapist (ST) and documented and verified that she told Resident #1 that a PBJ sandwich was an item the Resident was able to eat. The facility's failure to administer the correct diet according to the diet recommendations and nursing standards of practice resulted in an Immediate Jeopardy (IJ) to the resident's health and well being and had the potential to affect 3 sampled Residents (Resident #2, #4 and #5), and 46 unsampled residents who were on mechanical altered diets. The IJ began on 4/29/2017 when Resident #1 was served and ate the PBJ sandwich and was identified by the surveyor and relayed to the Administrator and Director of Nursing (DON) on 6/9/2017 at 11:10 a.m. The IJ was lifted on 5/30/2017, day 1 of survey, when facility staff were in serviced, and an acceptable plan of correction (POC) was put in place. Reference: http://www.mayoclinic.org/diseases-conditions/dysphagia/basics/definition/CON- 444?p=1 :Dysphagia-Difficulty swallowing (dysphagia) means it takes more time and effort to move food or liquid from your mouth to your stomach. http://medical-dictionary.thefreedictionary.com/rhonchi: a continuous sound consisting of a dry [MEDICATION NAME] noise with a lower pitch than that of a wheeze, produced in the throat or [MEDICATION NAME] tube due to a partial obstruction. 1. According to the facility Admission Record, Resident #1 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 4/28/2017, revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderately impaired cognition and that Resident #1 needed some assistance with meals and was on a therapeutic diet. Review of a Care Plan (CP), initiated 5/1/2017, did not include any reference to dysphagia or the residents diet orders. The CP did address fluctuating mood symptoms r/t (related to) a [DIAGNOSES REDACTED]. A Physician order [REDACTED]. However, the order was changed after a Speech Therapist (ST) Evaluation on 4/26/2017 to; Ground meat, puree vegetables, puree bread with thin liquids. Review of the ST Evaluation, dated 4/26/2017, included that the reason for the ST referral was due a report from the ST to the physician of the resident choking on thin liquids in the room. The ST Evaluation indicated that Resident #1 completed PO (by mouth) trials of dysphagia advanced (peanut butter and jelly sandwich), regular solids (cracker) and puree solids (applesauce) .(Resident #1) tolerated all trials of puree solids and thins via cup exhibiting (-) (no) s/s (signs/symptoms) of aspiration. (Resident #1) demonstrated oral dysphagia for sandwich and cracker, as characterized by prolonged mastication (chewing), decreased mastication effectiveness and bolus residue on lingual (tongue) blade, secondary to lack of dentition (teeth). (Resident #1) is recommended for ground meat, puree vegetables, puree bread and thin liquids at this time . During an interview with the surveyor on 6/12/2017 at approximately 10:00 a.m., the ST confirmed his documented assessment and recommendations. The ST stated that after the evaluation recommendations, the facility protocol is to indicate the diet on the POS and inform the unit nurse who will then send a diet recommendation form to the kitchen. Review of a Diet Order and Communication Form, dated 4/26/2017, the same day as the ST Evaluation and signed by the ST, indicated the resident was on a Dysphagia Puree diet with ground meat and thin liquids. Additionally, another Diet Order and Communication Form, dated 4/26/2017 and signed by a unit Registered Nurse (RN) indicated a Diet Order Change to Ground Meat with pureed vegetables and Pureed bread. Review of a Nutritional Assessment, dated 4/26/2017 at 3:59 p.m., by the Registered Dietician (RD) included that the resident was on a Diet Type of Regular Liberalized and a Diet Texture of ground meat, puree fruits/vegetables/bread. The RD indicated that she spoke with Resident #1 regarding current nutrition status. (Resident #1) denies issues (with) chewing/swallowing. Does not report active issues r/t n/v . (related to nausea/vomiting) .will relay to dietary and initiate choice menus to best meet preferences. (Resident #1) was very excited to know that she can order a PBJ (peanut butter and jelly) sandwich in replace of meals as needed . Additionally, the Nutritional Assessment included an area titled; Swallowing. Options to check off included but were not limited to; if the resident was holding food in mouth cheeks or residual food in mouth after meals or coughing or choking during meals or when swallowing medications. The RD checked off none of the above and documented none noted/reported. Additionally, the RD Nutrition Plan Recommendation included but was not limited to; continue mechanically altered diet as above per SLP (Speech Language Pathologist/Speech Therapist) recs (recommendations) and add HS (hour of sleep/evening) PBJ (peanut butter and jelly) sandwich to best meet needs . During an interview with the surveyor on 5/30/2017 at approximately 10:30 a.m., the surveyor asked the RD why she documented that Resident #1 was able to have a PBJ sandwich when the resident was on a diet of pureed bread. The RD confirmed that a PBJ sandwich is not considered puree and she made a mistake. The RD stated she probably was thinking that the resident's diet was liberalized .I made a mistake. I'm not sure why I told the resident that, because a sandwich is not puree, it is not the diet (and I) was not referring to puree. I would have written that. The RD further stated that the diet recommendation comes from the ST, a copy is sent to dietary services to implement the appropriate diet. Review of a Progress Note, dated 4/29/2017 at 4:16 p.m., and electronically signed by LPN #1, included; Resident was served lunch in her room, she refused everything except tea and peanut butter sandwich, safety measures maintain (sic), call bell within reach. Approximately 3p.m., POA (power of attorney) came to nursing station and reported sudden changes of resident condition, this nurse rushed to residents room, resident was noted with decreased level of consciousness and shaking 911 was called to transfer resident to .hospital for evaluation .MD (physician) made aware. Review of a written statement on an Incident/Accident Investigation sheet, dated 5/31/2017 by LPN #1, included but was not limited to; at approximately 11:30 a.m. LPN #1 saw the resident out of her w/c because she was concerned about a missing bag. After it was determined that the bag was not missing the resident requested to eat in her room instead of the dining room (DR) and LPN #1 was informed by a certified nurses aide (CNA) that the resident refused her lunch. LPN #1 stated she spoke with the resident who requested a PBJ sandwich so I (LPN #1) called the kitchen and requested the sandwich and made them aware that it was for (Resident #1) in room .In about 15 mins. (minutes) they brought the sandwich, I took it to her but I removed all the crust before giving it to her with a cup of tea. She started eating the sandwich before I left her . LPN #1 documented that at 2:00 p.m., she administered the resident's medications and the resident was okay sitting in the wheelchair. Around 2:30 to 3 p.m., resident's (family member) informed me that the resident did not look good .(LPN #1) noticed that the resident was shaking but able to answer questions .the charge nurse was called . During a telephone interview with the surveyor on 5/30/2017 at 12:30 p.m. and approximately 2:15 p.m., LPN #1 stated that she was aware the resident was on a ground food diet, not a regular diet prior to calling the kitchen on 4/29/2017. I think a ground diet is a sandwich without crust .I have seen people like that .When I called (the kitchen) I gave the name, room number and they checked the diet slip and they sent it up .I stayed with (Resident #1) for a little bit and she ate fine . LPN #1 stated she was not sure who she spoke with in the kitchen. Additionally, LPN #1 stated she left the resident with the sandwich and continued with her work. She was notified by the Resident's family member (FM) of the residents change in condition at approximately 2:30-3:00 p.m. and she noted that there was still one-half of the PBJ sandwich on the bedside table. During a telephone interview on 5/30/2017 at approximately 12:45 p.m., the unit Charge Nurse, Registered Nurse (RN) #2 stated she was giving medications on another hall when she was called to the residents room due to a change in status. RN #1 stated she was not familiar with the resident prior, but confirmed the resident was conscious. RN #2 confirmed she was not aware if the resident had been eating. Review of a Change in Condition Evaluation, signed by RN #2 and dated 4/29/2017 at 3:57 p.m., included that the resident had a sudden change in level of consciousness or responsiveness, was barely responsive to touch and verbal and was barely responsive, shaking, Vital Signs (VS) Blood Pressure - 157/75, Pulse - 94 and Respirations - 20. Review of the responding Basic Life Support (BLS) Emergency Medical Technician (EMT) County Run sheet, dated 4/29/2017, included that the resident was sitting in a wheelchair on arrival at 3:15 p.m. and Facility staff stated that the Pt. (Resident #1) was having a change in mental status and possibly aspirated. In addition, the resident's respiratory status Grunting (respirations) and left Rhonchi. Symptoms included Breathing Problem and Mental Status Changes with Impression of Airway obstruction and change in Mental Status. Review of the responding Advanced Life Support (ALS) EMT Run Sheet dated 4/29/2017, included that they arrived at the resident at 3:13 p.m. and included that the family of the resident had found the resident in her room, altered, vomit and food on chest and shaking. 911 was called. The Condition of the resident was documented as Altered Level of Consciousness, Difficulty Breathing with left and right rhonchi and wheezing. The Airway Exam included; Vocal cords: food present. The resident was transported to the hospital. During an interview with the surveyor on 5/30/2017 at approximately 1:00 p.m. and on 6/12/2017 at 2:40 p.m. the DON stated that she reviews all medical records of residents who are sent out of the facility via a 911 call but was not aware of any dietary issue with the resident prior to review of the medical record (MR) on 5/3/2017. The DON stated she discussed it with the Administrator and spoke with LPN #1 that day, 5/3/2017 and was told by LPN #1 that she did not check the diet prior to calling the kitchen for the PBJ sandwich on 4/29/2017. The DON stated she in-serviced LPN #1 on 5/3/2017, however, did not document it. The DON confirmed that she did not in-service the other nursing staff, the RD or any of the kitchen staff prior to day 1 of survey on 5/30/2017. Additionally, the DON added that a CP should be initiated by the nursing staff or the RD for a mechanically altered diet. During an interview with the surveyor on 6/12/2017 at 10:45 a.m., the RN Staff Educator confirmed that CPs should be initiated for a resident with a change from a regular to a mechanically altered diet. Review of a written statement, dated 5/30/2017, by the DON included that she spoke with LPN #1 on 5/3/2017 and LPN #1 stated that she did not confirm the diet order in the MR prior to calling the kitchen. During an interview with the surveyor on 5/30/2017 at 10:55 a.m. and 12:00 p.m., the Director of Dietary Services (DDS) stated that she was unable to go back and check the electronic dietary system related to (r/t) a resident no longer in the system past 3 days. The DDS confirmed she received the change of diet slips for Resident #1 and the diet would have been updated immediately upon receipt of the notification on 4/26/2017. The DDS confirmed that a PBJ sandwich is not part of a pureed diet. The DDS stated she was not aware/informed that a resident had not received the correct diet prior to the interview with the surveyor. Additionally, the DDS stated that only nurses were allowed to call the kitchen and request food for a resident and upon that request, the dietary staff manager was responsible for checking the diet also prior to sending the requested food. Review of a facility Diet Manual Guidelines, dated 10/2/2006 included but was not limited to; .provide food and nutrition services that meet the physiological and psychosocial needs of our .residents. .Menu Planning for Dysphagia Puree Diet included but was not limited to; Foods allowed: Pureed bread products . Foods to avoid .Avoid peanut butter unless part of a complete pureed recipe that is easy to swallow . The IJ to the resident's health and well being began on 4/29/2017 when Resident #1 was served and ate the PBJ sandwich and was identified by the surveyor and relayed to the Administrator and Director of Nursing (DON) on 6/9/2017 at 11:10 a.m. The IJ was lifted on 5/30/2017, day 1 of survey, when facility staff were in serviced and an acceptable plan of correction (POC) put in place as follows: 1. Resident #1 no longer residing at this facility. On 5/3/2017 LPN #1 was re-educated on importance of verifying resident's diet order prior to requesting and/or serving any food or liquid item. 2. All residents on altered diets have the potential to be affected by this practice. All resident's records have been reviewed to ensure that the correct diet is consistently documented throughout POC and Care Plan. 3. On May 30, 2017, all nursing staff were re-educated on proper procedure on the verification of diet order per POS prior to requesting and/or serving any food or liquid item to any resident. On May 30, 2017, all dietary staff were re-educated on the importance of verifying diet order from nursing for each resident prior to sending to nursing unit, to include upon special request by a nursing staff member. On May 30, 2017, the Registered Dietician was re-educated on ensuring diet ordered is consistent with the recommendation of the Speech Therapist as well as what is ordered by the Attending Physician. The Speech Therapist has been requested to recommend one of the available diets, as per facility policy, not a combination of two different diets. 4. All dietary special requests will be entered into a daily log, to be signed off by the requesting nurse as well as the dietary employee delivering same. This log will be reviewed by nursing administration and dietician at a minimum on a weekly basis, to ensure continued compliance. All discrepancies will be reported and addressed immediately. The findings will be documented and reviewed monthly to the CQI Committee. NJAC; 8:39-27.1 (a) 8:39-17.4 (a) (1) (2)

Based on observation, interview and record review, it was determined that the facility failed to identify residents to be at risk for the development of pressure ulcers and develop care plans and interventions to prevent skin breakdown. When care plans were developed, the facility failed to consistantly implement the interventions to promote healing and prevent re-occurance. **different tag This deficient practice was identified for 4 of 5 residents reviewed for pressure ulcers, Resident #10, #11, #12 and #15, who developed avoidable pressure ulcers or had a re-occurance of a pressure ulcer while in the facility. The facility also failed to include interventions pertaining to weight loss on the care plan for Resident #11, to ensure consistant implementation of the interventions. These deficient practices are evidenced by the following: 1. The surveyor reviewed the medical record of Resident # 10 on 7/7/16 at 10 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The surveyor observed the resident at that time, self -propelling his/her wheelchair in the hall. Further review of the medical record revealed Progress Notes, which indicated that the resident was admitted to the facility on [DATE], after sustaining a [MEDICAL CONDITION]. According to information provided by the facility on 7/11/2016, the resident had a pink discoloration on the sacrum upon admission, which was blanchable; discoloration of bilateral lower extremities; and his/her feet were dry and scaly. The facility also identified that the resident required extensive assist with transfers, and was non-ambulatory. Despite the above mentioned risk factors, the resident was identified by the Braden Scale (a pressure sore assessment tool), to be a mild risk for developing pressure ulcers. On 2/2/2016, a blister was noted on the resident's left heel, which measured 3 cm x 1 cm. The resident was seen by the wound care nurse on 2/4/2016, who also identified the resident to have a Deep Tissue Injury (DTI) of the sacrum. On 2/4/2016, the physician ordered a low air mattress, roho cushion and heel booties to be applied. The surveyor reviewed the Care Plan on 7/7/2016 at 1 p.m. which revealed that a care plan was initiated on 1/28/2016, and the resident was identified to be at risk for skin breakdown as evidenced by limited mobility and incontinence, nutritional concerns. Interventions included barrier cream with incontinence care, repositioning every 2 hours and monitoring and observing the skin. There were no interventions to protect the skin integrity of the resident's heels until 2/3/16, when an actual blister had developed on the resident's left heel. 2. The surveyor reviewed the medical record of Resident # 14 on 7/7/2016 at 11 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The resident was observed at that time in a wheelchair in the main dining room with protective boots on both feet. Further review of the medical record revealed that from 2/12/16 - 3/3/2016, the resident was hospitalized on a dementia unit for behavior issues. Upon return to the facility, the resident had an unsteady gait and was wheelchair dependent, with a Braden Scale that indicated that he/she was at mild risk for skin breakdown, despite the above risk factors. Review of Progress Notes in the medical record revealed that on 5/29/2016, the resident developed new, in-house acquired pressure ulcers on both heels, and on 6/4/2016, an open area on the sacrum. Review of information provided by the facility on 7/11/16 at 1 p.m., revealed that the heel blisters were believed to be caused by tight fitting shoes, increased weight gain and decreased mobility. The note further indicated that the opening to the sacrum on 6/4/2016 was consistent with sheering. Further review of the medical record revealed that on 5/29/2016 (the day the heel ulcers were identified), a care plan was developed to address actual skin breakdown, related to shear/friction risks. Interventions included to float heels while in bed. There was no evidence that the facility identified the resident to be at risk for skin breakdown or developed a plan of care to prevent the development of pressure ulcers. 3. The surveyor reviewed the medical record of Resident # 21 on 7/12/16 at 10:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident required extensive assistance of two persons for bed mobility and transfers. On 7/12/16 at 11 a.m., the surveyor observed the resident in bed awake, lying on the left side, with a specialized air mattress in use. Further review of the resident's medical record revealed [REDACTED]. Documentation dated on 6/2/16, revealed that the unstageable wound to the resident's left lateral leg (tibial tuberosity) had fully [MEDICATION NAME]. On 6/15/16, the resident developed a new pressure ulcer to the to the left lateral leg (tibial tuberosity). The new ulcer was noted as a stage 3, and measured 2.5 cm x 1.5 cm x 0.3 cm. Review of the phyisican's order (PO) revealed a PO dated 4/27/16 for heel lift boots and turn every 2 hours. The surveyor observed the resident's pressure ulcer on 7/13/16 at 10:00 a.m., which revealed a 0.5 cm x 0.5 cm, stage 2 pressure ulcer. Interview with the resident's Certified Nurses Aide (CNA) stated, I don't think everyone is repositioning the (resident) the way (resident) should be repositioned. The resident prefers to lie on the left side. The CNA told the surveyor that the resident's lower extremities are protected with pillows. On 7/13/16 at 10:15 a.m., the Director of Rehabilitation told the surveyor that Resident # 21 was last seen by Occupational Therapy (OT) from 11/18/15 through 11/24/15. There was no further evaluation by either physical or occupational therapy in order to re-evaluate the resident for positioning and continued use of the the heel lift boots bilaterally. Review of the care plan initiated on 2/5/16, revealed that the resident had an actual skin breakdown related to contractures, history of pressure ulcer, and limited mobility. The care plan included interventions for turning and repositioning every 2 hours, lower extremity protectors and pressure redistribution surfaces to bed as per protocol. The care plan was not revised following the reoccurrence of the pressure ulcer development, with specific interventions as to how the area should be offloaded in order to promote wound healing and prevent further pressure ulcer reoccurrences to the area. There was no documented evidence identifying the causative factor for the reoccurrence of a Stage 3 pressure ulcer to the resident's left lateral lower leg. 4. The surveyor reviewed the medical record of Resident # 15 on 7/11/16 at 10 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The surveyor observed the resident at that time in bed with severe bilateral hand contractures. Bilateral hand grips were in place and finger nails on both hands were long. An interview with the CNA assigned to Resident # 15 confirmed that the CNA's were responsible for trimming the resident's fingernails, but the CNA was unsure, because she was from an agency. Review of the facility's policy titled Activities of Daily Living (ADLs) revealed that Nail Care was referred to Activities of Daily Living Documentation procedure. Both the Director of Nursing and the Administrator confirmed that the CNA's are responsible for nail care for the residents. Further review of the medical record revealed that on 6/29/16 the resident developed a new open area to the left hand .and replacing of hand splint. The open area to the left hand was assessed as a Stage II opening to the resident's left plantar hand. Review of the care plan initiated on 3/29/16, revealed that the resident will not show signs of skin breakdown x 30 days. The care plan included interventions for repositioning every two hours, evaluate for skin risk factors per protocol, float heels while in bed, and incontinence care. There were no interventions implemented in order to address the prevention of pressure ulcers related to the resident's severe bilateral hand contractures and the care plan was not revised with specific interventions such as bilateral hand grips and nailcare once the resident developed a stage II pressure ulcer to the left plantar hand. 5. The surveyor reviewed the medical record of Resident # 11 on 7/8/16 at 9:30 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. Further review of the medical record revealed that the resident's weight upon admission, 1/12/16, was l54.4 pounds (lbs). Review of the Weight Summary report revealed the following dates and weights of the resident: 1/20/16: 154.0 lbs, and on 6/3/16, a weight of 127.0 lbs. Review of the resident's Admission Minimum Data Set ((MDS) dated [DATE], revealed that the Care Area assessment (CAA) Summary for nutritional status area was triggered but the care planning decision was not proceeded despite the initial nutritional assessment dated [DATE], which revealed confusion, acute [MEDICAL CONDITION], and [MEDICAL CONDITION]; unable to open mouth all the way 2/2 reported surgery in the past? small surgical scars to bilateral jaw observed still able to eat effectively. will alert SLP. Review of the care plan initiated on 4/28/16 revealed that the resident was identified at risk related to weight loss trend. The care plan was not initiated until 4/28/16 which was 3 months after the resident's admission and after an unplanned and unintentional 18 pound weight loss. On 7/12/16 at 12:10 p.m., the RD confirmed that any dietary recommendations are communicated by filling out a communication slip that is given to nursing on the unit who follows up with the doctor and care plan interventions are initiated and implemented by the RD. The RD further stated that she is new to the facility. On 7/12/16 at 12:20 p.m., the surveyor observed the resident ambulating out of the dining room during lunch to the nurses station and redirected by the nursing staff. Refer to F314 NJAC 8:39-11.2(e)2.

Based on observation, interview and record review, it was determined that the facility failed to identify residents who were at risk to develop pressure ulcers; identify the causal factors of the pressure ulcers; and develop and implement interventions to prevent and heal pressure ulcers. This deficient practice was identified for 4 of 5 residents reviewed for pressure ulcers, Resident #10, #14, #15 and #21, who developed pressure ulcers while in the facility. Each resident had clinical indications and risk factors that put them at risk for pressure sore development. Resident #10, with a [DIAGNOSES REDACTED].#14, a dependent wheel-chair bound resident was readmitted after a 1 month hospital stay, and developed bilateral heel ulcers and a sacral ulcer; Resident #15, a resident with bilateral hand contractures, developed a Stage II opening to the left hand; and Resident #21, re-developed a pressure sore to the leg. This deficient practice resulted in Substandard Quality of Care, as evidenced by the following: 1. The surveyor reviewed the medical record of Resident # 10 on 7/7/16 at 10:00 a.m., which revealed the resident had [DIAGNOSES REDACTED]. The surveyor observed the resident at that time, self -propelling his/her wheelchair in the hall. Further review of the medical record revealed Progress Notes, which indicated that the resident was admitted to the facility on [DATE], after sustaining a [MEDICAL CONDITION]. According to information provided by the facility on 7/11/2016, the resident had a pink discoloration on the sacrum upon admission, which was blanchable, discoloration of bilateral lower extremities and his/her feet were dry and scaly. The facility also identified the resident to require extensive assist with transfers, and was non-ambulatory. Despite the above mentioned risk factors, the resident was identified by the Braden Scale (a pressure sore assessment tool), to be a mild risk for developing pressure ulcers. On 2/2/2016, a blister was noted on the resident's left heel, which measured 3 cm x 1 cm. The resident was seen by the wound care nurse on 2/4/2016, who also identified the resident to have a Deep Tissue Injury (DTI) of the sacrum. On 2/4/2016, the physician ordered a low air loss mattress, roho cushion and heel booties to be applied. The surveyor reviewed the Care Plan on 7/7/2016 at 1 p.m., which revealed that a care plan was initiated on 1/28/2016, and the resident was identified to be at risk for skin breakdown as evidenced by limited mobility and incontinence, nutritional concerns. Interventions included barrier cream with incontinence care, repositioning every 2 hours and monitoring and observing the skin. There were no interventions to protect the skin integrity of the resident's heels until 2/3/16, when an actual blister had developed on the resident's left heel. The surveyor observed the resident's heel on 7/13/2016 at 8:45 a.m. in the presence of facility staff. Resident #10 had a healing Stage 2 pressure ulcer of the left heel. On 7/13/2016 at 10 a.m., The Director of Nurses (DON) told the surveyor that the resident was at high risk to develop heel ulcers due to a [DIAGNOSES REDACTED]. 2. The surveyor reviewed the medical record of Resident # 14 on 7/7/2016 at 11 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The resident was observed at that time in a wheelchair in the main dining room with protective boots on both feet. Further review of the medical record revealed that from 2/12/16 - 3/3/2016, the resident was hospitalized on a dementia unit for behavior issues. Upon return to the facility, the resident had an unsteady gait and was wheelchair dependent, with a Braden Scale of 22 which indicated that he/she was at mild risk for skin breakdown, despite the above risk factors. Review of Progress Notes in the medical record revealed that on 5/29/2016, the resident developed new, in-house acquired pressure ulcers on both heels, and on 6/4/2016, an open area on the sacrum. Review of information provided by the facility on 7/11/16 at 1 p.m., revealed that the heel blisters were believed to be caused by tight fitting shoes, increased weight gain and decreased mobility. The note further indicated that the opening to the sacrum on 6/4/2016 was consistent with sheering. Further review of the medical record revealed that on 5/29/2016 (the day the heel ulcers were identified), a care plan was developed to address actual skin breakdown, related to shear/friction risks. Interventions included to float heels while in bed. On 7/13/2016 at 8:30 a.m., the surveyor observed the resident's heel ulcers with the assistance of facility staff. The surveyor observed healing Stage 2 ulcers on both heels. The resident's sacral opening was resolved on 6/23/2016, according to the unit manager. There was no evidence that the facility identified the resident to be at risk for skin breakdown or developed a plan of care to prevent the development of pressure ulcers. 3. The surveyor reviewed the medical record of Resident # 15 on 7/11/16 at 10 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The surveyor observed the resident at that time in bed with bilateral hand contractures. Bilateral hand grips were in place and the resident's fingernails on both hands were long. The resident's CNA removed both hand grips at that time, and the surveyor observed the palm of the resident's left hand to be excessively dry. The CNA told the surveyor that the CNA's were responsible for trimming the resident's fingernails, but was unsure because she was from an agency. Review of the facility's policy titled Activities of Daily Living (ADLs) revealed that Nail Care was referred to Activities of Daily Living Documentation procedure. Both the Director of Nursing and the Administrator confirmed that the trimming of fingernails was the responsibility of the CNA's. Further review of the medical record revealed that on 6/29/16 the resident developed a new open area to (the resident's) left hand .and replacing of hand splint. The open area to the left hand was assessed as a Stage II skin opening to the resident's left plantar hand. Review of the July 2016 physician's orders [REDACTED]. The unit manager (UM) told the surveyor that on 6/29/16 the nurse obtained the order from the physician, but did not write the order for the bilateral palm guards. The UM later provided the surveyor with a telephone verbal order (TVO) dated 7/11/16 (during the survey) at 11:15 a.m. for 1. apply heel protectors; remove for ADL's/skin checks and 2. palm guards bilaterally; remove for ADL's/skin checks. On 7/11/16 at 11:20 a.m., the Director of Rehabilitation (DR) told the surveyor that Resident # 15 was seen by occupational therapy from 12/30/15 through 1/6/16 to address the bilateral hand contractures and at that time OT recommended bilateral palm grips. The rehab director further stated that Resident # 15 was re-screened by OT on 6/29/16 regarding the development of the left hand pressure ulcer. At that time the therapist did not observe the resident wearing the bilateral hand grips and therefore re-educated the staff regarding placement of palm grips. The DR could not provide the surveyor with documented evidence of the 6/29/16 OT re-screening, or that the therapist re-educated the staff regarding the placement of the palm grips. Review of the care plan initiated on 3/29/16, revealed that the resident will not show signs of skin breakdown x 30 days. The care plan included interventions for repositioning every two hours, evaluate for skin risk factors per protocol, float heels while in bed, and incontinence care. 4. The surveyor reviewed the medical record of Resident # 21 on 7/12/16 at 10:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed that the resident required extensive assistance of two persons for bed mobility and transfers. On 7/12/16 at 11 a.m., the surveyor observed the resident in bed, lying on the left side with a specialized air mattress in use. Further review of the resident's medical record revealed [REDACTED]. On 6/15/16, the resident developed a new pressure ulcer to the left lateral leg (tibial tuberosity). Review of the skin assessment dated [DATE] revealed the new ulcer was assessed as a Stage 3, and measured 2.5 cm x 1.5 cm x 0.3 cm. On 7/13/16 at 10 a.m., the surveyor observed the resident's pressure ulcer in the presence of two CNA's which revealed a Stage 2 pressure ulcer, measuring 0.5 cm x 0.5 cm. An interview with the resident's CNA stated, I don't think everyone is repositioning (the resident) the way (the resident) should be repositioned. On 7/13/16 at 10:15 a.m., the Director of Rehabilitation told the surveyor that Resident # 21 was last seen by Occupational Therapy (OT) from 11/18/15 through 11/24/15. There was no further evaluation by either physical or occupational therapy in order to re-evaluate the resident for positioning and continued use of pressure-relieving devices. Review of the care plan initiated on 2/5/16, revealed that the resident had an actual skin breakdown related to contractures, history of pressure ulcer, and limited mobility. The care plan included interventions for turning and repositioning every 2 hours, lower extremity protectors and pressure redistribution surfaces to bed as per protocol. The care plan was not revised following the re-occurrence of the pressure ulcer development to the left lateral leg (tibial tuberosity) dated 6/15/16. NJAC 8:39-27.1 (e)

COMPLAINT # NJ , Based on interview, review of Medical Records and other facility documentation, it was determined that the facility failed to provide adequate supervision for 1 of 2 Residents reviewed for risk of elopement and exhibited exit seeking behaviors, Resident #2. This created an Immediate Jeopardy (IJ) situation for Resident #2 who eloped on [DATE] and was found approximately 3.6 miles away from the facility at his childhood home. In addition, the facility used a wander guard system for 9 of 9 Residents (Resident #2 and 8 unsampled Resident's) as an intervention for elopement. The facility failed to develop and implement a system to ensure the function of that system creating an IJ situation for all 9 Residents. The Administrator was notified of the IJ on [DATE] at 9:34 am. This deficient practice was evidenced by the following: According to the Admission Record, Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a Social History and Initial Assessment completed by a Social Worker, signed as completed on [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. There was no documentation in Resident #2's Medical Record of an admission elopement assessment having been done in accordance with facility policy. A review of the facility policy titled Elopement of Patient documented under Process 1. Assessment/Evaluation: 1.1 Identify patient's elopement risk by reviewing the following upon admission, re-admission, quarterly, or with a significant change in conditions as defined by the RAI Manual criteria. A review of the Progress Notes (PN) signed by a Registered Nurse(RN) dated [DATE] documented that the Resident had made several attempts to leave the building and was redirected back to the floor on which the Resident resides. In a PN signed by a Licensed Practical Nurse (LPN) dated [DATE] timed at 18:57 (6:57 pm) the documentation read Resident continues to try to leave the building, several attempts offered to prevent this without success. A review of a Facility Reportable Event Record/Report dated [DATE], documented that the Nurse went to give Resident #2 medications on [DATE] at 7:45 pm and the Resident was not in their room. The Report further documented that a search of the facility failed to find the Resident and 911 was called. The Report documented that a wander guard bracelet was applied in the afternoon with the daughter's assistance after the Resident had been voicing the desire to leave the facility. The Report documented that the family was called when the Resident returned to his childhood home. The Resident was returned to the facility by a family member and the facility assigned staff to provide a 1:1 supervision for the Resident. A review of the Risk Management System form dated [DATE] timed at 7:45 pm, documented under last date and time Resident was seen [DATE] at 7:00 pm. The form further documented under Summary of Investigation Root Cause/Conclusion Resident with a history of wandering in the community. Family no longer able to care for the Resident at home. A review of the facility's Summary of Incident regarding Saturday [DATE]. The summary documented that at approximately 6:30 pm the medication nurse assisted the Resident to the bathroom and when the nurse went to give the Resident medications at 7:45 pm the staff was unable to locate the Resident in the facility. The summary documented that the occupants of the home notified the family that the Resident was there. The Summary documented that It cannot be determined how the Resident was able to leave the facility. A review of a hand written statement dated [DATE] signed by the ,[DATE] pm receptionist read that Resident #2 constantly tried to get out the front door. The statement further documented that the ankle bracelet went off every time the Resident got near the door. The statement documented that the Receptionist went to the bathroom at 7:55 pm for 2 minutes and the Resident was no where in sight. In a telephone interview with the Receptionist on [DATE] at 3:38 pm, the Receptionist stated that the Resident was trying to get out the front door ,[DATE] times and the alarm sounded each time. The Receptionist further stated that while she was in the bathroom she did not hear the wander guard alarm sound. The Receptionist also stated that if the Resident had been by the door and the alarm sounded she would have had to reset the alarm with a code on the keypad behind the desk. The Receptionist went on to say that when the Resident returned with the family the alarm sounded and that she turned the alarm off so the Resident could enter the building and then reset the alarm. The surveyor accompanied by the Administrator on [DATE] at 3:45 pm, went into the ladies room used by the receptionist and had another surveyor set off the wander guard alarm and it was heard in the bathroom. In an interview with the Administrator on [DATE] at 2:30 pm, the Administrator stated that the Reception desk has someone on duty from 7 am until 11 pm daily. The Administrator also stated that on Friday and Saturday from 11 pm-7 am there is a security guard on duty, A review of further statements by the facility staff documented that the Resident required redirection back to his unit on multiple occasions throughout the day due to exit seeking behavior. On [DATE] at 3:40 pm in the presence of the surveyor the Resident approached the front door and the door was heard by the surveyor locking. The surveyor then attempted to open the door and was unable to as the door was locked. The surveyor opened the front door and had the Resident approach the door and the alarm sounded. The Resident was within approximately 3 feet of the door when the door locked and/or alarm sounded. In a telephone interview on [DATE] at 2:53 pm with the Registered Nurse (RN) Nursing Supervisor who was working on [DATE] from 7 am- 7 pm, the RN Supervisor stated that Resident #2 was exit seeking all day. The RN Supervisor further stated that a wander guard was placed on the Resident with the Resident's daughters help. The RN Supervisor stated that the Resident continued to exit seek and was redirectable at times. The surveyor questioned the RN Supervisor as to what other measures were taken due to the continued exit seeking behavior. The RN Supervisor stated that My thinking was that the Resident had a wander guard on and the alarm would go off and I felt that was sufficient for the Resident. In an interview with the Administrator on [DATE] at 2:30 pm, the Administrator stated that the facility still does not know how the Resident was able to leave the facility. The Administrator also stated that the wander guard alarm went off when the Resident was returned to the facility by the family. The Administrator went on to say that the Resident has the same wander guard on now that was placed on [DATE]. The Administrator also stated that the distance from the facility to the Resident's childhood home was approximately 3 miles. The surveyor clocked the distance from the facility to the main road in the town where the Resident resided as a child, and the mileage was 3.6. In an interview with the Administrator on [DATE] at 9:10 am, the Administrator stated that the facility was aware of the Resident's history of wandering and going to his childhood home but felt that the facility could handle the Resident's needs. The Administrator went on to say that the testing of the function of the wander guard transmitters would be started on [DATE]. In an interview with the Director of Nursing (DON) on [DATE] at 3:00 pm, the DON stated that the facility had just implemented a protocol to check the function of the wander guard transmitters once a week with the transponder provided by the wander guard company. The DON further stated that the facility had not been checking the function of the wander guard transmitters on any Resident with a wander guard prior to the elopement of Resident #2. In an interview with the Director of Maintenance (Director) on [DATE] at 1:07 pm, the Director stated that the front door is the only door in the facility that has the wander guard system. The Director also stated that all other exit doors are alarmed and have keypads with codes to exit. The surveyor accompanied by the Director checked all other exit doors (10 including the loading dock and the employee entrance) with keypads and alarms and all doors were locked and alarmed when opened. The Director further stated that it does not matter if 1 or 10 persons with a wander guard transmitter go through the door the alarm would still sound. The Director further stated that he wouldn't know if there was a frequency issue with the wander guard system unless someone complained. The Director also stated that the alarm company does not have logs of when the alarms would have sounded. The Director stated that he does monthly checks of all the exit doors to make sure the alarms are functioning. The facility is located on a 2 lane highway. Directly across the street from the facility is a park with a lake with free access to the water. There was a black top path that is on the outer perimeter of the park. The distance from the path to the water line is approximately ,[DATE] of a mile. There was construction being done on the roadway at the time of the survey. In staff interviews, the staff stated that pictures of wandering Residents are placed at the front desk. The surveyor observed the pictures located behind the front desk. The staff also stated that they do not know who tests the function of the wander guard transmitters. A review of the Physician Order Sheet (POS) dated [DATE] timed at 9:30 am after the Resident's elopement, documented maintain wander guard, maintain 1:1 observation for safety. A review of the Treatment Administration Record (TARS) for Resident #2 documented an order to check placement of the wander guard to left ankle every shift. The facility failed to provide documentation that the wander guard transmitters were checked for function. A review of the care plan for elopement documented a creation date of [DATE] and including Utilize and monitor security bracelet per protocol. The facility failed to provide a protocol for the monitoring of the wander guard transmitter. The surveyor requested to see the facility policy on checking the function of the wander guard transmitters. The Administrator stated We don't have a wander guard policy. A review of the Wandering Management Transmitters User Guide on page 13, the guide documents that Transmitters in use must be tested at least weekly. The Immediate Jeopardy to the health and safety of Resident #2 and the other 8 additional Resident's with a wander guard transmitter began on [DATE] and was identified by the surveyor on [DATE], and communicated to the Administrator on [DATE] at 9:34 am. The Immediate Jeopardy was lifted upon receipt and implementation of an acceptable plan of correction that was received by the surveyor on [DATE] at 12:30 pm. The Plan of Correction (POC) submitted stated the following: The concern noted during survey has been addressed. All transmitters have been checked for proper functioning and inspected for damaged (sic) {damage}and expiration date verified. On Saturday [DATE], Resident #2 started making attempts to leave the facility. The supervisor, with the assistance of the resident's family member, applied the wander guard to the resident's ankle. The supervisor then alerted the staff to be cautious and to apply more supervision to monitor this resident due to his exit seeking. Resident #2 was placed on a one to one care since his return to the facility the evening on Saturday [DATE]. Resident #2 remains on a one to one care until his discharge from the facility. All Residents that are at risk for elopement and are wearing a wander guard have the potential to be affected by this practice. All licensed nursing staff have been re-educated on the procedure of checking placement every shift and the documentation of this verification on the TAR. All Unit Managers have been re-educated on the procedure of weekly checking the operation of the transmitter, visually inspecting the transmitter weekly for damage or loose parts, and weekly checking the warranty expiration date stamped on the transmitter to verify it has not expired. If the warranty has expired, the transmitter has been discarded and replaced immediately. All receptionist have been re-educated on the importance of ensuring that the front desk area remains closely monitored throughout shift; that coverage is provided in the absence of the assigned receptionist. The CNA and nurse assigned to resident #2 on [DATE], were counseled on not closely monitoring Resident #2 and were re-educated on the importance of providing closer supervision by closely monitoring exit seeking residents, particularly in reference to resident #2. Beginning on [DATE], all nursing staff were re-educated on the importance of providing closer supervision by closely monitoring those residents that are exit seeking, to include Resident #2. On [DATE], the receptionist was counseled on the concern of leaving the desk unattended and was re-educated on the importance of ensuring that the front desk remains closely monitored at all times during assigned shift, especially for exit seeking residents. Alternated coverage is to be provided in the absence of the assigned receptionist. Starting on [DATE], training was provided to all receptionists the importance of closely monitoring the front desk during assigned shift, especially for exit seeking residents. Alternate coverage is to be provided in the absence of the assigned receptionist. Unit Managers, DON, and Administrator will monitor for compliance on a weekly basis. The Interdisciplinary Team on a weekly basis at the Customer at Risk meeting will verify that the operation of the transmitter has been checked, that each transmitter has been inspected for damage or loose parts and that the expiration date has been checked to verify is (sic) (it) has not expired. If the warranty period has expired, the transmitter has been discarded and replaced immediately. The Head receptionist, administrator and supervisor will monitor for continued coverage on a daily basis. Findings will be reported to the CQI Committee monthly. Completion Date: [DATE] NJAC: 8:,[DATE].1 (a)

Based on interviews and record review, it was determined that the facility failed to implement an identified care plan intervention to provide for a resident's safety. Resident #11 had a fall and sustained a [MEDICAL CONDITION] femur during care. The resident required hospitalization for pain management and immobilization of the right femur fracture. This deficient practice was identified for 1 of 7 residents (Resident #11) reviewed for care plan interventions and was evidenced by the following: The surveyor reviewed the medical record of Resident #11 on 5/8/14 at 8:50 a.m. The admission Face Sheet revealed that the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Comprehensive care plan dated 1/14 revealed the resident had a plan for Activities of Daily Living (ADL) initiated since 7/2/2010 last revised 6/2011. A review of the resident's plan for ADL revealed the following: "The resident required assistance with ADL, care in bathing, bed mobility due to chronic compromising functional ability, and cardio-vascular accident ([MEDICAL CONDITION]) with [MEDICAL CONDITION]. The interventions included Resident #11 required extensive assistance of two persons assist with bed mobility. According to an Interdisciplinary Progress Notes dated 4/23/14 at 9:40 p.m. the resident fell from the bed during care. A review of the Resident/Patient Incident Report dated 4/23/14 at 9:40 p.m. indicated that the resident fell from bed during care and sustained a [MEDICAL CONDITION] femur. A review of the investigative report for the above incident revealed that the Certified Nursing Assistant (CNA) failed to follow the care plan. Resident #11 was assessed as being totally dependent on staff for bed mobility and transfer and required two persons physical assist with bed mobility. The CNA did not call for assistance while turning the resident from side to side to make the bed. The resident told the CNA that he/she could not hold on any longer to the bed rail. The CNA continued to make the bed and ignored the resident's request. The resident fell and sustained a non displaced [MEDICAL CONDITION] femur. Refer to F323 NJAC 8:39-11.2, 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to: follow identified care plan interventions to address fall risk for 1 of 7 residents reviewed for falls and accidents ( Resident #11). Resident #11 had a fall and sustained a non displaced fracture of the right femur during care which required hospitalization for pain management and immobilization. In addition, the facility failed to ensure medications were not openly accessible on 1 of 2 medication carts. These deficient practices were evidenced by the following: 1. The surveyor reviewed the medical record of Resident #11 on 5/5/14 at 12:50 p.m. The Admission Face Sheet revealed the resident had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 1/29/14, revealed the resident had mild cognitive impairment. The MDS also reflected that Resident #11 was totally dependent on staff for bed mobility and transfer. On 5/5/14 at 12:45 p.m. the resident stated to the surveyor that he/she fell from the bed two weeks ago and sustained a fracture of the right femur. The surveyor observed the resident who was in bed propped with supportive pillows. The head of the bed was elevated and the resident had an immobilizer applied to the right leg. On 5/8/14 at 12:15 p.m. the surveyor interviewed the resident regarding the incident that occurred on 4/23/14. The resident told the surveyor that he/she fell from the bed during care. The resident stated that the Certified Nursing Assistant (CNA) had him/ her turned onto the left side and that he/she was holding on to the side rail while she (CNA) was making the bed. The resident informed the CNA that he/she could not hold onto the side rail any longer. The CNA continued to make the bed. The resident stated that he/she slipped and fell from the bed onto the floor. Further review of the medical record on 5/8/14 at 11:30 a.m. revealed that Resident #11 had a care plan in place for Activities of Daily Living (ADL) initiated 7/2/10 and last revised 6/2011. The care plan for ADL indicated the resident required assistance with ADL care, bed mobility, and transfer due to chronic compromising functional ability. The care plan also indicated that the resident required extensive assistance of two persons assist with bed mobility. Review of the CNA care plan on 5/12/14 at 10:30 a.m., revealed the resident was totally dependent on staff and required the physical assistance of two persons for bed mobility and transfer, and physical assist of two to three persons assist with mechanical lift. Review of a "Resident/Patient/Incident Report" provided by the facility dated 4/23/14, revealed that at 9:40 p.m. the resident fell from the bed during care. The resident was transferred to the hospital and diagnosed with [REDACTED]. The resident returned to the facility on [DATE]. Review of the investigative report dated 4/25/14 revealed that the CNA did not use two persons as required and performed this activity alone. According to the narrative statement written by the CNA on 4/25/14, the CNA turned the resident to the left side to make the bed. The resident told the CNA that he/she could not hold on any longer to the bed rail and to hurry up. The CNA continued to make the bed. The resident slipped and fell from the bed onto the floor. An interview with the Director of Nursing (DON) on 5/12/14 at 9:45 a.m. confirmed the resident required two persons physical assist with bed mobility. The DON stated that the CNA should not have cared for the resident alone. On 5/14/14 at 10:30 a.m. the surveyor interviewed the CNA who cared for Resident #11 on 4/23/14 on the 3-11 shift. The CNA stated on 4/23/14 at 9:40 p.m. while she cared for the resident, the resident fell from the bed onto the floor. The CNA indicated that while she was making the bed, she had the resident turned to the left side and holding on the bed rail to make the bed. The CNA confirmed that the resident informed her that he/she was unable to hold on any longer to the bed rail. The CNA also stated that she told the resident she was almost done. The CNA continued to make the bed, the resident slipped and fell from the bed to the floor. The CNA stated that she had cared for the resident daily and had never asked for assistance during care. The CNA also stated that she was not aware that the resident required two persons physical assist with bed mobility. That same day at 11:15 a.m. the surveyor showed the resident's care plan to the CNA. The CNA maintained that she always cared for the resident alone and was not aware that the resident required two persons physical assist with bed mobility. 2. On 5/6/14 at 8:25 a.m. during the medication administration observation, the surveyor observed a measuring cup with a clear liquid substance on top of the medication cart. The medication nurse was not observed in the hallway. The surveyor also observed two residents seated in the hallway. At 8:30 a.m. the nurse entered a room in the north hallway and left the medication cart in the hallway with the clear liquid substance on top of the medication cart. At 8:50 a.m. the nurse told the surveyor the clear liquid substance was Neurontin, an anti-seizure medication for Resident #27. The nurse left the medication cart in the hallway, went to the refrigerator and returned with the Neurontin bottle. The nurse placed the Neurontin bottle on top of the medication cart along with the clear liquid substance. At 9:00 a.m. the nurse entered room 123 then room 125, administered medications to these residents and left both the bottle of Neurontin and the measuring cup of the clear liquid substance unattended on top of the medication cart in the hallway. At 9:05 a.m. the nurse drew the curtain, administered medications to room 123 then went to the bathroom and washed her hands. That same day at 9:25 a.m. the nurse administered medication to another resident, went to the bathroom and washed her hands. The bottle of Neurontin and the clear liquid substance were left on top of the medication cart until 9:25 a.m. At 9:30 a.m. the nurse returned the bottle of Neurontin to the cart and disposed of the clear liquid substance in the receptacle bin. An interview with the medication nurse on 5/6/14 at 9:30 a.m. revealed that she had pre-poured the Neurontin at 7:30 a.m. and placed the medication on top of the medication cart. The nurse further stated that the resident does not like to drink cold liquid. A review of Resident #27's Medication Administration Record dated 4/14 revealed the resident had an order for [REDACTED]. On 5/12/14 at 1:30 p.m. the DON stated that he was made aware of the concern with the Neurontin left on top of the medication cart and added that the nurse should not have stored the medication on top of the medication cart. NJAC 8:39-27.1(a) NJAC 8:39-31.2 (e)