Every finding on record at Sinai Post-Acute Nursing & Rehab Center

Complaint #2981619 Based on observations, interviews, and review of pertinent facility documentations on 8/7/26, it was determined that the facility failed to administer medications in a timely manner, and in accordance with the acceptable standard of nursing practice. This deficient practice was identified for 2 of 6 residents (Residents #3 and #4) reviewed for timely medication administration and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. The surveyor reviewed the medical records of Resident #3. A review of Resident #3's admission record (AR), an admission summary record, indicated the resident was admitted to the facility with the diagnoses that included but were not limited to major depressive disorder, type 2 Diabetes Mellitus, anemia, obesity, unspecified psychosis, anxiety disorder, chronic kidney disease, and schizophrenia.A review of the resident's Minimum Data Set (MDS), a comprehensive assessment tool, dated 5/5/26, revealed the resident's Brief Interview of Mental Status (BIMS), revealed the resident's BIMS score was 14 indicating the resident's cognition was intact.A review of Resident #3's Medication Admin Audit Report (MAAR) dated 7/24/26- 8/7/26, revealed the following medications were not administered according to their scheduled time: 1.Benztropine Mesylate Oral Tablet 0.5 mg. Give 1 tablet by mouth two times a day for EPD [extrapyramidal symptoms].Schedule Date and time: 7/24/26 at 8:00 AM - the medication was administered at 10:39 AM.Schedule Date and time: 7/27/26 at 8:00 AM - the medication was administered at 11:48 AM.2. Secure Safe Safety Pen Needles (insulin pen needle). Inject 1 application subcutaneously in the morning for DM.Schedule Date and time: 7/27/26 at 9:00 AM - the medication was administered at 11:48 AM.Schedule Date and time: 7/30/26 at 9:00 AM - the medication was administered at 11:09 AM.Schedule Date and time: 7/31/26 at 9:00 AM - the medication was administered at 11:35 AM. 3.Lantus Subcutaneous Solution 100 Unit/ml (insulin glargine). Inject 17 units subcutaneously in the morning for DM taype2.Schedule Date and time: 7/27/26 at 9:00 AM - the medication was administered at 11:48 AM.Schedule Date and time: 7/28/26 at 9:00 AM - the medication was administered at 11:57 AM.Schedule Date and time: 7/30/26 at 9:00 Am - the medication was administered at 11:09 AM.Schedule Date and time: 7/31/26 at 9:00 AM -the medication was administered at 11:34 AM. 4.Clonazepam Oral Tablet 0.5 mg. Give 1 tablet by mouth every 12 hours for anxiety.Schedule Date and time: 7/27/26 at 9:00 AM - the medication was administered at 11:48 AM.Schedule Date and time: 7/30/26 at 9:00 AM - the medication was administered at 11:09 AM.Schedule Date and time: 7/31/26 at 9:00 AM -the medication was administered 1:57 PM. 5.Geodon Oral Capsule 80 mg. Give 1 tablet by mouth in the morning for depression with psychosis.Schedule Date and time: 7/27/26 at 9:00 AM - the medication was administered at 11:48 AM.Schedule Date and time: 7/28/26 at 9:00 AM - the medication was administered at 11:58 AM.Schedule Date and time: 7/30/26 at 9:00 AM - the medication was administered at 11:09 AM.Schedule Date and time: 7/31/26 at 9:00 AM - the medication was administered at 11:35 AM.Accu- checks (blood sugar monitoring) two times a day:Scheduled for 7/27/26 at 7:30 AM, provided at 11: 48 AM, which is 2 hours late.Scheduled for 7/29/26 at 7:30 AM, provided at 9: 10 AMScheduled for 7/31/26 at 7:30 AM, provided at 11: 36 AM, which is 2 hours late. The surveyor reviewed the medical records of Resident #4.A review of Resident #4's admission record (AR), an admission summary record, indicated the resident was admitted to the facility with the following diagnoses that included but were not limited to chronic obstructive pulmonary disease with acute exacerbation, anxiety disorder, opioid dependence, anemia, insomnia, and muscle wasting.A review of the resident's Minimum Data Set (MDS), a comprehensive assessment tool, dated 6/21/26, revealed the resident's Brief Interview of Mental Status (BIMS), revealed the resident's BIMS score was 13 indicating the resident's cognition was intact. The surveyor reviewed Resident #4's Medication Administration Audit Report (MAAR) dated 11/01/25-11/30/25, 12/01/25- 12/31/25, and 7/24/26- 8/7/26,which revealed the following medications were not administered according to their scheduled time: 1. Biktarvy Oral Tablet 50-200-25 mg, give 1 tablet by mouth in the morning. Take with breakfast, do not crush.Schedule for 11/2/25 at 8:00 AM, the medication was administered at 11:27 AM.Scheduled for 11/3/25 at 8:00 AM, the medication was administered at 10:51 AM.Scheduled for 11/6/25 at 8:00 AM - the medication was administered at 10:21 AM.Scheduled for 11/8/25 at 8:00 AM, the medication was administered at 11:39 AM.Scheduled for 11/11/25 at 8:00 AM, the medication was administered at 1:30 PM.Scheduled for 11/14/25 at 8:00 AM, the medication was administered at 11:33 AM.Scheduled for 11/15/25 at 8:00 AM, the medication was administered at 10:44 AM.Scheduled for 11/17/25 at 8:00 AM, the medication was administered at 1:31 PM.Scheduled for 11/18/25 at 8:00 AM, the medication was administered at 10:22 AM.Scheduled for 11/20/25 at 8:00 AM, the medication was administered at 10:45 AM.Scheduled for 11/22/25 at 8:00 AM, the medication was administered at 10:58 AM.Scheduled for 11/24/25 at 8:00 AM, the medication was administered at 1:38 PM.Scheduled for 11/26/25 at 8:00 AM, the medication was administered at 10:54 AM.Schedule for 11/27/25 at 8:00 AM, the medication was administered at 1:38 PM. 2. Bictegravir-Emtricitab-Tenofov Oral tablet 50-200-25 mg; give 1 tablet by mouth in the morning. Scheduled for 12/2/25 at 9:00 AM, the medication was administered at 11:26 AM.Scheduled for 12/7/25 at 9:00 AM, the medication was administered at 2:10 PM.Scheduled for 12/9/25 at 9:00 AM, the medication was administered at 1:07 PM.Scheduled for 12/14/25 at 9:00 AM, the medication was administered at 11:11 AM.Scheduled 12/22/25 at 9:00 AM, the medication was administered at 2:08 PM.Scheduled for 12/24/25 at 9:00 AM, the medication was administered at 12:12 PM.Scheduled for 12/27/25 at 9:00 AM, the medication was administered at 2:41 PM.Scheduled for 12/29/25 at 9:00 AM, the medication was administered at 11:21 AM. 3. Biktarvy Oral Tablet 50-200-25 mg. Give 1 tablet by mouth in the morning with breakfast Scheduled for 7/29/26 at 9:00 AM, the medication was administered at 12:47 PM.Scheduled 8/5/26 at 9:00 AM, the medication was administered at 12:15 PM. 4. Protonix Oral Tablet Delayed Release 40 mg, give 1 tablet by mouth in the morning for GERD [gastro-esophageal reflux disease][heart burn].Scheduled for 11/2/25 at 9:00 AM, the medication was administered at 11:27 AM.Scheduled for 11/3/25 at 9:00 AM, the medication was administered at 10:52 AM.Scheduled for 11/8/25 at 9:00 AM, the medication was administered at 11:41 AM.Scheduled for 11/11/25 at 9:00 AM, the medication was administered at 1:30 PM.Scheduled 11/14/25 at 9:00 AM, the medication was administered at 11:33 AM.Scheduled for 11/17/25 at 9:00 AM, the medication was administered at 1:34 PM.Scheduled 11/22/25 at 9:00 AM, the medication was administered at 10:58 AM.Scheduled for 11/24/25 at 9:00 AM, the medication was administered at 1:28 PM.Schedule Date: 11/26/25 at 9:00 AM - the medication was administered at 10:55 AM.Schedule Date: 11/27/25 at 9:00 AM - the medication was administered at 1:38 PM. On 8/7/26 at 2:40 PM, the surveyor interviewed the Director of Nursing (DON) and the Regional Nurse (RN) in the presence of the Licensed Nursing Home Administrator (LNHA). The DON stated the nurses were in-serviced regarding late medications and signing late. The DON further stated that they had education ongoing and in progress.A review of the facility's policy titled, Administering Medications, reviewed and approved on 6/2026, under its Policy heading: Medications are administered in a safe and timely manner, and as prescribed., under its Policy Interpretation and Implementation, .4. Medications are administered in accordance with prescribed orders, including any required time frame.9. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.25. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.N.J.A.C.8:39-29.2(d)

Complaint #: NJ2795447, NJ 2694655, and 2648314Based on observations, staff interviews, and policy review, the facility failed to ensure that the physical environment was maintained in a safe, functional, and sanitary condition for residents and staff. This deficient practice was evidenced by the following:Findings include:During the observation on 04/08/2026 from 8:38 to 10:35 AM, the surveyor observed the following: At 8:38 AM, in the presence of the Director of Dietary (DOD) and the Assistant DOD (ADOD), gray water was observed standing on the floor under the sink in the dishwasher room on both the clean and dirty sides. A blanket with brown staining was noted on the floor, wet under the edge of the dishwasher. At 8:40 AM, mouse droppings were noted along the baseboards in the shower room of the third floor on the north wing. The surveyor observed a live trap under the sink in the soiled utility room and mouse droppings were noted along the baseboard and not within the trap. At 9:20 AM, mouse droppings were noted along the baseboards in the soiled utility room on the sixth floor. At 9:48 AM, mouse droppings were noted along the baseboard and under the head of the bed in Resident (R) 5's room. At 10:35 AM, gray water remained standing under the sink in the dishwasher room. Broken floor tiles were observed to be lower than the lip of the sump pump, preventing proper drainage and effective function of the sump pump. During an interview on 04/09/26 at 8:50 AM, with the DOD, he/she stated the leaking dishwasher had been reported to maintenance. He/she stated the water was coming out of the bottom, from a leaking seal. He/she confirmed the sink on the dirty side of the dish room, which leaked gray water out onto the floor. Maintenance had ordered a needed part that arrived on 4/10/26 but was not going to be put in place until Monday (April 13). During an interview on 04/09/26 at 10:04 AM, the housekeeping director (HK) stated that there are daily reports about mice from the residents and the HK staff. The HK further stated, we have been seeing mice on all floors. There are things that the residents hoard, and the cold weather makes the mice come more. During an interview on 04/09/26 at 10:04 AM, the Maintenance Director (MD) stated, There has been a problem all the time in this building, because of where the building is in the city. When they tear down buildings around us, we get more mice and bugs. The pest company comes out twice a week and treats our building. The main office only wants them to come once or twice a month. On 04/09/26 at 10:34 AM, the [NAME] President of Environmental Services (VP-ES) provided the Pest control logs. I have received the report sheets from the floors where mice and other bugs have been observed by staff. Pest control has been coming, but the problem is still there. During an interview on 04/09/26 at 11:45 AM, the [NAME] President of Environmental Service (VP-ES) stated that he/she was aware of the dishwasher leaking water, but not aware of the sinks leaking onto the floor. He/she observed the missing tiles, sinks and sump pump and confirmed the gray water could only get pumped out if someone mopped it into the pit. Review of the facility policy reviewed and updated on 09/2025 titled, Cleaning and disinfection of environmental Surfaces.Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA bloodborne pathogens standard.

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified in 3 of 5 nursing units observed for environment and evidenced by the following: 1. On 6/9/25 at 10:12 AM, during initial tour of the 5th floor Nursing Unit, the surveyor observed Resident room [ROOM NUMBER]. The wall by the headboard had chipped paint, the cove base on the wall under the room sink was soiled with a dark black substance, there was a missing floor tile under the Tube Feeding pump, the bathroom walls had chipped paint, the floor tiles were broken and soiled and the cove base on the wall behind the toilet was heavily soiled and pulled out from the wall. On 06/09/25 at 12:21 PM, the surveyor observed Resident room [ROOM NUMBER]. The wall by the headboard had torn sheetrock with full thickness open holes, the chair rail was detached and hanging from one end of the wall, on the wall by the hand sink there was a large tear and holes to the right and above the hand sink, the bathroom walls had bubbled peeling paint, built up dirt and debris in the corners. On 6/12/25 at 10:30 AM, the surveyor observed room [ROOM NUMBER] and room [ROOM NUMBER] and found the same condition of the walls, floor and tiles as were observed on the initial tour. On 6/12/25 at 10:40 AM, during an interview with the surveyor, the Licensed Practical Nurse/ Unit Manager (LPN/UM) stated that any maintenance concerns observed on the 5th floor unit were reported to her or the maintenance staff directly. If the concerns were reported to her, she would put it into the Tels electronic system which the facility used to communicate the concens to the maintenance department. The surveyor reviewed the TELS report and observed there were no reports for room [ROOM NUMBER] or room [ROOM NUMBER]. 2. On 6/9/25 at 11:25 AM, during initial tour of the facility, the surveyor observed resident room [ROOM NUMBER]. the windowsill and wall framing around the window was severely damaged from what appeared to be water damage. The sill above the window had large gaping holes of missing and crumbling drywall, the right side of the sill was bubbled and had the appearance of damage from water saturation, the floor beneath the window and around the air conditioning/heating unit had a layer of a dark brown/black substance, the ceiling tile in the corner of the room nearest to the window had a brownish colored stain which appeared to be caused by fluid, the baseboard underneath the resident's sink was replaced with large portions of plywood screwed to the wall and had what appeared to be expanding foam sprayed behind the plywood and expanded up past the plywood. On 6/12/25 at 10:02 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN #1) who stated that all staff members have the responsibility to report to maintenance any required or observed repairs in the building. She further stated that the facility utilized an electronic, computerized reporting system to notify the maintenance department of all requests for repairs. On 6/12/25 at 10:08 AM, the surveyor observed resident room [ROOM NUMBER] and found the same condition of the walls, windowsill, floor, and ceiling tiles as were observed upon initial tour. On 6/12/25 at 10:27 AM, the surveyor interviewed the Director of Maintenance (DM) who stated the facility, all staff, and all departments are responsible to notify maintenance of any repairs needing to be made using the electronic work order system. The DM further stated that he is aware of an ongoing concern of water leak, particularly with rain on certain floors including the fourth floor and especially on the west wing portion of the building. He further stated that the DM performs weekly rounds to ensure everything is in good repair in the building and nothing is missed. He stated that wall damage should not take more than a couple days to repair and is an in-house repair not requiring a vendor. The surveyor provided the DM photos of the observations made in room [ROOM NUMBER], to which the DM acknowledged should have been addressed and was not acceptable and that it appeared to be damage which was a result of a longer period rather than a new issue. The DM stated that the facility's environment and resident rooms should be kept in good repair to ensure a homelike, comfortable environment. On 6/12/25 at 10:43 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who confirmed the use of the computerized work order system and should be utilized by all staff in all departments. He further acknowledged that the facility maintenance department director had a routine schedule to tour and look for repairs which needed to be made. The surveyor showed the LNHA the photos of the damage in room [ROOM NUMBER], to which he acknowledged was not an acceptable state and confirmed that the damaged appeared to have occurred over a prolonged period of time. The LNHA further confirmed that this repair should have taken a couple days to complete and that most repairs are able to be handled internally by the maintenance department. The LNHA further acknowledged the importance of maintaining a homelike environment for residents. 3. On 6/09/25 at 10:52 AM, during initial tour the surveyor observed the 3rd floor men's shower room. The left side shower stall was noted with mismatched tiles and a few missing tiles. The right side shower stall was noted with approximately twenty six missing 1 inch tiles near the drain. On 6/10/25 at 12:19 PM, the surveyor observed the 3rd floor men's shower room with the same missing tiles as noted on initial tour. On 6/11/25 at 11:50 AM, the surveyor observed the 3rd floor men's shower room with the same missing tiles as noted on initial tour. On 6/12/25 at 09:51 AM, the surveyor interviewed certified nursing assistant (CNA) #1, regarding the 3rd floor men's shower room, who stated she never really noticed the shower stall with missing tiles as she uses mostly the female shower room. On 6/12/25 at 10:06 AM, the surveyor interviewed the 3rd floor Licensed Practical Nurse/Unit Manager (LPN/UM) regarding the 3rd floor men's shower room, who stated that's not ok, maintenance should replace those tiles. She stated an electronic work order system is utilized, and they also report verbally to the maintenance department. On 6/12/25 at 10:22 AM, the surveyor requested the electronic work order report for the 3rd floor for 2 months. On 6/12/25 at 11:00 AM, the LNHA provided the work order report for 3rd floor for April and May 2025. The 3rd floor shower rooms were not on report. On 6/12/25 at 12:05 PM, the surveyor interviewed the DM, who stated that he conducts weekly rounds on the units. The surveyor showed him a photo of the 3rd floor men's shower room. He stated that he was not aware of this shower stall. The surveyor requested the electronic work order report for June to present and his weekly rounds of the third floor. On 6/12/25 at 01:08 PM, the LNHA and DON were advised of the concerns regarding the 3rd floor men's shower room. On 6/13/25 at 10:15 AM, the LNHA informed the surveyor the missing tiles were replaced in the 3rd floor men's shower room. A review of the facility's Homelike Environment policy updated 4/2025 included but was not limited to: residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible . the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. A review of facility provided policy, Maintenance Services and Work Orders revised 10/1/24 included: Policy: To assure that the facility's buildings, grounds and equipment are maintained in a safe and operable manner at all times. Procedure: 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 2. The Maintenance Department will work with facility administration and corporate Facility Services staff to establish priorities and replacement of critical building components and infrastructure. 3. The Maintenance Department will provide and document routine and emergency maintenance service to all areas of the facility. 4. The Maintenance Department will perform other tasks and/or functions that may become necessary or appropriate. 6. The facility utilizes (name redacted) for all work orders. All staff are educated on the process of entering work orders into the (name redacted) system. The Maintenance dept is responsible for addressing the work orders in a timely fashion. NJAC 8:39-4.1(a)11. 31.4 (a), (b), (c), (f)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure dental procedures were arranged as recommended by consulting dentistry for 1 of 1 resident (Resident #109) reviewed for dental care. This deficient practice was evidenced by the following: On 6/9/25 at 11:27 AM, during initial tour of the facility, the surveyor observed Resident #109 in their room watching television. The resident informed the surveyor that they had been wanting to see a dentist and have teeth extracted for months and felt that nothing was being done. The resident did not complain of any discomfort or pain, rather wanting to have rotten teeth extracted and be evaluated for dentures. On 6/10/25 at 10:43 AM, the surveyor reviewed Resident #109's electronic medical record (EMR) and the following was identified: A review of the resident's admission Record indicated that the resident was admitted to the facility with diagnosis which included but was not limited to type two diabetes and severe obesity. A review of the resident's quarterly Minimum Data Set (MDS) (an assessment tool) dated 4/2/25 indicated that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, was independent with eating and oral hygiene, did not have pain, did not have a swallowing disorder, and did not have dentures. A review of the physician's Order Summary Report indicated and order with an order date of 6/25/24 for dental consult, an order dated 9/26/24 for dental consult and treatment as needed, and an order dated 10/16/24 for dental referral. A review of dental consultation notes dated 6/5/24 indicated that the resident had poor oral hygiene, and to refer the resident for extraction of all remaining teeth. On 6/11/25 at 11:44 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the resident had informed him that some foods such as waffles are too difficult for the resident to chew. On 6/11/25 at 11:49 AM, the surveyor interviewed the LPN Unit Manager (LPN/UM) who reviewed the resident's medical record with the surveyor, confirmed that Resident #109's last dental visit was 6/5/24, verified and confirmed that the consultation recommendation was to have all remaining teeth extracted, stated that arranging for this procedure should have taken approximately two to four weeks depending on the scheduling department for the facility that performs the procedure, and acknowledged that Resident #109's referral was over one year old and that it should not have taken this long for the facility to arrange for the resident to be sent to have this procedure. On 6/11/25 at 12:11 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the consultant dentist comes to see residents approximately two to three times per month. She stated that when a consultation recommendation for dental procedures are made, the facility was to follow up and arrange for the resident to be sent to have the procedure at the appropriate location. She stated that an appropriate time frame for a resident to be sent out for a procedure of teeth extraction should be approximately one month. At this time, the DON reviewed Resident #109's EMR and acknowledged that the resident's teeth extraction consultation was over one year old and was not completed and stated it was not acceptable for it to not have been done by now. A review of the facility's Consultation and Referral policy with a last revised date of 9/2024 included but was not limited to: it is the policy of the facility to ensure timely and appropriate referral of residents to external and internal consultant (e.g., psychiatry, podiatry, dental, neurology, behavioral health, wound care, etc.) based on clinical necessity, regulatory requirements, or as ordered by the attending physician or interdisciplinary team. Referrals shall be coordinated, documented, and followed up to promote resident health, safety, and quality of care. NJAC 8:39-15.1(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident. This deficient practice was identified for 1 of 35 residents reviewed for accommodation of needs (Resident #39), and was evidenced by the following: On 6/9/25 at 11:00: AM, the surveyor observed Resident #39 in bed, and observed that the resident's call bell was out of reach on the floor to left side of bed. The surveyor asked the resident how the resident gets help, the resident stated that they call out for help when needed. On 6/11/25 at 11:35 AM, the surveyor observed Resident # 39 in bed, and observed that the call bell was still on left side of bed on floor, outside of the resident's reach. The surveyor reviewed the medical record for Resident #39. A review of the admission Record reflected that Resident #39 was admitted to the facility with diagnoses that included but were not limited to left sided weakness and paralysis due to cerebral infarction, difficulty walking, diabetes and depression. A review of Resident #39's Annual Minimum Data Set (MDS), an assessment tool dated 5/26/2025 revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which no cognitive impairment. Section GG indicated Resident #39 requires staff assistance for activities of daily living and transfers. A review of the facility's Call Light System policy, last reviewed 9/2024 reflected, Essential points, Unless indicated in the care plan, each resident, when in their room or in bed, must have the call light placed within reach at all times. Regardless of staff assessment of resident ability to use it On 6/11/25 at 11:40 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) assigned to Resident #39's care. The CNA stated that the call bell should be in he residents reach when in bed or when seated in room in chair/wheelchair. The surveyor asked the CNA about the purpose and importance of call bells, and the CNA stated that the call bells are how residents gets help when they need it. On 6/11/25 at 11:45 AM, the surveyor interviewed the Licensed Pratical Nurse, Unit Manager, who stated that the call bells should be answered with 10-15 minutes and they should always be within the resident's reach. On 6/12/25 at 1:00PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator and Director of Nursing. NJAC 8:39- 4.1(a)11; 31.1(b)

Based on interview and record review it was determined that the facility failed to ensure a.) discharge care planning was developed by the interdisciplinary team and involved the resident to reflect their goals and preferences, the comprehensive care plan and discharge plan were updated in response to the information received from local contact agency (LCA) after a referral was made, and b.) the resident's discharge participation and goal setting were accurately assessed. This deficient practice was identified for 1 of 3 residents reviewed for closed record (Resident #414) and was evidenced by the following: 1.)According to Resident #414's admission Record (AR), the resident was admitted with diagnoses that included but were not limited to: muscle wasting and atrophy (loss of muscle mass and strength) difficulty in walking, bipolar disorder, major depressive disorder and anxiety disorder. According to the Minimum Data Set (MDS), an assessment tool dated 3/13/25, Resident #414 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Section GG, Functional Abilities-Discharge included the resident required supervision or touching assistance for lower body dressing, toileting hygiene, shower/bathing. Further review of the MDS indicated the resident required a helper assists prior to or following the activity of 1 step up and down a curb, four (4) to 12 steps with or without a rail, picking up objects and 50 feet with two turns to 150 feet in a corridor. Under section Q - Participation in Assessment and Goal Setting revealed an active discharge planning was not occurring, a referral to the LCA was not made and the reason indicated that the resident did not want the referral. A review of the individualized comprehensive care plan did not include a focus on discharge planning for Resident #414 to include the resident's goals and preferences. A review of the progress notes, under interdisciplinary team (IDT; comprised of the interdisciplinary team/ group of professionals who collaborate to achieve a common goal) care conference note, did not reflect a discharge care plan meeting was held. Further review of the IDT notes did not reveal the resident's goals and preferences for discharge was discussed with the resident. On 6/11/25 at 10:22 AM, during an interview with the surveyor, the Director of Social Services (DSS) stated that she oversaw the department and supervised two (2) social workers who conducted assessments, care planning and included discharge care planning. On 6/12/25 at 9:56 AM, during a follow-up meeting, the surveyor and the DSS reviewed Resident #414's record together. The SSD acknowledged and confirmed, there were no documentation to show that interdisciplinary team met with the resident to address discharge planning and the resident's goals and preferences for discharge. At that time, the DSS stated the resident was discharged to LCA because they were not allowed to discharge directly to the shelter. At that time, the DSS stated that moving forward, the social worker who conducted the discharge would ensure the resident was invited to participate in the discharge care plan meeting, the interdisciplinary team met for the discharge care planning, the care plan was updated with the response from the LCA after the resident was referred, followed-up with the resident , the agency, and the physician after the discharge . The DSS stated these were important to prevent rehospitalization, establish that there were no barriers to the Resident's health outcomes and to make certain of bridging the gap from the facility to the LCA/shelter. On 6/12/25 at 1:08 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Regional Clinical Nurse (RCN) and the [NAME] President of Clinical, the surveyor discussed the concern regarding the care plan that did not include discharge care planning, the missed IDT meeting for the discharge, to include the request for participation of Resident #414, their goals and preferences for discharge, the care plan that was not updated with the response from the LCA after a referral was made On 6/16/25 at 10:00 AM, during a meeting with the survey team, the DON, the RCN, and the Regional Administrator, the LNHA stated that education was provided for proper discharge care planning, the follow-up after discharge and the inclusion of the resident in the process. 2.) On 6/16/25 at 10:00 AM, the surveyor discussed the concern with the RCN regarding the conflicting information provided and the submitted MDS. The MDS reflected that at the time of discharge a discharge care plan had not occurred, a referral to LCA had not occurred and the resident had not wanted a referral to the LCA. On 6/16/25 at 10:27 AM, in the presence of the surveyor and the DSS, the RCN confirmed that there was an MDS error in coding the resident's discharge and that the MDS would be modified after surveyor inquiry. At that time, the DSS stated that Resident #414 was referred to LCA and dropped off at the LCA. A review of the provided facility policy, Discharge Plan reflected the care plan team/ IDT team will collaborate with the resident and his or her family to develop the discharge plan. A discharge plan included the resident's and family's preference of care .Social services will review the plan with the resident and family at least 24 hours prior to discharge . A review of the provide facility policy, Resident Assessment Instrument (RAI) Process, included to ensure the MDS for each resident was completed accurately and timely in accordance with State and Federal regulations. NJAC 8:39-4.1(32), 5.5(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow care plan interventions to provide safe transfer of resident utilizing mechanical lift. This deficient practice was identified for 1 of 5 residents reviewed for accidents (Resident #2). The deficient practice was evidenced by the following. On 6/9/25 at 10:47 AM, during the initial observations and tour on the 5th floor of the facility, the surveyor knocked on the open door for 536-2 and entered the room. The surveyor observed Resident #2 in process of being transferred out of bed via mechanical lift by the Certitified Nursing Assistant (CNA). The CNA performed the procedure without a second staff member present to assist. On 6/11/25 at 11:40 AM, the surveyor interviewed the CNA, and the CNA acknowledged she was trained on mechanical lift use by the facility and that there should be two people when transfering a resident via a mechanical lift. The CNA acknowledged that she did not have 2 people during the observed transfer via a mechanical lift. On 6/12/25 at 2:00 PM, the surveyor interviewed the Licensed Practical Nurse, Unit Manager, LPN/UM, who stated that mehcaincal lift use should be performed by two staff members. The surveyor asked for the purpose of this requirement and the LPN/UM stated it was for safety of staff and residents. On 6/12/25 at 2:05 PM, the surveyor interviewed the LPN assigned to Resident #2. The LPN confirmed that the policy was to have two staff members perform every mechanical lift patient transfer. The surveyor asked the LPN what the purpose of this requirement was and LPN stated for safety The surveyor reviewed the admission record reflected that Resident #2 was admitted to the facility with diagnoses that included but were not limited to; left leg amputation above the knee, right leg amputation below the knee, muscle wasting and atrophy and generalized muscle weakness. The surveyor reviewed Resident # 2's care plan interventions, which revealed that the resident should be trasnfered via mechanical lift with two persons assist. The surveyor also reviewed the resident's Minimum Data Set (MDS), an assessment tool dated 6/5/25 revealed Resident #2 had a brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderate cognitive impairment. Section GG indicated Resident 2 required staff assistance for activities of daily living and transfers. Surveyor reviewed the facility's policy Lifting Machine, Using a Mechanical lift, undated reflected The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. General guidelines item number 1 reads At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift On 6/12/25 at 1:00 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator and Director of Nursing. NJAC 8:39- 33.1(d)

Complaint NJ00182662 Based on record review and interview it was determined that the facility failed to consistently provide ostomy care for a resident who was dependent on staff for colostomy management. The deficient practice was cited for 1 of 3 residents (Resident #1017) reviewed for the need of assistance with activities of daily living and was evidenced by the following. The surveyor reviewed the closed record for Resident #1017 which revealed the following information. The admission Record indicated the resident was admitted with diagnoses including but not limited to colon cancer and colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon). The admission Minimum Data Set (MDS) assessment tool indicated the resident utilized an ostomy for bowel continence (Section H0400). The MDS indicated the resident was dependent upon staff for managing the ostomy (Section GG). The 12/22/25 toileting care plan for colostomy care included instructions for nursing to keep skin around the stoma clean and dry. A 2/9/25 facility Concern Form provided by the Director of Nursing (DON) described an incident in which the colostomy drainage bag had not been emptied during the 11 PM to 7 AM shift by the nurse on duty. On 6/12/25 at 10:11 AM the surveyor interviewed the Certified Nursing Assistant (CNA #1) who worked the oncoming 7 AM to 3PM shift. She stated when she came onto her shift she checked the resident who had a full colostomy drainage bag which had burst. She stated stool was on the resident and on the bed. CNA #1 alerted her nurse supervisor (Nurse #1). On 6/12/25 at 10:19 AM the surveyor interviewed Nurse #1 who had worked the oncoming 7 AM to 3 PM shift. Nurse #1 stated CNA #1 called her into the room of Resident #1017. She observed the full and open colostomy drainage bag. Nurse #1 stated she assessed the resident who did not have any excoriation of the surrounding skin. The resident was washed. Nurse #1 notified the resident's responsible party and also reassured the resident. Nurse #1 called the 11-7 nurse (Nurse #2) who was responsible for the resident's care. Nurse #2 stated she got busy and forgot to check on the resident. The surveyor was unable to speak with CNA #2 or Nurse #2 at the time of the survey. On 6/12/25 at 1:00 PM the surveyor discussed the concern with the DON and the Administrator. The surveyor reviewed the facility policy and procedure titled Ostomy Care (Colostomy, Jejunostomy, Illeostomy, Ileo Conduit), last reviewed September 2024. The policy statement read as follows: The facility strives to provide ostomy care to residents in a manner that promotes dignity and resident health by maintaining cleanliness and skin integrity, preventing odors, and preventing infections. NJAC 8:39-27.1(a); 27.2

Complaint # NJ 00175968 Based on observation, interview, and review of medical records, it was determined that the facility failed to provide necessary treatment and services consistent with professional standards of clinical practice by not ensuring that a.) a resident with an Implanted Cardioverter Defibrillator (ICD) received care and services as recommended by the manufacturer's specifications (Resident #1018) and b.) a resident received passive range of motion (ROM) exercises as recommended by the physical therapist (Resident #39). This deficient practice was observed for 2 of 35 residents reviewed for care and services and was evidenced by the following: 1. On 6/12/25 at 9:00 AM, the surveyor reviewed the closed medical record for Resident #1018. A review of the admission Record reflected that Resident #1018 was admitted to the facility with diagnoses which included but were not limited to; atrial fibrillation (an irregular heartbeat that may cause the heart to beat faster than usual) and the presence of an automatic (implantable) cardiac defibrillator (ICD) (a small, implantable device that monitors and corrects irregular heart rhythms (arrhythmias). When it detects a potentially life-threatening arrhythmia, it delivers an electrical shock to the heart to restore a normal rhythm.) A review of the most recent comprehensive Minimum Data Set (MDS), an assessment dated [DATE], reflected the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated severe cognitive impairment. A review of the Cardiologist Consultation dated 8/20/2018 reflected: the resident was doing better, needs ICD checked, to follow up on 11/15/2018 at 11:00 AM. A review of the Cardiologist Consultation dated 11/15/2018 reflected: Needs ICD checked, to follow up February 7, 2019, at 2:00 PM. The facility was unable to provide any documentation indicating that Resident #1018 was seen by the cardiologist for ICD check on 2/7/2019. Further review revealed Resident #1018 had not had any documentation of follow up appointments with the cardiologist for ICD monitoring from 11/15/2018 through 7/2024. A review of a nurses progress note dated 6/15/24 reflected [Resident] went out on pass with daughter. Expected to return 6/16/24. A review of a nurses progress note dated 6/16/24 at 22:51 reflected the resident had not returned to the facility. The Licensed Practical Nurse (LPN) called the daughter who informed the LPN that she had brought the resident to the emergency room and that the resident had a high heart rate and low blood pressure. A review of the hospital note dated 6/18/24 revealed: On arrival patient found to be in atrial fibrillation up to 140 bpm, was started on Cardizem drip; now atrial fibrillation controlled ventricular rate 70-80 bpm. A review of the admission nurses note reflected the resident returned from the hospital on 6/27/24 at 11:00 PM in stable condition. A review of the facility provided Concern Form dated 6/28/24 reflected the Resident's daughter informed the social worker that the [Resident] had a decline and that she took the [Resident] to the hospital. Upon evaluation the daughter was informed that the resident's pacemaker was not functioning. A review of the Licensed Practical Nurse/Unit Manager's (LPN/UM) reflected ICD with battery depletion needs to follow up with their electrophysiologist. The cardiology appointment set for 7/3/24. A review of the Cardiac Consultation dated 7/3/24 reflected: ICD follow up in one month, recurrent atrial fibrillation, device functioning normal. On 6/13/25 at 8:50 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that there was no documentation that Resident #1018 had their ICD checked by the cardiologist or the electrophysiologist from11/15/18 through 7/3/24. The DON confirmed that the facility should have followed up with the cardiologist to see when the resident needed the next ICD check and acknowledged it should be monitored every 3-6 months depending on the cardiologist's recommendations. On 6/13/25 at 12:49 PM, during an interview with the DON, the surveyor requested the make, model and manufacturers specification for the ICD. On 6/13/25 at 1:50 PM, during an interview with the surveyor, the Regional DON stated that it was up to the cardiologist how often the ICD was monitored. The surveyor asked the Regional DON who should ensure the resident went to their follow up appointment with the cardiologist. The Regional DON did not respond. The surveyor asked the Regional DON to provide the make, model and manufacturers specifications for the ICD. On 6/16/25 at 8:15 AM, the surveyor attempted a phone interview with the Resident's cardiologist with no return call. On 6/16/25 at 10:05 AM, during an interview with the surveyor, the DON stated the implantable cardioverter-defibrillator was an [NAME] Unify Assura device 3257-40. On 6/16/25 at 10:10 AM, during a phone interview with the surveyor, the resident's primary care physician (PCP) stated that it was up to the cardiologist to determine how often the ICD should be checked. The PCP could not speak to why the facility had not ensured that the Resident's ICD was monitored by a cardiologist from 2018-7/3/24. A review of the IDT Nurses note dated 7/3/24 reflected resident went to the cardiology appointment in stable condition and returned in stable condition with his/her daughter. [Resident] has a follow up appointment on 8/13/24 at 9:45 AM. A review of the Nurses Note dated 7/30/24 reflected Resident being transferred to another facility. A review of the manufacturer's specifications for the ICD reflected: An [NAME] Unify Assura device (like the 3257-40, which is an implantable cardioverter-defibrillator or ICD) requires regular checks to ensure its functioning properly and to monitor battery life. Frequency of Checks: Initial period: Immediately after the device is implanted, your doctor may check it more frequently, possibly every 3 months. Ongoing Monitoring: If the ICD is functioning well, follow up appointments may be spaced out to about every six months. Battery Monitoring: When the battery starts showing signs of needing replacement, your doctor may schedule more frequent check-ups to monitor it closely. The lithium battery can last 5 to 7 years. Vibrator Alert: The device is designed to provide a vibratory alert when the battery is nearing its end of life. You should contact your physician promptly if you feel this alert. On 6/16/25 at 11:58 AM, the surveyor discussed the above observations and concerns with the DON who acknowledged the facility should have ensured the device was monitored every 3-6 months per the manufacturer's specifications. No further documentation was provided by the facility. 2. On 6/11/25 at 12:00 PM, the surveyor interviewed the Director of Therapy Services (DTS), who stated that the therapists in the facility would request orders to begin resident on a Restorative Nursing Program (RNP) and are responsible for discontinuing orders. The DTS confirmed that Resident # 39 had an order for Occupational Therapy (OT) on 3/29/25 and he confirmed that the RNP program was not discontinued and was running concurrently with OT. On 6/12/25 at 1:55 PM, the surveyor interviewed the Certified Nursing Assistant (CNA), who was assigned to the care of Resident #39. The CNA stated that the RNP task information would appear on the screen of tasks that a CNA completed. The CNA stated that she may receive this information from the nurse or off-going CNA during a handoff report. The CNA stated that whatever tasks she completed for a resident during her shift would be charted into the Electronic Health Record (EHR). The surveyor asked the CNA if she is frequently assigned to Resident # 39 for care and CNA stated Sometimes. Surveyor asked CNA if she was aware of any RNP exercises or tasks assigned to CNA for Resident # 39 and she stated no. On 6/12/25 at 2:00 PM, the surveyor interviewed the LPN and Unit Manager for 5th floor. Surveyor asked about responsibility for RNP exercises and LPN stated that the CNAs perform daily tasks on a Plan of Care (POC). The surveyor asked about how the staff shows accountability and if there is a co signature or if documentation is checked by the nurse to confirm that exercises were completed and the LPN stated stated No. The surveyor reviewed the medical record for Resident #39. The surveyor reviewed the admission Record, which reflected that Resident #39 was admitted to the facility with diagnoses that included but were not limited to Left sided weakness due to cerebral infarction, difficulty walking, diabetes and depression. A review of Resident #39's Annual Minimum Data Set (MDS), an assessment tool dated 5/26/2025 revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which no cognitive impairment. Section GG indicated Resident #39 requires staff assistance for activities of daily living and transfers. The surveyor reviewed Resident #39's current care plan, which reflected the resident's limited ROM/mobility and hemiplegia. Thre care plan's interventions and tasks included, but not limited to, the RNP order, bed mobility, rolling from side-to-side x 10 repetitions x 3 sets as tolerated, to maintain muscle and joint integrity. The suurveyor reviewed current physician orders, which revealed active orders for AAROM to BLE dated 9/1/23. The orders revealed an active order for bed mobility and rolling from side-to-side x 10 repetitions x 3 sets as tolerated. The surveyor reviewed the documentation report for the months of March, April and May of 2025. The reports revealed that no bed mobility exercise appeared on the March report. In the April and May 2025 report, the bed mobility appeared as an as needed or as needed task. The surveyor reviewed the task report for daily AAROM to BLE for month of March 2025 and CNA sign offs appeared on 0 of 31 days. For the month of April 2025, the CNAs signed off that the task was performed on 2 of 30 days. For the month of May 2025, the CNA signed off only for 1 of 31 days. On 6/12/25 at 1:00 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator and Director of Nursing NJAC 8:39- 3.2(a),(b); 27.1

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by ensuring; a.) the first dose of a medication (Fluconazole)(a medication used to treat fungal infections) was accurately administered and documented to one (1) of five (5) residents, (Resident #190), discovered by surveyor inquiry during the medication administration observation and b.) accurately clarifying the transcription and documentation of a physician's order for a medication (Coreg)(a medication used to treat high blood pressure) by one (1) of three (3) nurses for one (1) of five (5) residents, (Resident #190), observed during the medication administration observation. The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/10/25 at 9:15 AM, during the medication administration, the surveyor observed the Licensed Practical Nurse (LPN #1) preparing to administer four (4) medications to Resident #190 which included one (1) tablet of Fluconazole 200 milligrams (MG) and two (2) tablets of Coreg 3.125 MG. At that time, LPN #1 removed a card containing Fluconazole 200 MG tablets labeled for Resident #190 with (1) tablet remaining with instructions to administer 2 Tablets (400 MG) BY MOUTH IN THE MORNING FOR INFECTION FOR 1 DAY. The label indicated there was two (2) tablets contained in the card and filled by the provider pharmacy 6/6/25. LPN #1 stated according to that label she had to administer two tablets and removed another card containing Fluconazole 200 MG tablets labeled for Resident #190 with 13 tablets. LPN #1 then reviewed the electronic medication administration record (EMAR) and stated that the physician's order (PO) indicated to administer one (1) 200 MG tablet. LPN #1 reviewed the instructions on the label of the second card containing Fluconazole which indicated to administer 1 TABLET BY MOUTH EVERY MORNING FOR 13 DAYS. The label indicated there was 13 tablets that were filled by the provider pharmacy on 6/7/25. LPN #1 stated that she had not worked on this medication cart during the weekend or yesterday and was unable to speak to why the first card containing Fluconazole 200 MG tablets had instructions to administer two (2) tablets on day 1 and there was a remaining 200 MG tablet of Fluconazole. Also, at that time, LPN #1 removed a card containing Coreg 3.125 MG tablets labeled for Resident #190 with instructions to administer 2 TABLETS (6.25 MG) BY MOUTH EVERY 12 HOURS FOR HYPERTENSION (HTN)(high blood pressure) WITH MEALS/FOOD. LPN #1 then referred to the electronic PO which indicated to administer Carvedilol (Coreg) Oral Tablet 6.25 MG, Give 1 tablet by mouth every 12 hours for HTN offer food with medication, hold for SBP (systolic blood pressure) less than 100, HR (heart rate) less than 60. LPN #1 stated that the PO had 6.25 MG but according to the label two (2) of the 3.125 MG tablets was the same as one tablet of Coreg 6.25 MG. LPN #1 was unable to speak to why the PO had not reflected what was sent by the pharmacy. The surveyor reviewed the medical record for Resident #190. A review of the admission Record (an admission summary) reflected diagnoses which included but not limited to essential (primary) HTN. A review of the most recent comprehensive quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 4/17/25, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the June EMAR reflected a PO with a start date of 6/7/25 for Fluconazole Oral tablet 200 MG, Give 2 tablet by mouth in the morning for infection for 1 day. The PO was signed as administered by LPN #2 at 9 AM on 6/7/25. Further review of the EMAR reflected a PO with a start date of 5/1/25 for Carvedilol (Coreg) Oral Tablet 6.25 MG, Give 1 tablet by mouth every 12 hours for HTN offer food with medication, hold for SBP <100, HR<60. The PO was signed as administered by LPN #1 6/10/25. On 6/10/25 at 12:27 PM, the surveyor interviewed Resident #190 who stated that they knew they were taking a new medication recently started. Resident #190 added that the nurses gave them their medication and was unsure what the medication was but knew that it was a pink tablet. Resident #190 also stated that they thought they had taken one tablet yesterday and one tablet today in the morning. On 6/10/25 at 12:46 PM, the surveyor interviewed the LPN #1 who stated that she had not told her Unit Manager (UM) about the remaining Fluconazole tablet on the first card because she could not speak to what happened. LPN #1 also stated that she had administered the correct dose of Coreg and could not speak to why the provider sent the Coreg 3.125 MG tablets instead of 6.25 MG tablets. On 6/10/25 at 1:30 PM, the surveyor interviewed the UM/LPN regarding the remaining Fluconazole 200 MG tablet and the PO for Coreg 6.25 MG that had 3.125 MG tablets sent by the provider pharmacy for Resident #190. UM/LPN stated she would have to review. On 6/11/25 at 10:03 AM, the surveyor interviewed the UM/LPN who stated that the original Fluconazole PO was to administer on the first day two (2) tablets of 200 MG for a total dose of 400 MG and then for the next 13 days to administer one (1) Fluconazole 200 MG tablet so that was why there was two cards. UM/LPN explained the first Fluconazole dose of 400 MG was to be administered on 6/7/25 and the nurse (LPN #2) who signed the electronic medication administration record (EMAR) as administering the two (2) 200 MG tablets was being contacted because they were from an agency. The UM/LPN further explained that on 6/8/25 the nurse followed the PO and administered one 200 Mg tablet of Fluconazole from the first card with the two (2) tablets and thought the 400 MG had already been administered and that was why there was one remaining tablet during the medication observation on 6/11/25. The UM/LPN then stated that she interviewed the Registered Nurse (RN #1) who signed for the administration of the 200 MG dose on 6/9/25 but the medication was not administered. UM/LPN stated that she was in the process of completing medication error reports. UM/LPN acknowledged that there was no documentation regarding the missed dose on 6/7/25 or 6/9/25 in the progress notes. UM/LPN added that the physician had been notified. In addition, UM/LPN stated that Resident #190 had been readmitted to the facility and previously had a PO for two (2) tablets of Coreg 3.125 MG to be administered but upon readmission the Coreg was ordered for 6.25 MG and the provider pharmacy sent the 6.25 MG tablets. UM/LPN stated that LPN #1 was using the Coreg 3.125 MG tablets from the previous PO. UM/LPN also stated that the PO had to match what was being administered. On 6/12/25 at1:07 PM, the survey team met with the facility administrative team. The Director of Nursing stated that she was aware of the medication error reports being completed by the UM/LPN. On 6/13/25 at 9:43 AM, the surveyor interviewed via telephone the Consultant Pharmacist (CP) who stated that the nurses were to follow a PO to a tee meaning that if a dose of a medication was ordered for 10 MG, the nurses were not to administer two (2) 5 MG tablets. The CP added that the pharmacy would have to be called, and the PO must match what was being administered and documented in the EMAR. The surveyor reviewed the facility policy dated as reviewed 2/2025 for Medication Administration Policy which reflected Prior to Medication Administration: Verify each medication preparation that the medication is the RIGHT DRUG, at the RIGHT DOSE, the RIGHT ROUTE, at the RIGHT RATE, at the RIGHT TIME, for the RIGHT CUSTOMER. Verify that the MAR reflects the most recent medication order. In addition, Medication Administration: Medications are administered in a timely fashion as specified by policy. And After Medication Administration: Document necessary medication administration/treatment information (e.g.,when medications are administered, medication injection site, refused medications and reason, prn (as needed) medications, etc.) on appropriate forms. NJAC 8:39-11.2(b); 29.2(a)(d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) refrigerated medications were removed from active inventory when residents were discharged from the facility for two (2) of three (3) refrigerators inspected and b.) a medication (Tivicay)(an antiretroviral medication used to treat human immunodeficiency virus) was labeled appropriately with a resident's name found in one of eight (8) medication carts inspected. The deficient practices were evidenced by the following: On 6/11/25 between 11:26 AM to 11:31 AM, the surveyor inspected the 5th floor medication room refrigerator in the presence of the Licensed Practical Nurse (LPN #1). The surveyor observed two packaged pen injectors of Trulicity (a medication used to help manage blood sugar levels) 3 milligrams (MG) per 0.5 milliliters (ML) labeled for unsampled Resident #1. LPN #1 stated that unsampled Resident #1 had expired and the Trulicity pen injectors should have been removed from the refrigerator. At that time, the surveyor also observed an opened 10 ML vial of Lantus insulin (a long-acting medication used to lower blood sugar levels) labeled for unsampled Resident #2 with a written date on the label of 6/4/25. LPN #1 stated 6/4/25 was the date the vial was opened and unsampled Resident #2 had gone to the hospital. LPN #1 added that the vial of Lantus remained because the nurses thought the resident was going to return the same day. LPN #1 asked another nurse when unsampled Resident #2 had gone to the hospital and LPN #1 then stated that the resident went to the hospital on 6/9/25 and had not returned. LPN #1 added that any resident that was no longer in the facility should have all medications removed from the medication cart and refrigerator. The surveyor reviewed the medical record for unsampled Resident #1 which reflected that the resident had expired 4/1/25. On 6/11/25 at 11:49 AM, the surveyor inspected the 3rd floor medication room refrigerator in the presence of the LPN #2. The surveyor observed three (3) intravenous 50 milliliter bags of Daptomycin (an antibiotic) labeled for unsampled Resident #411 with a used by date on the label of 6/9/25. LPN #2 stated unsampled Resident #411 had moved to the 6th floor about two days ago and the medication should have been sent with the resident. The surveyor showed LPN #2 the use by date on the labels for 6/9/25 and LPN #2 then stated the medication should be removed and destroyed. On 6/11/25 at 11:49 AM, the surveyor inspected the 3 South medication cart with LPN #2. The surveyor observed a bottle labeled Tivicay 50 MG tablets with no resident name labeled on the bottle. LPN #2 stated that he knew the medication was for unsampled Resident #259 and thought the label with the resident's name may have come off the bottle. On 6/11/25 at 12:38 PM, the Licensed Nursing Home Administrator provided the surveyor with a policy dated as reviewed and updated 11/2024 for Storage of Medications. The policy reflected Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. On 6/11/25 at 12:57 PM, the surveyor interviewed the Director of Nursing (DON) who stated that when residents were discharged or hospitalized the nurses were to follow the same procedure for discontinued, outdated or deteriorated drugs indicated in the Storage of Medications policy and remove the medications from active inventory. On 6/12/25 at 11:50 AM, the surveyor interviewed LPN #3 who stated that she was the medication nurse for the 3 South medication cart for the day. LPN #3 showed the surveyor a card containing Tivicay 50 MG tablets that had been delivered to the facility by the provider pharmacy on 6/11/25. LPN #3 was unable to speak to what happened to the bottle of Tivicay 50 MG tablets. LPN #3 added that all medications were required to have a resident's name except if the medication was a house stock over the counter medication provided by the facility. On 6/12/25 at 11:52 AM, the surveyor interviewed the 3rd floor Unit Manager (UM)/LPN who stated she thought the nurse had to reorder the Tivicay. UM/LPN added that she was aware of a bottle of Tivicay 50 MG tablets from yesterday but was unsure where the bottle came from, and LPN #2 was not working today. UM/LPN acknowledged that medications were required to be labeled with a resident's name. On 6/13/25 at 9:43 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated unit inspections were conducted monthly which included checking the medication carts and refrigerators and would make sure there were no expired medications. The CP added that he used the facility census to make sure residents that have been discharged , expired or hospitalized had their medications removed from active inventory but that sometimes he was not always aware of the residents that have been discharged . The CP added that the nurses were expected to remove the medications for those residents as soon as possible. On 6/13/24 at 10:27 AM, the survey team met with the administrative team. The DON acknowledged that proper labeling of medications and removing medications when residents were discharged was required. Further review of the facility policy Storage of Medications reflected The facility stores all drugs and biologicals in a safe, secure, and orderly manner. NJAC 8:39-29.4(g)(h)

Based on observation, interview, and record review it was determined that the facility failed to consistently maintain appropriate infection control practices to limit the spread of infection. The deficient practice was observed with 1 staff person and 2 residents, (#2 and #39) and observed in 1 resident room, (room [ROOM NUMBER]), and evidenced by the following. 1. The surveyor observed the lunch meal in the 3rd floor day room on 6/10/25 at 12:31 PM. An Activity Aide (AA) was observed as she passed out hand sanitizing wipes to 6 individual residents. The AA collected the 6 used wipes in her hand and disposed of them. Without performing hand hygiene, the AA wiped the hands of 3 additional residents. She did not perform hand hygiene in between residents. The AA proceeded to the pantry hand-wash sink, applied soap to her hands, lathered for 10 seconds and rinsed the soap from her hands. The surveyor spoke with the AA explaining the surveyor's observations to the AA. The AA stated she should have performed hand hygiene in between resident contact and should have lathered with soap for 30 seconds before rinsing. The surveyor discussed the infection control concern with the Director of Nursing (DON) and the Administrator on 6/12/25 at 1:30 PM. The DON provided the facility policy and procedure titled Handwashing/Hand Hygiene, October 2024. The Policy Statement indicated the facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. Indications for hand hygiene included immediately before touching a resident and after touching a resident. 2. On 6/9/25 at 11:00 AM, the surveyor observed two grey round wash basins stored on floor unlabeled and uncovered in room [ROOM NUMBER]. On 6/12/25 at 11:30 AM, the surveyor made a second observation room [ROOM NUMBER] and still observed two unlabeled and uncovedred grey round basins and also observed a grey fractured bedpan stored unlabeled underneath the hand washing sink in the resident's room. On 6/11/25 at 11:00 AM, the surveyor interviewed the Licensed Pracrtical Nurse, Unit Manager (LPN/UM), who stated that the wash basins and bedpans are cleaned after use and should be labeled with resident's name and should be stored with the resident's belongings. On 6/12/25 at 1:00 PM, the surveyor discussed the concerns with the Administrator and DON. The DON acknowledged that containers should not be stored in that manner and should be labeled to prevent cross contamination between residents. No further information provided by facility. NJAC 8:39-19.4 (a)

Based on observation, interview and record review it was determined that the facility failed to a.) maintain a Tube Feeding (TF) pump and pole in, safe, sanitary and optimal condition for Resident # 349 and b.) maintain a geriatric chair in safe, sanitary and optimal condition for Resident #2. This deficient practice was observed for 2 of 35 residents reviewed and was evidenced by the following: On 6/9/25 at 11:15 AM, the surveyor observed Resident #349 in bed on a specialty mattress. The Resident did not respond to the surveyor's greeting. The surveyor observed a TF Pump (used to deliver nutrition to patients who cannot obtain such by swallowing) at resident #349's bedside. The TF pump was soiled with a brown and white substance and the pole was soiled with a brown and white substance and was heavily rusted. On that same date, at that same time, during an interview with the surveyor, the Licensed Practical Nurse/ Unit Manager (LPN/UM) stated that Resident #349 received tube feedings which started in the afternoon. The surveyor reviewed the medical record for Resident #349. A review of Resident #349's admission Record revealed the resident was admitted to the facility with diagnoses that included but were not limited to; diabetes mellitus, aphasia, hemiplegia (mild or partial weakness or loss of strength on one side of the body), hemiparesis (severe or complete loss of strength or paralysis on one side of the body and dysphagia, multiple pressure ulcers, dysphagia (difficulty swallowing) and gastrostomy status (a surgically placed tube through the stomach providing a route for delivering nutrition.) A review of the current Order Summary Report reflected a physician's order for nothing by mouth, enteral feed order in the afternoon for dysphagia: Glucerna 1.5 at 65 milliliters per hour via G-tube until a total volume of 1200 ml completed. Up at 1400 hours and down upon completion of 1200 ml with a start date 6/9/25 and Enhanced Barrier Precautions (an infection control strategy used to reduce the spread of multidrug-resistant organisms (MDROs) with a start date 3/12/25. A review of the most recent Minimum Data Set (MDS) an assessment tool dated 5/10/25 reflected Resident #349's cognitive skills for daily decision making was moderately impaired. Section K assessed the resident had a feeding tube. A review of Resident #349's Individualized Care Plan (CP) had a focus area that indicated [Resident] requires tube feedings r/t dysphagia, swallowing problems initiated 10/223/24 and revised on 4/29/25 with interventions that included but were not limited to; [Resident]is dependent on tube feeding and water flushes. On 6/12/25 at 1:20 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing and VP of clinical operations. On 6/13/25 at 10:15 AM, the DON confirmed that the nurses were responsible for cleaning the TF pump and the housekeepers were responsible for cleaning the poles. The DON confirmed that the pump should have been cleaned properly and that the pole should have been discarded. A review of the facility's Enteral Feeding policy dated 9/24 revealed: Purpose: To maintain a clean, safe, and hygienic environment for all residents, patients, visitors, and staff .this policy applies to all cleaning staff, healthcare workers, and any personnel responsible for the cleanliness of the facility and equipment .Infection Control .Follow hand hygiene protocols before and after cleaning .cleaning schedules must be logged and signed off daily .All staff must undergo training on cleaning protocols. NJAC 8:39-27.1 (a) Based on observation, interview and record review it was determined that the facility failed to maintain a geri-chair recliner in safe and optimal condition for resident 2 in room [ROOM NUMBER]-2. This deficient practice was identified for 1 of 35 residents reviewed for safe operating of equipment (Resident #2). This deficient practice was evidenced by the following: On 6/9/20 at 10:50 AM, during the initial tour of room [ROOM NUMBER] the surveyor noted the Resident #2 was seated a geri-chair that had signs of disrepair including but not limited to broken panels and torn cushions. On 6/12/2025 at 10:06 AM, during resident interview with Resident # 2, the resident granted surveyor permission to examine geri-chair. The surveyor observed the geri-chair's left side panel was broken with missing pieces in 2 places. The left arm rest pad was torn and frayed, the right arm rest pad was missing, the foot rest was torn and frayed and the frame, panels and wheels of geri-chair were visibly soiled On 6/12/25 at 11:20 AM, the surveyor interviewed the Certified Nursing Assistant (CNA), who was assigned to Resident # 2. The CNA verbalized to surveyor that she noticed that arm rest was missing when transferring him to chair in the morning. The surveyor asked what the process or expectation was when she found faulty or damaged resident equipment, and she stated I would tell the nurse and the CNA stated she did not tell the nurse about the Geri-Chair arm rest missing. On 6/12/25 at 11:50 AM, the surveyor interviewed the Director of Housekeeping (DOH). The DOH confirmed that the housekeepers clean all geri-chairs on 3-11 shift and they are cleaned 4x weekly, and DOH confirmed housekeeping staff was expected to report any issues to the supervisor. On 6/12/25 at 11:55 AM, the surveyor interviewed the Director of Maintenance (DOM). The DOM confirmed that minor repairs and replacement of parts for Geri-chairs are performed by facility maintenance staff. DOM confirmed all staff are trained to report all facility and resident equipment issues with a work order in TELS electronic system. The surveyor reviewed facility policy titled Maintenance services and work orders and dated 10/1/24. The facility policy states under Procedure, item # 6 The facility utilizes TELS for all work ordered. All staff are educated on the process of entering work orders into the TELS system. The maintenance dept is responsible for addressing the work order in a timely fashion. The surveyor reviewed TELS work order report for months of May 2025 and June 2025, and there was no entry for request to repair chair for Resident #2 room [ROOM NUMBER]-2 for repair of geri-chair in month of May 2025 or June 2025. On 6/12/25 at 1:00 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator and Director of Nursing. NJAC 8:39 - 31.2(e)

Complaint #: NJ186463 Based on observation, review of the medical record and other pertinent facility documents on [DATE], it was determined that the facility failed to develop a comprehensive care plan for emotional services/support for a resident who witnessed the death of another resident. This deficient practice was identified for 1 of 6 residents reviewed for care plans (Resident#2), and was evidenced by the following: On [DATE] at 12:15 PM, the surveyor interviewed Resident #2, who stated Resident #1 and an unidentified resident came to their room and all three residents were smoking crack and cocaine. According to Resident #2, they observed Resident #1 in the chair falling to the side and Resident #2 notified the Licensed Practical Nurse (LPN #1), who told the resident and the unidentified resident to leave the room. Resident #2 observed LPN #1 perform cardiopulmonary resuscitation (CPR; emergency life-saving procedure performed when someone's breathing or heart beat has stopped) on Resident #1. On [DATE] at 9:22 AM, the surveyor interviewed Resident #2, who stated their anxiety and depression was up since Resident #1 passed away, and no one spoke to the resident regarding Resident #1's death. Resident #2 further stated that due Resident #1's death, they had smoked cocaine one time that they obtained from someone from outside the facility, who brought the cocaine into the facility. Resident #2 stated they were not mentioning names, and did not provide the date, time or location they smoked the cocaine. According to the admission Record face sheet (an admission summary), Resident #2 was admitted to the facility with diagnoses which included but were not limited to; mood disorder, opioid abuse, and anxiety disorder. According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident's cognition was intact. The MDS also indicated that Resident #2 was independent for activities of daily living (ADLs). A review of the resident's individualized comprehensive care plan (ICCP) initiated on [DATE], did not include emotional service's or support for witnessing the death of another resident. During an interview with the surveyor on [DATE] at 12:00 PM, the Social Worker (SW) stated that she spoke with Resident #2 on [DATE], and Resident #2 refused to have a conversation with her concerning the incident on [DATE], regarding witnessing the death of another resident. The SW further stated that she did not report the resident's refusal to the Director of Nursing (DON) or the Licensed Nursing Home Administrator (LNHA). During an interview with the surveyor on [DATE] at 12:10 PM, the DON stated it was the responsibility of the SW to update the care plan. The surveyor reviewed Resident #2's ICCP with the DON, who confirmed emotional support services should have been included for the resident after witnessing the death of another resident. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated revised 03/2022, indicated under Policy Interpretation and Implementation that Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. NJAC 8:39-11.2(i); 27.1(a)

Complaint #: NJ186463 Based on interviews, review of the medical records review and other pertinent facility documentation on [DATE] and [DATE], it was determined that the facility failed to ensure a.) adequate supervision for a Resident (Resident #1) with a known history of drug and drug paraphernalia (equipment needed for or connected with a particular activity) in the facility who had an unexpected death in the facility and was administered Narcan (drug used to reverse an opioid overdose) by nursing staff and b.) conduct and document a thorough investigation for incidents where Narcan was administered to prevent further accidents related to drug use. This deficient practice was identified for 1 of 2 residents reviewed for accidents and hazards (Resident #1), and was evidenced by the following: On [DATE] at 12:15 PM, the surveyor interviewed Resident #2, who stated on [DATE], Resident #1 and another unidentified resident came to Resident #1's room, and all three of the residents were smoking crack and cocaine. According to Resident #2, they observed Resident #1 in the chair falling to the side, so the resident notified the Licensed Practical Nurse (LPN #1), who told the resident and the unidentified resident to leave the room. Resident #2 stated they observed LPN #1 perform cardiopulmonary resuscitation (CPR; emergency life-saving procedure performed when someone breathing or heart beat stopped) on Resident #1. According to the admission Record face sheet (an admission summary), Resident #1 was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder, opioid abuse, cocaine abuse, and bradycardia (slow heart rate). According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. The MDS also indicated that Resident #1 required setup and one-person assistance with most activities of daily living (ADLs) and was independent with locomotion on and off the unit. A review of Resident #1's individualized comprehensive care plan (ICCP) included a focus area dated [DATE], that the resident had a history of poly-substance abuse. The goals included that the resident will abide by the facility's rules and policies against the use of illegal substances through the next review date. Interventions included to: obtain an order for Narcan as needed (PRN) for suspicion of illicit drug use with signs of overdose; the physician will be notified of suspicion of overdose of illicit drug; psychology consultation to develop coping mechanisms to deal with addiction; monitor for signs and symptoms of drug use and overdose; the resident to receive random room search per facility policy; and the resident will receive random toxicology screening if found. A review Resident #2's ICCP included a focus area dated [DATE], for a history of poly-substance abuse and was presently on the methadone program. The goals included that the resident will abide by the facility's rules and policies against the use of illegal substances. Interventions include to: give the resident the opportunity to vent feelings related to addiction issues; identify activities or recreation specific to the resident to provide a distraction; the resident will receive random room searches as per facility policy; the resident will receive random toxicology screenings if found; the physician will be notified of suspicion of overdose of illicit drugs; and obtain an order for Narcan (PRN) for suspicion of illicit drug use with signs of overdose. On [DATE] at 2:15 PM, the surveyor interviewed the Director of Nursing (DON), who stated that she was aware Resident #1 was found in Resident #2's room on the 6th floor nursing unit unresponsive and Narcan was administered twice by LPN #1. The DON further stated that Resident #1 had a history of substance abuse. The DON stated Resident #2's room was searched by the staff for drugs and paraphernalia, but none were found. On [DATE] at 3:29 PM, during an interview with the the surveyor, the Licensed Nursing Home Administrator (LNHA) stated he was aware of Resident #1's unexpected death. The LNHA further stated the resident had a history of substance abuse, and the supervisor searched Resident #2's room and no drugs or paraphernalia were found. The LNHA stated that the DON should have conducted an internal investigation, and the Social Worker and the Registered Nurse (RN) Supervisor should have documented the incident in progress notes and interviewed Resident #2 about the incident. On [DATE] at 3:49 PM, the surveyor interviewed LPN #1, who stated that she responded to an adult emergency services on the 6th floor in Resident #2's room, and assisted the assistant supervisor with CPR and administered Narcan to Resident #1 twice. LPN #1 stated that she did not see any drugs or paraphernalia in the room. LPN #1 further stated she was not interviewed by the LNHA about the incident. On [DATE] at 4:43 PM, the surveyor conducted a follow-up interview with the DON, who stated that staff had searched the pocket of Resident #1 and no drugs or paraphernalia were found. The surveyor asked the DON if the facility conducted an investigation, and the DON stated that an investigation was not warrant at that time. On [DATE], the surveyor received an email from the DON with the following: Summary of Investigation and copies of accident/incident employee statements. The DON stated that a random canine (K9; police dog) search would be conducted on any residents with a suspicion of drugs. If residents were out on pass and returned to the facility, security would search all their bags. If drugs were found, they would notify the DON, or the supervisor and the police would be notified and given the drugs. On [DATE] at 11:00 AM, the surveyor interviewed the DON regarding the random K9 search. The DON stated that according to the facility's Drug Screening and Searches for Resident policy, once items such as drugs, drug paraphernalia, or pills were confiscated by security, the resident's out on pass (OOP) privilege were suspended for 30 days, and they were referred for Harm Reduction Counseling. According to the random K9 search on [DATE], Resident #2 was found with drugs paraphernalia and Depakote pills (prescription medication that can be used to treat psychological disorders). Resident #2 was seen by Harm Reduction Counseling on [DATE], and OOP was suspended on [DATE], and would resume on [DATE]. A review of the facility's ''Substance Abuse policy updated February 2025, included the following: Under: Policy Interpretations and Implementation: Resident identified as high risk for illegal drug use by the nursing department will be subject to have security conduct a search when returning from an authorized Out on Pass visit. On [DATE] at 11:27 PM, the surveyor interviewed the DON regarding residents identified as high risk, and the DON stated Resident #2 was considered high risk, and those were residents who were found with drugs and paraphernalia. The DON stated that staff were aware those residents were high risk, and staff would frequently make rounds (every two hours) and monitor for high traffic in their room. A review of the facility's policy titled Incident and Accident Report and Investigation updated [DATE], revealed the following: Under the Policy: 1. The facility staff will document all incidents and accidents, or any unusual occurrences experienced by the resident on an Incident/Accident Report. 2. The form must be completed immediately or no later than the shift that the incident occurred or when the event has been discovered. 3. Investigations must be started as soon as the event has been reported and a final disposition/ conclusion must be completed accordingly. A review of the facility's Administrator Job Description included under Responsibilities/Accountabilities to ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individual's needs and rights . NJAC 8:39-27.1(a)

Complaint #: NJ186463 Based on observation, interview, and record review, it was determined that the facility failed to ensure that a Licensed Practical Nurse (LPN) had the specific competencies and skill sets necessary to care for a resident's pain management needs. This deficient practice was identified for 1 of 6 residents reviewed for resident needs (Resident #5), and was evidenced by the following: According to Resident #5's admission Record face sheet (an admission summary), the resident was admitted to the facility with diagnoses that included but were not limited to; displaced intertrochanteric fracture of the right femur (broken hip bone at the neck of the thigh bone causing the bone to shift or separate) and unspecified fracture of sacrum (lower back). According to the Minimum Data Set (MDS), an assessment tool dated 05/14/2025, Resident #5 had severe cognitive impairment. The MDS also indicated that Resident #5 required assistance from staff for completion of their activities of daily living (ADLs). A review of Resident #5's Order Summary Report (OSR) with an admission date of 05/20/2025, included a verbal order entry for Aspercreme lidocaine external patch 4% (lidocaine); apply to right hip topically in the morning for pain management and remove per schedule. A review of Resident #5's Medication Administration Record (MAR) dated 05/21/2025, included the lidocaine order to apply to the resident's right hip topically in the morning for pain management and remove per schedule. On 05/27/2025 at 10:15 AM, the Unit Manager (UM) and the surveyor were making rounds on the residents with lidocaine patches. The UM and the surveyor observed Resident #5 had a lidocaine patch on the right thigh. The resident's physician's order indicated to apply the lidocaine patch to the resident's right hip. At that time, the UM requested the Licensed Practical Nurse (LPN) to join them in Resident #5's room, and in the presence of the surveyor, read Resident #5's lidocaine order. The LPN confirmed the lidocaine patch was on the resident's right thigh and not on the right hip. On 05/27/2025 at 11:00 AM, the surveyor interviewed the Director of Nursing (DON), who stated the LPN should have followed the physician's order to place the lidocaine patch on the resident's right hip an not the right thigh. A review of the facility's policy titled Medication Administration dated revised April 2019, indicated . Medication are administered in accordance with prescribe orders, the individual administering the medication checks the label three (3) TIMES to verify the right resident, right medication, right dosage, right time and method (route) of administration before giving the medication . NJAC 8:39-25.2(a)

Complaint #: NJ186463 Based on interviews, review of medical records, and review of other pertinent facility documentation on [DATE] and 5/2725, it was determined that the facility failed to provide a resident with behavioral healthcare services after the resident (Resident # 2) witnessed the death of another resident in their room after allegedly using illicit drugs. This deficient practice was identified for 1 of 5 residents reviewed for resident care (Resident #2), and was evidenced by the following: A review of the progress notes revealed that on [DATE] at approximately 6:00 PM, adult emergency services was called to the 6th floor nursing unit to Resident #2's room, where Resident #1 was found unresponsive. The Licensed Practical Nurse (LPN #1) entered Resident #2's room, and found Resident #1 unresponsive. Narcan (drug used to reverse opioid overdose) was administered twice by LPN #1, cardiopulmonary resuscitation (CPR; emergency life-saving procedure performed when someone's breathing or heartbeat has stopped) was initiated, and Resident #1 was pronounced dead at 6:59 PM by Emergency Services. According to the admission Record face sheet (an admission summary), reflected that Resident #2 was admitted to the facility with diagnoses that included but were limited to; major depressive disorder, unspecified mood (affective) disorder, opioid abuse, alcohol abuse, substance-induced mood disorder, schizoaffective disorder, and anxiety disorder. According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident's cognition was intact. The MDS also indicated Resident #2 was independent for activities of daily living (ADLs). A review of the resident's individualized comprehensive care plan (ICCP) dated [DATE], included a focus area that the resident had a history of poly-substance abuse and was presently on the methadone program. The goals included that the resident will abide by the facility's rules and policies against the use of illegal substances. Interventions included to: give the resident an opportunity to vent feelings related to addiction issues; identify activities or recreation specific to the resident to provide distraction; the resident will receive random room searches as per facility policy; the resident will receive random toxicology screenings if found; the physician will be notified on suspicion of overdose of illicit drug; and obtain an order for Narcan as needed (PRN) for suspicion of illicit drug use with signs of overdose. On [DATE] at 12:15 PM, the surveyor interviewed Resident #2, who stated Resident #1 and an unidentified resident came to their room, and all three residents were smoking crack and cocaine. According to Resident #2, they observed Resident #1 in the chair falling to the side and Resident #2 notified LPN #1, who told the resident and the unidentified resident to leave the room. Resident #2 observed LPN #1 perform CPR on Resident #1. On [DATE] at 9:22 AM, the surveyor interviewed Resident #2, who stated their anxiety and depression was up since Resident #1 passed away, and no one spoke to the resident regarding Resident #1's death. Resident #2 further stated that due Resident #1's death, they had smoke cocaine one time that they obtained from someone outside the facility who brought the cocaine into the facility. Resident #2 stated they were not mentioning names, and did not provide the date, time or location they smoked the cocaine. On [DATE] at 12:01 PM, the surveyor interviewed the Social Worker (SW), who stated that they spoke to Resident #2 on [DATE]. According to the SW, Resident #2 did not want to have a conversation with the SW regarding the incident. The SW stated she did not make further attempts to reach out to the resident after their refusal. The SW could not provide documentation of Resident #2's refusal for follow-up care post incident. On [DATE] at 12:10 PM, the surveyor interviewed the Director of Nursing (DON), who stated she was not aware the SW visited the resident on [DATE], and that they refused to have a conversation regarding the incident on [DATE]. The DON further stated the SW should have documented and did a Interdisciplinary Care Plan (IDCP) meeting (care plans of care created by representatives from several medical disciplines or specialties, each focus on a specific resident conditions, treatment goals, and mention for improvement outcomes) and discuss it in morning meeting. On [DATE] at 12:15 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated the SW spoke with Resident #2 on [DATE], regarding the incident, and the SW should have documented it in the progress notes. On [DATE] at 1:00 PM, the surveyor reviewed the progress notes which revealed that the Physician/Practitioner saw the resident on [DATE], and the note did not include psychosocial support. The resident was also seen by the Psychiatric Nurse Practitioner (NP) on [DATE], who recommended to start Abilify (antidepressant) 5 milligrams (mg) daily for schizoaffective disorder. A review of the facility's policy titled Incident and Accident Report and Investigation did not include a policy and procedure related to psychosocial support. A review of the facility's Social Worker Job Description included : Responsibilities/Accountabilities: 1. Work directly with residents and families experiencing personal and environmental difficulties or concerns related to the resident's physical or emotional condition. 2. Acts as a liaison between residents, families, outside agencies, and the facility Administrator to ensure that the resident's rights are maintained. 3. Ensured that residents receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals need and rights . A review of the facility's Administrator Job Description included: Responsibilities/Accountabilities: Ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individual's needs and rights . NJAC 8:39-27.1(a)

C #: NJ 175921 Based on record review, as well as review of pertinent facility documents on 7/31/24 and 8/1/24, it was determined that the facility failed to review and revise the care plan timely for 1 of 5 sampled residents (Residents #2) reviewed for care plans. This deficiency is evidenced by the following: 1. The Admission Record for Resident #2, showed that the Resident was initially admitted to the facility with diagnoses that included but were not limited to: Displaced Oblique Fracture of Shaft of Right Fibula, Muscle Wasting and Atrophy, Opioid Dependence, and Cocaine Abuse. The Minimum Date Set (MDS), an assessment tool dated 7/3/24, showed that the resident was cognitively intact with a BIMS of 15 and required a partial/moderate assistance from staff with Activities of Daily Living (ADL). Review of Resident #2's incident report (RI #1) and corresponding documentation from the progress notes (PN), revealed that on 7/1/24 at 2:20 p.m. resident was found on floor grunting, not responding to simple commands, Narcan was administered once, resident responded after 3 minutes. Subsequently, on 7/7/24 at 4:35 p.m. IR #2 indicated that the resident was found unresponsive and 4 mg [milligram] Narcan given x3 [3 times]. Review of Resident #2's progress notes (PN) dated 7/1/24 at 5:42 p.m., documented by the Licensed Practical Nurse (LPN) RESIDENT WAS FOUND LEHARGIC IN PRONE POSITION ON THE FLOOR IN HER ROOM. PRN NARCAN WAS ADMINISTERED (Draft). The PN further indicated that on 7/8/24 at 10:05 p.m., documented by a Registered Nurse (RN #1) Resident was found unresponsive 4mg of Narcan 3 were given, resident regain conscious and verbally responsive .resident is alert and stable, no injury noted. The Care Plan (CP) initiated on 6/27/24, showed that the Resident had a risk for falls evidenced by difficulty walking and muscle weakness, and has a history of poly-substance abuse. The facility failed to revise care plan after resident had a fall on 7/1/24. In addition, the CP was not reviewed and/or revised to reflect the overdoses on 7/1/24 and 7/7/24. During an interview with Unit Manager/LPN (LPN #1), who was assigned on the 4th floor, on 8/1/24 at 1:21 pm., she confirmed the aforementioned incident on 7/1/24 at 5:42 p.m. and confirmed that she did not update the (CP). During an interview with the Director of Nursing (DON) with Assistant DON (ADON #1 and #2), Assistant Administrator, and the Administrator on 8/1/24 at 1:58 p.m., the DON stated that the CP had to be updated within 24 to 48 hours when there is a change in condition. The policy updated 6/2023, titled Care Plan, showed under Procedure .#11: Care plans will be updated timely and necessary revisions will be made . NJAC 8:39-11.2(2)

C#: NJ 175921 Based on interviews and record review, as well as review of pertinent facility documents on 7/31/24 and 8/1/24 it was determined that the facility failed to follow the Physician's order and to implement the facility policy titled Medication Administration Policy for 2 residents (Resident #3 and Resident #4), reviewed for medication administration. This deficient practice was evidenced by the following: 1. According to the ADMISSION RECORD (AR), Resident #3 was admitted with diagnosis that included but were not limited to Surgical Aftercare Following Surgery On The Skin and Subcutaneous Tissue. According to the Resident's Minimum Data Set (MDS), an assessment tool dated 5/7/24, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident's cognition was intact. The care plan (CP), initiated on 5/1/24 and revised on 5/20/24, indicated that Resident #3 had an actual skin breakdown, potential for deterioration and further skin breakdown. Interventions included but not limited to administer treatment as ordered. A review of the form ORDER SUMMARY REPORT (OSR) revealed an order to cleanse site with normal saline, pat dry, apply light coat of Silvadene cream to incision sites, cover with dry gauze wrap with kerlix then ace wrap daily (wipe previous days Silvadene off prior to reapplication) every evening shift for surgical care, dated 6/4/24. A review of Resident #3's Medication Administration Record (MAR), for 7/2024, confirmed the aforementioned physician order. The MAR revealed that on 7/5/24, 7/12/24, and 7/19/24 there was no documentation to indicate that the treatment was provided. In addition, there was no documented evidence in Resident# 3's Medical Record (MR) to indicate that the Primary Care Physician (PCP) was notified on the aforementioned dates. 2. According to the AR, Resident #4 was admitted with diagnosis that included but were not limited to Opioid Dependence. According to the MDS, dated [DATE], Resident #4 had a BIMS score of 15, indicating that the resident's cognition was intact. The CP was reviewed and revised on 5/6/24 and revised on 5/20/24,this indicated that Resident #4 had a history of poly-substance abuse and was on methadone program. A review of the form OSR revealed an order for Methadone Oral Solution 10 milligram (mg)/5 Milliliter (ml), give 65 mg by mouth in the morning for Opioid Dependence ordered on 1/4/24. A review of Resident #4's MAR for 7/2024, confirmed the aforementioned physician order. The MAR revealed that on 7/19/24, there was no documentation to indicate that the Methadone was administered. In additional, there was no documented evidence in the Resident's MR to indicate that the PCP was notified on the aforementioned date. During an interview with the surveyors on 8/1/24 at 21:46 p.m., the Unit Manager/Licensed Practical Nurse (UM/LPN #1) stated that the nurses were expected to administer the medication according to the PCP order. The UM/LPN further stated that nurses were also expected to document in the resident's MR the reason why the medications were not administered and if the PCP was notified. The UM/LPN explained that if not documented, means it was not done. During an interview with the surveyors on 8/1/24 at 2:05 p.m., the Director of Nursing (DON), in the presence of Assistant DON (ADON#1), ADON #2, and Administrator stated that nurses were expected to follow the Physician's order. The DON further stated that if the medication was not administered, the nurses were to call the residents PCP and document in the resident's MR. The DON explained that if not documented, means it was not done. A review of the facility policy titled, Medication Administration Policy, reviewed on 04/2024, indicated POLICY All medications will be prepared .and administered in a manner consistent with the general requirements outlined in this policy .K. After Medication Administration: 1. Document necessary medication administration /treatment information (e.g., when medications are administered, medication injection site, refused medications and reasons, prn medications, etc.) on appropriate forms . N.J.A.C 8:39-29.2(d)

Complaint # NJ 175415 Refer to F 550 K, Refer to F 557 K, Refer to F 561 K, Refer to F 603 K, Refer to F 604 K, Refer F to 679 E. Based on interviews, record review, and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to a.) ensure the facility implemented policies and procedures for Resident Rights and Self Determination as well as policies and procedures to prevent physical restraints and seclusion. The LNHA also failed to ensure 11 of 11 Justice Involved Residents (JIRs) (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) b.) signed Admission Agreements on admission to the facility and c.) were afforded the autonomy to participate in group activities, community dining, serving meals in a dignified manner, freely communicate with visitors, and to leave rooms at will . The failure to ensure the facility established and maintained systems that were effective and efficient to operate the facility in a manner to safely meet residents' needs had the likelihood to cause serious injury and psychological harm which resulted in an IJ situation. The Immediate Jeopardy (IJ) began on 07/02/24, the date that the first JIR (Resident #1) was admitted to the facility and was secluded by law enforcement officers of the Bureau of Prison (BOP). The IJ situation was identified on 07/12/24, when Residents #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 were observed being secluded to their rooms guarded by law enforcement officers, secluded from participating in group activities, community dining, being served meals in a dignified manner, intermingling with other residents, communicating with visitors and leaving the room at will. The facilities Licensed Nursing Home Administrator (LNHA) was informed of the IJ situation on 07/12/24 at 3:49 PM, that an Immediate Jeopardy situation existed. An acceptable removal plan was received on 7/29/24 at 9:59 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: All Justice Involved Residents were discharged from the facility as of 7/26/24. The facility will no longer admit Justice Involved Residents. Administration will be able to follow policies pertaining to resident rights, restraints, ADL's and activities. The survey team verified the removal plan on-site on 7/29/24, and determined the was removed as of 7/26/24. The findings were as follows: The facility policy dated 02/2024 and titled, Resident Rights indicated that all residents would be treated equally regardless of age, race, sex, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The resident has a right to be treated with dignity and respect including being free from any physical or chemical restraints imposed for the purposes of discipline or convenience. The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility . the right to receive visitors of his or her own choosing subject to the resident's right to deny visitation when applicable .right to participate in family groups .the right for personal privacy includes accommodations, medical treatment, telephone communications, personal care, visits and meetings of family and residents groups. A review of a facility policy titled Resident Rights dated 02/2024, included under Policy Explanation and Compliance Guidelines that prior to or upon admission, the social service designee, or another designated staff member, will inform the resident of the resident's rights and responsibilities. 2. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. 5. Respect and Dignity. The resident has a right to be treated with respect and dignity including the right to be free of any physical or chemical restraint . 6. Self-determination. The resident has the right to, and the facility must promote and facilitate residents' self-determination through support of resident's choice, including but not limited to the right to choose activities, make choices about aspect of his or her life, right to interact with members of the community both inside and outside the facility, and the right to receive visitors. 7. Information and communication. The resident has the right to be informed of his or her rights and of all the rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. 8. Privacy and confidentially. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment written and telephone communication, personal care, visits, and meetings of family and resident groups. The facility policy dated 12/2010, revised 4/2024 and titled, Physical Restraints indicated that restraints should only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline of staff convenience. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms. Restraints should only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. The order shall include the specific reason for the restraint; how the restraint will be used to benefit the resident's medical symptom; and the type of restraint, and period of time for the use of the restraint. On 07/15/24 at 10:00 AM, the LNHA provided the surveyors with a facility policy titled, Activity Programs. The activity programs policy with a revised date of February 2024 states under the policy interpretation and implementation section, 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 3. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include, as a minimum: j. Social activities are scheduled to increase self-esteem, to stimulate interest and friendships, and provide fun and enjoyment. The LNHA provided the surveyors with multiple facility policies including The dining environment and activity programs. The dining environment policy with a revised date of January 2024 states under the policy section, A pleasant environment is essential to promoting a positive dining experience. The activity programs policy with a revised date of February 2024 states under the policy interpretation and implementation section, 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 3. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include, as a minimum: J) Social activities are scheduled to increase self-esteem, to stimulate interest and friendships, and provide fun and enjoyment. A review of the facility policy titled Care Plan with a review date of April 2024 revealed under, Policy that, It is the policy of [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. A review of the undated facility's Job Description and Performance Standards for Administrator document revealed that the duties of the Administrator included but not limited to: a.) Develop, maintain, and implement operational policies and procedures to meet residents' needs in compliance with federal, state, and local requirements. b.) Determine the personnel requirements of the facility and hire or arrange for sufficient staff to implement the facility policies and procedures. c.) Develop a monitoring system to assure compliance with federal, state, and local requirements. On 07/11/24 at 09:00 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Nursing (DON) who stated that she was notified by the facilities Cooperate Offices (CO) that JIRs were entering the facility. She stated that the facilities CO instructed the facilities administration (DON, Administrator, Admission Coordinator, Social Services, Activities Director, and Unit Managers) not to mix the JIR with other residents and that they needed to be roomed together. She stated that the JIRs would be guarded by law enforcement and their ankles would be shackled with metal cuffs. She stated that the CO also instructed the facility not to mix or intermingle the JIR with other residents in the facility. On 07/11/2024 at 09:35 AM, Surveyor #1 and #2 interviewed the Minimum Data Set Coordinator (MDS) who stated that the eleven (11) JIRs had entry MDS's completed, however comprehensive MDS's were not completed until day 14 of admission. The MDS provided the surveyors with the entry MDS's for all 11 JIRs. On 07/11/2024 at 10:20 AM, Surveyor #1 and Surveyor #2 toured the fourth floor and interviewed the Licensed Practical Nurse (LPN #1) who stated that he worked for an agency and that it was his first time working at the facility. LPN #1 stated that there were 6 (six) JIRs residing on his unit (Resident #2, 5, 6, 8, 9, and 11). He stated that there were law enforcement officers guarding the residents and that the residents wore metal ankle cuffs. He continued to explain that he was not sure what the residents' limitations were and was not aware of any behaviors that the JIRs had. He also added that he was not aware of any complaints about these residents from other residents that resided on his unit. On 07/11/2024 at 10:25 AM, Surveyor #1 observed the JIRs from the hallway. The six residents that resided on the fourth floor were observed in their rooms being guarded by law enforcement officers. On 07/11/2024 at 10:30 AM, Surveyor #1 and Surveyor #2 interviewed a gentleman outside in the hallway who identified himself as a contracted Supervisor of the United States Marshals (SUMS). He stated that the surveyors were not allowed to enter the JIRs rooms and would not allow the surveyors to interview the JIR on the 4 (four) [NAME] unit (Resident #2, 5, 6, 8, 9, and 11). The SUMS explained to Surveyor #1 and Surveyor #2 that the JIRs were at the facility for rehabilitation services. He stated that all JIRs were to wear metal ankle restraints, and all were to be chained to the bed. He explained that wearing of ankle restraints depended on the resident's medical condition. He stated that all residents could not attend facility activities and could not intermingle with other residents and could only talk amongst other JIR residents. He stated that the JIR residents could only leave their rooms with law enforcement escorts for showering or any other reason which was approved by the U.S. Marshals. He stated that the JIRs must eat in their rooms and could not eat in the main dining room with the other residents. He stated that visitation of anyone must be approved by the US Attorney or Judge. On 07/11/2024 at 10:42 AM, Surveyor #1 observed Resident #5 and #6 from the hallway lying in bed guarded by 3 (three) law enforcement officers. The residents were observed wearing metal ankle restraints that were chained to the bed. On 07/11/2024 at 11:20 AM, Surveyor #1 and Surveyor #2 interviewed Licensed Practical Nurse Unit Manager (LPN/UM #1) who stated that Resident #3 resided on the 6th floor and had the diagnoses of Methicillin Resistant Staphylococci Aureus (MRSA) in the right axilla (armpit) and was on oral antibiotics. She also identified the resident as a prisoner. She stated that Resident #3 was not allowed to come out of the room unless it was to shower and had to eat meals in the room. She stated that the resident had activities in the room but was not allowed to attend activities in the main activity room because there was no intermingling with prisoners and long term care residents. LPN/UM #1 stated that Resident #7 also resided on the 6th floor and had a history of back pain. She stated that Resident #7's restrictions were the same as Resident #2. On 07/11/2024 at 11:35 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Recreation (DOR) who stated that she was informed by the Licensed Nursing Home Administrator (LNHA) that when the JIR were admitted to the facility that she was to have no interactions with them. She stated that she was told not to complete an activities assessment on admission. She stated that she provided the JIR residents with a basket of puzzles and cards on admission, however the residents were not to attend any activities out of their rooms and mail would go through administration. On 07/11/24 at 11:42 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Social Work (DSW) who stated that she had been employed by the facility for about one year. She explained what her role was when residents were admitted to the facility and stated that during the admission process, she performed a social service assessment with the resident. Explained the process of completing an advanced directive, discharge planning and held Care Plan meetings. She stated that when the JIRs were admitted to the facility she provided them with a list of resident rights, advanced directives, billing information and pain management. She stated that based on federal regulations in nursing homes keeping a resident in the room guarded and not being able to freely leave the room was a form a resident seclusion. She stated that the JIRs were being isolated for safety reasons and that was against the federal regulations. On 07/11/24 at 12:20 PM, during an interview with Surveyor # 1 the LNHA stated that shackles were considered a restraint. Further, he confirmed that seclusion, restriction of visitors, being served food with plastic and paper products and requiring supervision during activities of daily living were all violations of federal regulations of Long-Term Care regulations. He concluded that if a long-term care resident was not able to intermingle with other residents, then that would be a form of seclusion. On 07/12/2024 at 9:30 AM, during an interview with Surveyor # 3 and # 5, Unit Manager # 3 confirmed that the JIRs stay in their rooms. Further, she confirmed that the JIRs received disposable trays for their meals. Lastly, she confirmed that they only come out of their rooms for showers on Tuesday and Thursday evenings. On 07/12/24 at 09:34 AM, Surveyor #1 and Surveyor #2 interviewed the LNHA who stated that the facility could accommodate the JIRs medical needs however after he received the Centers for Medicare and Medicaid Services (CMS) memo S & C: 16-21-ALL with revised date 12/23/2016, he understood that it was against federal regulation to restrain or seclude the JIRs. He stated that he called the nursing home in New York to inform them to stop sending the JIRs to the facility, but they just kept sending them. He stated that he did not refuse to admit the residents to the facility because the JIRs had nowhere else to go. He then stated that it's not the facility that was imposing these restrictions on the JIRs, it's the Bureau of Prisons that is imposing them. He added that the facility was aware that the JIRs were being treated differently by the facility than other residents and that it was not the facility's standard of practice however he felt that the Department of Justice (DOJ) was a strong governing body and that he was between the Department of Health and the DOJ. On 07/12/24 at 12:15 PM, Surveyor #1 and Surveyor #2 interviewed the LNHA who stated that resident being secluded to their room, seclusion from other residents and not being able to attend activities or eat in the main dining rooms were all a form of seclusion, however it was not the LNHA that was enforcing this on the JIR residents, it was the Bureau of Prisoners. On 07/12/24 at 1:24 PM, Surveyors conducted a phone interview with the Medical Director (MD) who stated that he had been on vacation when the 11 JIRs were admitted to the facility. He was not aware that the 11 JIRs were secluded to their rooms or that they were all restrained with ankle shackles. The MD further stated that he did not write physician orders for restraints for any of the 11 JIRs. On 07/15/24 at 09:44 AM, Surveyor #2, # 3 and # 5 together interviewed the LNHA who stated that until he met with or was contacted by the New Jersey Department of Health (NJDOH), Centers for Medicare and Medicaid (CMS), and a contracted company [name redacted] he could not submit a removal plan for any of the Immediate Jeopardies because the JIRs would have to be removed from the facility and that was not possible at this time. On 07/15/2024 at 9:45 AM, during an interview with the Surveyor # 2 and # 3, the Licensed Nursing Home Administrator confirmed that the 11 JIRs involved residents were still being secluded and still being restrained. A review of the 11 JIR's Electronic Medical Record (EMR) under physician's orders did not reveal any orders for restraints. The orders did reveal a dietary order specifying that only plastic spoons are to be on the tray. A review of the 11 JIR's EMR under Care Plan did not reveal any focus for activities, choices, or restraints. NJAC 8:39-4.1 NJAC 8:39-4.1 (6) NJAC 8:39-4.1 (a), 11 NJAC 8:39-7.3(a) NJAC 8:39-9.2(a) NJAC 8:39-27.1(a)

Complaint # NJ 175415 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that 11 of 11 Justice Involved Residents (JIR) were afforded the autonomy to participate in group activities, community dining, serving meals in a dignified manner, freely communicate with visitors, leave rooms at will and be free from physical restraints for (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). The failure to treat residents respectfully and in a dignified manner had the likelihood to cause serious injury and psychological harm. This was cited as a pattern that immediately jeopardizes the health and safety of the JIR residents, as well as all other residents that reside in the facility which resulted in an IJ situation. The Immediate Jeopardy (IJ) began on 07/02/24, the date that the first JIR (Resident #1) was admitted to the facility and was secluded by law enforcement officers of the Bureau of Prison (BOP). The IJ was identified on 07/12/24, when Residents #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 were observed being secluded to their rooms, guarded by law enforcement officers, were not permitted to participate in group activities and community dining. Further observation revealed the JIRs were not allowed to intermingle or communicate with other residents or visitors and were restricted from leaving their rooms at will. The facilities Licensed Nursing Home Administrator (LNHA) was informed of the IJ on 07/12/24 at 3:49 PM, that an immediate jeopardy existed which also constituted Substandard Quality of Care (SQC) for 42 Code of Federal Regulations (CFR) 483.10 (a) (1). A facility must treat each resident with respect and dignity and care for each resident in a manner and an environment that promotes maintenance or enhancement of their quality of life and recognize each residents' individuality. The facility must protect and promote the rights of the resident. An acceptable removal plan was received on 7/29/24 at 9:59 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: All Justice Involved Residents were discharged from the facility as of 7/26/24. The facility will no longer admit Justice Involved Residents. The survey team verified the removal plan on-site on 7/29/24 and determined the IJ was removed as of 7/26/2024. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. The LNHA provided the surveyors with multiple facility policies including The dining environment and activity programs. The dining environment policy with a revised date of January 2024, included under the policy section, A pleasant environment is essential to promoting a positive dining experience. The activity programs policy with a revised date of February 2024, included under the policy interpretation and implementation section, 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 3. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include, as a minimum: J) Social activities are scheduled to increase self-esteem, to stimulate interest and friendships, and provide fun and enjoyment. The facility policy dated 02/2024 and titled, Resident Rights indicated that all residents would be treated equally regardless of age, race, sex, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The resident has a right to be treated with dignity and respect including being free from any physical or chemical restraints imposed for the purposes of discipline or convenience. The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility . the right to receive visitors of his or her own choosing subject to the resident's right to deny visitation when applicable .right to participate in family groups .the right for personal privacy includes accommodations, medical treatment, telephone communications, personal care, visits and meetings of family and residents groups. 1. According to the Admission Record, Resident #1 was admitted to the facility with diagnoses which included osteomyelitis (infection of the bone) of the right hand. According to the Admission assessment dated [DATE], Resident #1 was assessed as having no behaviors, and utilized no physical or chemical restraints. According to the Admission Progress note dated 07/02/24 at 3:20 PM, revealed the resident was alert and oriented. A review of the Individualized Care Plans (CP) revealed no care plans were initiated for the supervision of Activities of Daily Living (ADL) care, restraints, activities, or seclusion. Further review of the medical record revealed that Resident #1 did not sign the facility Admission Agreement (AA). The Comprehensive Minimum Data Set (MDS) was in progress and unavailable for review. 2. According to the Admission Record Resident #2 was admitted to the facility with diagnoses which included multiple sclerosis (autoimmune disease). According to the Admission assessment dated [DATE], Resident #2 was assessed as having no behaviors, and utilized no physical or chemical restraints. A review of the CP revealed no CP were initiated regarding supervision with ADLs, restraints, activities, or seclusion. Further review of the medical record revealed that Resident #2 did not sign the facility AA. The Comprehensive Minimum Data Set (MDS) was in progress and unavailable for review. 3. According to the Admission Record Resident #3 was admitted to the facility with diagnoses which included polyneuropathy (peripheral nerve damage). According to the Admission assessment dated [DATE], Resident #3 was assessed as having no behaviors, and utilized no physical or chemical restraints. A review of the CP revealed no CP were initiated regarding supervision with ADLs, restraints, activities, or seclusion. Further review of the medical record revealed that Resident #3 did not sign the facility AA. The Comprehensive Minimum Data Set (MDS) was in progress and unavailable for review. 4. According to the Admission Record Resident #4 was admitted to the facility with diagnoses which included polyneuropathy. According to the Admission assessment dated [DATE], the resident was assessed as having no behaviors and utilized no physical or chemical restraints. The Admission Assessment indicated the resident was independent in their decision-making. A review of the CP revealed no CP were initiated regarding supervision with ADLs, restraints, activities, or seclusion. According to the Admission summary progress note dated 07/02/24 at 1:37 PM, revealed the resident was alert and oriented. Further review of the medical record revealed that Resident #4 did not sign the facility AA. The Comprehensive Minimum Data Set (MDS) was in progress and unavailable for review. 5. According to the Admission Record, Resident #5 was admitted to the facility with diagnoses which included local infection of the skin and subcutaneous tissue. According to the Admission assessment dated [DATE], the resident was assessed as having no behaviors and utilized no physical or chemical restraints. According to an Interdisciplinary progress note dated 07/10/24, revealed the resident was alert and verbally responsive. A review of the CP revealed no CP were initiated regarding supervision with ADLs, restraints, activities, or seclusion. Further review of the medical record revealed that Resident #5 did not sign the facility AA. The Comprehensive Minimum Data Set (MDS) was in progress and unavailable for review. 6. According to the Admission Record Resident #6 was admitted to the facility with diagnoses which included polyneuropathy. According to the Admission assessment dated [DATE], the resident was assessed as having no behaviors and utilized no physical or chemical restraints. According to the Social Service progress note dated 07/03/24 at 9:45 PM, resident #6 was assessed as alert and oriented with a Brief Interview for Mental Status of 15 out of 15, indicating that the resident had an intact cognition. A review of the CP revealed no CP were initiated regarding supervision with ADLs, restraints, activities, or seclusion. Further review of the medical record revealed that Resident #6 did not sign the facility AA. The Comprehensive Minimum Data Set (MDS) was in progress and unavailable for review. 7. According to the Admission Record Resident #7 was admitted to the facility with diagnoses which included low back pain. According to the Admission assessment dated [DATE], the resident was assessed as having no behaviors and utilized no physical or chemical restraints. According to the Admission summary note dated 07/04/24 at 11:12 AM, revealed the resident was alert, and able to verbalize their needs to staff. A review of the CP revealed no CP were initiated regarding supervision with ADLs, restraints, activities, or seclusion. Further review of the medical record revealed that Resident #7 did not sign the facility AA. The Comprehensive Minimum Data Set (MDS) was in progress and unavailable for review. 8. According to the Admission Record Resident #8 was admitted to the facility with diagnoses which included dilated cardiomyopathy (disease of the heart muscle). According to the Admission assessment dated [DATE], the resident was assessed as having no behaviors and utilized no physical or chemical restraints. According to the Admission progress note dated 07/09/24 at 2:40 PM, revealed the resident was alert, responsive and able to make their needs known. A review of the CP revealed no CP were initiated regarding supervision with ADLs, restraints, activities, or seclusion. Further review of the medical record revealed that Resident #8 did not sign the facility AA. The Comprehensive Minimum Data Set (MDS) was in progress and unavailable for review. 9. According to the Admission Record Resident #9 was admitted to the facility with diagnoses which included dementia. According to the Admission assessment dated [DATE], the resident was assessed as having no behaviors and utilized no physical or chemical restraints. According to the Admission progress note dated 07/10/24 at 1:36 PM, revealed the resident was alert with periods of forgetfulness. A review of the CP revealed no CP were initiated regarding supervision with ADLs, restraints, activities, or seclusion. Further review of the medical record revealed that Resident #9 did not sign the facility AA. The Comprehensive Minimum Data Set (MDS) was in progress and unavailable for review. 10. According to the Admission Record Resident #10 was admitted to the facility with diagnoses which included clostridium difficile colitis (C. diff) (bacterial infection of the colon). According to the Admission assessment dated [DATE], the resident was assessed as having no behaviors and utilized no physical or chemical restraints. The Admission summary progress note dated 07/02/24 at 2:40 PM, revealed the resident was alert and oriented x [times] 3 and able to make their own decisions. A review of the CP revealed no CP were initiated regarding supervision with ADLs, restraints, activities, or seclusion. Further review of the medical record revealed that Resident #10 did not sign the facility AA. The Comprehensive Minimum Data Set (MDS) was in progress and unavailable for review. 11. According to the Admission Record Resident #11 was admitted to the facility with diagnoses which included polyneuropathy. According to the Admission assessment dated [DATE], the resident was assessed as having no behaviors and utilized no physical or chemical restraints. According to the progress note dated 07/08/24 at 4:08 PM, revealed the resident was alert verbally responsive and able to make their needs known. A review of the CP revealed no CP were initiated regarding supervision with ADLs, restraints, activities, or seclusion. Further review of the medical record revealed that Resident #11 did not sign the facility AA. The Comprehensive Minimum Data Set (MDS) was in progress and unavailable for review. On 07/11/24 at 10:30 AM, resident interviews were attempted by surveyor #1 and #2, and was prohibited by the law enforcement officers. A supervisor of the U.S. Marshall's was interviewed and stated that all justice involved residents required approval by the U.S. Attorney's office or judge to have interviews or visitation. On 07/11/24 at 11:05 AM, Surveyor #2 was allowed by the prison guard to interview Resident #4 who stated they were not allowed to shower unless supervised by a prison guard. The resident stated that they had to eat meals in their room with disposable utensils and was secluded to the room and not allowed to intermingle with other residents. Resident #4 stated that they could only talk on the phone privately if speaking with their lawyer, otherwise they had to be supervised. On 07/11/24 at 11:12 AM, Surveyors #1 and #2 interviewed Resident #1, who stated that they had to eat their meals inside the room and was only allowed to leave the room for showers. On 07/11/24 at 11:42 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Social Work (DSW) who stated that she had been employed by the facility for about one year. She explained what her role was when residents were admitted to the facility and stated that during the admission process, she performed a social service assessment with the residents. She explained the process of completing an advanced directive, discharge planning and held Care Plan meetings. She stated that when the JIR were admitted to the facility she provided them with a list of resident rights, advanced directives, billing information and pain management. She stated that based on federal regulations in nursing homes keeping a resident in the room guarded and not being able to freely leave the room was a form a resident seclusion. She stated that the JIR residents were being isolated for safety reasons and that that was against the federal regulations. On 07/12/24 at 09:30 AM, Surveyors #3, #4, and #5 interviewed the 3rd floor Licensed Practical Nurse Unit Manager (LPN/UM), who stated the JIRs are served all their meals on disposable plates, utensils and cups as well as having their meals checked by the prison guards prior to serving. The LPN/UM further stated the JIR's shower schedule was Tuesday and Thursday in the evening and the prison guards stayed in the shower room with the JIR. On 07/12/24 at 09:40 AM, Surveyors #3 and #5 attempted resident interviews with Resident #8 and #9, but were told by the prison guard that interviews were not permitted but the surveyors could observe the JIRs through the doorway of their rooms. Surveyor #5 observed Resident #8's breakfast meal tray on the bedside table, the resident's meal was served on a disposable tray with paper plates, cups, and utensils. Resident #8 was observed in the room in wheelchair with an ankle restraint connected by a chain to the resident's bed. Resident #9 was observed in bed with an ankle restraint connected by a chain to the resident's bed. At that time, the surveyors observed that the non JIRs on the unit were utilizing non disposable trays, and regular dishware (plates, cups and utensils). On 07/12/24 at 09:45 AM, Surveyor #5 interviewed the Licensed Practical Nurse (LPN #1) who was the nurse for both Resident #8 and #9. LPN #1 stated the JIRs stay in their rooms all day except on shower days. LPN #1 stated the JIRs do not participate in group activities, go into the main dining area, and did not believe they were allowed visitors. On 07/12/24 at 10:10 AM, Surveyor #5 reviewed the electronic medical record (EMR) for Resident #8 and #9. Resident #8 had a Physician Order (PO) with a start date of 7/8/24 for, recreation as tolerated. Resident #9 had a PO with a start date of 7/5/24 for, recreation as tolerate. However, further review of the medical record revealed there was no documented recreation screen/assessment, notes or care plans for Resident # 8 and #9. NJAC 8:39-4.1(a) 11

Complaint # NJ 175415 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents were treated in a dignified and respectful manner 11 of 11 Justice Involved Residents (JIR) by physically restraining, secluding the residents from participating in group activities, community dining, intermingling with other residents, communicating with visitors and leaving the room at will. This was cited as a pattern that immediately jeopardizes the health and safety of the JIR residents, as well as all other residents that reside in the facility which resulted in an Immediate Jeopardy (IJ) situation. The Immediate Jeopardy (IJ) began on 07/02/24, the date that the first JIR (Resident #1) was admitted to the facility and was secluded to the room by law enforcement officers of the Bureau of Prison [BOP]. The IJ situation was identified on 07/12/24, when Residents #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 were observed being secluded to their rooms guarded by law enforcement officers, not permitted to participate in group activities and community dining, being served meals in a dignified manner, intermingling with other residents, communicating with visitors, and leaving the room at will. The facilities Licensed Nursing Home Administrator (LNHA) was informed of the IJ situation on 07/12/24 at 3:49 PM, that an immediate jeopardy situation existed. An acceptable removal plan was received on 7/29/24 at 9:59 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: All Justice Involved Residents were discharged from the facility as of 7/26/24. The facility will no longer admit Justice Involved Residents. The survey team verified the removal plan on-site on 7/29/24 and determined the IJ was removed as of 7/26/2024. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL, documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. A review of a facility policy titled Resident Rights dated 02/2024, included under Policy Explanation and Compliance Guidelines that prior to or upon admission, the social service designee, or another designated staff member, will inform the resident of the resident's rights and responsibilities. 2. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. 5. Respect and Dignity. The resident has a right to be treated with respect and dignity including the right to be free of any physical or chemical restraint . 6. Self-determination. The resident has the right to, and the facility must promote and facilitate residents' self-determination through support of resident's choice, including but not limited to the right to choose activities, make choices about aspect of his or her life, right to interact with members of the community both inside and outside the facility, and the right to receive visitors. 7. Information and communication. The resident has the right to be informed of his or her rights and of all the rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. 8. Privacy and confidentially. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment written and telephone communication, personal care, visits, and meetings of family and resident groups. The surveyor reviewed Resident # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11's medical records. 1. Review of the Admission Record (AR), Resident # 1 was admitted to the facility with diagnoses which included but was not limited; to osteomyelitis (infection of the bone) of the right hand. Review of an Admission progress note dated 07/02/2024 at 3:20 PM, revealed that Resident #1 was alert and oriented. Review of the Admission Assessment (AA) dated 07/02/2024, Resident #1 was assessed as not having any behaviors or required physical or chemical restraints, however Resident #1 was observed by Surveyor #1 and Surveyor #2 on 07/11/24 at 11:04 AM, wearing metal ankle cuffs. There were no consents for the use of metal ankle cuffs. Review of the physician's orders (PO) reflected that there were no orders for the use of metal ankle cuffs, however a PO order dated 07/02/24, reflected an order to monitor skin integrity under the cuff area every shift. Review of the resident's Individualized Care Plans (CP) dated 07/02/24, which revealed that a CP was not implemented for the use of restraints. The CP did not address that the resident required constant supervision from the detention guards for all aspects of activities of daily living (ADLs). The CP did not address that the resident was not permitted to leave the room unless for showering and accompanied by the detention guards and there was no documentation on the CP to address restrictions from attending community activities and community dining. A comprehensive Minimum Data Set (MDS) and assessment tool that facilitates a resident's care, was not yet completed. Resident #1 did not sign the facility Admission Agreement,a contract which included all documents that a resident or responsible person must sign at the time of, or as a condition of, admission). 2. According to the AR, Resident #2 was admitted to the facility with the diagnoses which included but was not limited to multiple sclerosis (autoimmune disease). Review of the AA dated 07/05/2024, Resident #2 was assessed as not having any behaviors or required physical or chemical restraints, however Resident #2 was observed by Surveyor #1 and Surveyor #2 on 07/11/24 at 10:44 AM, wearing metal ankle cuffs. There were no consents for the use of metal ankle cuffs. Review of the resident's CP dated 07/05/24, revealed that a CP was not implemented for the use of restraints. The CP did not address that the resident required constant supervision from the detention guards for all aspects of activities of daily living (ADLs). The CP did not address that the resident was not permitted to leave the room unless for showering and accompanied by the detention guards and there was no documentation on the CP to address restrictions from attending community activities and community dining. Review of the physician's orders (PO) reflected that there were no orders for the use of metal ankle cuffs, however the Treatment Administration Record (TAR) reflected an order dated 07/11/24, to check skin integrity under bilateral ankle cuffs every shift. A comprehensive MDS was not yet completed. Further review of the medical record revealed that Resident #1 did not sign the facility Admission Agreement. 3. According to the AR, Resident #3 was admitted to the facility on [DATE] with diagnoses which included but not limited; to polyneuropathy. Review of the AA dated 07/05/24 revealed Resident #3 assessed as not having any behaviors or required physical or chemical restraints. A review of a Progress Note dated 07/05/24, revealed Resident # 3 was alert and verbally responsive. A review of the Care Plan initiated on 07/05/24 revealed no Care Plans were initiated regarding supervision with Activities of Daily Living, restraints, activities, or seclusion. A comprehensive MDS was not yet completed. Further review of the medical record revealed that Resident # 3 did not sign a facility Admission Agreement. 4. According to the AR, Resident #4 admitted into the facility July 2024 with diagnoses which included but not limited to; polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body causes pain, tingling or burning sensations on the body), hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone), hypertension (elevated blood pressure), Atrial Fibrillation (irregular, rapid heart rate)and dysphagia (difficulty swallowing). Review of the AA dated 07/02/2024, revealed the resident was assessed as not having any behaviors, was independent with their decision-making, and required no physical or chemical restraints. A review of the admission summary progress note dated 07/02/24 at 01:37 PM, the resident was alert and oriented. Review of the resident's individualized comprehensive care plan date initiated 07/02/24, did not include any indicate focus areas that would address supervision from law enforcement with Activities of daily living, restraints, activities, or seclusion. Review of the order Summary Report revealed a physician order (PO) dated 7/11/24, to check the skin integrity on bilateral ankle cuffs every shift. Further review revealed that there were no orders for restraints and seclusion from the rest of the facility with continuous monitoring from law enforcement. Review of the MDS revealed a comprehensive MDS was not yet completed. Further review of the medical record revealed that Resident #4 did not sign the facility Admission agreement. 5. According to the AR, Resident #5 was admitted to the facility with diagnoses which included but not limited to; local infection of the skin and subcutaneous tissue. Review of the AA dated 07/03/24, revealed that the resident was assessed as not having any behaviors or required physical or chemical restraints. A review of the Care Plan initiated on 07/03/24, revealed no Care Plans were initiated regarding supervision with Activities of Daily Living restraints, activities, or seclusion. Review of an Interdisciplinary progress note dated 07/10/24,revealed that Resident # 5 was alert and verbally responsive. Review of the Minimum Data Set revealed a comprehensive MDS was not yet completed. Further review of the medical record revealed that Resident #5 did not sign a facility Admission Agreement. 6. According to the AR; Resident # 6 was admitted to the facility on [DATE] with diagnoses which included but not limited to; polyneuropathy. Review of the AA dated 07/03/24, revealed that the resident was assessed and did not have any behaviors or required physical or chemical restraints. Review of the Care Plan initiated on 07/03/24, revealed no Care Plans were initiated regarding supervision with ADLs, restraints, activities, or seclusion. Review of the MDS revealed a comprehensive MDS was not yet completed. Further review of the medical record revealed that Resident #6 did not sign a facility Admission Agreement. 7. According to the AR, Resident # 7 was admitted to the facility on [DATE] with diagnoses which included but not limited; to low back pain. Review of the AA dated 07/04/24, revealed that the resident was assessed as not having any behaviors or required physical or chemical restraints. Review of a progress note dated 07/04/24, revealed that Resident #7 was alert and oriented. Review of the Care Plan initiated 07/04/24, revealed no Care Plans were initiated regarding supervision with Activities of Daily Living, restraints, activities, or seclusion. Review of the MDS revealed a comprehensive MDS was not yet completed. Further review of the medical record revealed that Resident #7 did not sign a facility Admission Agreement. 8. According to the AR, Resident #8 was admitted to the facility on [DATE] with diagnoses which included but not limited to; dilated cardiomyopathy (disease of the heart muscle). Review of the AA dated 07/08/24, revealed revealed that the resident was assessed as not having any behaviors or required physical or chemical restraints. Review of the Care Plan initiated on 07/08/24, no Care Plans were initiated regarding supervision with Activities of Daily Living, restraints, activities, or seclusion. Review of a progress note dated 07/09/24, revealed that Resident #8 was alert and verbally responsive. Review of the MDS revealed a comprehensive MDS was not yet completed. Further review of the medical record revealed that Resident # 8 did not sign a facility Admission Agreement. 9. According to the AR, Resident #9 was admitted to the facility with diagnoses which included but was not limited to dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). Review of the AA dated 7/5/2024, revealed the resident was assessed as having no behaviors and required no physical or chemical restraints, however on 07/11/24 at 10:43 AM, Surveyor #1 and Surveyor #2 observed the resident in the room with metal cuff affixed to both ankles. A review of the CP dated 07/05/24, revealed that a CP was not implemented for the use of restraints. The CP did not address that the resident required constant supervision from the detention guards for all aspects of activities of daily living (ADLs). The CP did not address that the resident was not permitted to leave the room unless for showering and accompanied by the detention guards and there was no documentation on the CP to address restrictions from attending community activities and community dining. Review of the progress admission note dated 07/10/2024 at 1:36 PM, revealed that the resident was alert with periods of forgetfulness. Review of the physician's orders (PO) reflected that there were no orders for the use of metal ankle cuffs, however the PO reflected an order dated 07/11/24, to check skin integrity under on bilateral ankle cuffs every shift. There were no consents found in the EMR regarding the use of ankle restraints. Review of the MDS revealed a comprehensive MDS was not yet completed. Further review of the medical record revealed that Resident #9 did not sign a facility Admission Agreement. 10. According to the AR, Resident #10 was admitted on [DATE], and had diagnoses which included but not limited to; enterocolitis due to clostridium Difficile (inflammation of the digestive tract due to an infection), depression, anxiety disorder, and diverticulitis (inflammation or infection in digestive tract). Review of the admission summary progress note dated 07/02/24 at 2:40 PM, revealed the resident was alert and oriented x3 and was able to make their own decisions Review of the order Summary Report revealed physician orders (PO) dated 07/02/24, revealed no order for restraints or seclusion from the rest of the facility with continuous monitoring from law enforcement. Review of the resident's individualized comprehensive care plan date initiated 07/02/24, did not indicate focus areas that would address supervision of law enforcement with Activities of daily living, restraints, activities, or seclusion. Review of the MDS revealed a comprehensive MDS was not yet completed. Further review of the medical record revealed that Resident #10 did not sign a facility Admission Agreement. 11. Review of the AR indicated that Resident #11 was admitted to the facility with diagnoses which but was not limited to; polyneuropathy (Damage to multiple peripheral nerves). Review the AA dated 07/03/24, revealed the resident was assessed as not having any behaviors and did not require physical or chemical restraints, however Resident #11 was observed by Surveyor #1 and Surveyor #2 on 07/11/24 at 10:44 AM, wearing metal ankle cuffs. A review of the CP dated 07/03/24 revealed that a CP was not implemented for the use of restraints. The CP did not address that the resident required constant supervision from the detention guards for all aspects of activities of daily living (ADLs). The CP did not address that the resident was not permitted to leave the room unless for showering and accompanied by the detention guards and there was no documentation on the CP to address restrictions from attending community activities and community dining. According to the progress note (PN) dated 07/08/24 at 4:08 PM, the resident was alert verbally responsive and able to make their needs known. Review of the physician's orders (PO) reflected that there were no orders for the use of metal ankle cuffs, however the TAR reflected an order dated 07/11/24, to check skin integrity under bilateral ankle cuffs every shift. On 07/11/24 at 09:00 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Nursing (DON) who stated that she was notified by the facilities Cooperate Offices (CO) that JIRs were entering the facility. She stated that the facilities CO instructed the facilities administration (DON, Administrator, Admission Coordinator, Social Services, Activities Director, and Unit Managers) not to mix the JIR with other residents and that they needed to be roomed together. She stated that the JIRs would be guarded by law enforcement and their ankles would be shackled with metal cuffs. She stated that the CO also instructed the facility not to mix or intermingle the JIR with other residents in the facility. On 07/11/2024 at 09:35 AM, Surveyor #1 and #2 interviewed the Minimum Data Set Coordinator (MDSC) who stated that the eleven (11) JIRs had entry MDSs completed, however comprehensive MDSs were not completed until day 14 of admission. The MDSC provided the surveyors with the entry MDSs for all 11 JIRs. On 07/11/2024 at 10:20 AM, Surveyor #1 and Surveyor #2 toured the fourth floor and interviewed Licensed Practical Nurse (LPN#1) who stated that he worked for an agency and that it was his first time working at the facility. LPN #1 stated that there were 6 (six) JIRs residing on his unit (Resident #2, 5, 6, 8, 9, and 11). He stated that there were police officers guarding the residents and that the residents wore metal ankle cuffs. He continued to explain that he was not sure what the residents' limitations were and was not aware of any behaviors that the JIRs had. He also added that he was not aware of any complaints about these residents from other residents that resided on his unit. On 07/11/2024 at 10:25 AM, Surveyor #1 observed the JIRs from the hallway. The six residents that resided on the fourth floor were observed in their rooms being guarded by law enforcement officers. On 07/11/24 at 10:30 AM, resident interviews were attempted by Surveyor #1 and #2, and was prohibited by the law enforcement officers. On 07/11/2024 at 10:30 AM, Surveyor #1 and Surveyor #2 interviewed a gentleman outside in the hallway who identified himself as a contracted Supervisor of the United States Marshalls (SUSM) (federal law enforcement agency in the United States, enforcing the federal courts). He stated that the surveyors were not allowed to enter the JIRs rooms and would not allow the surveyors to interview the JIRs on the 4 (four) [NAME] Unit (Resident #2, 5, 6, 8, 9, and 11). The SUSM explained to Surveyor #1 and Surveyor #2 that the JIRs were at the facility for rehabilitation services. He stated that all JIRs were to wear metal ankle restraints, and all were to be chained to the bed. He explained that wearing of ankle restraints depended on the resident's medical condition. He stated that all residents could not attend facility activities and could not intermingle with other residents and could only talk amongst other JIR residents. He stated that the JIR residents could only leave their rooms with escorts for showering or any other reason which was approved by the U.S Marshals. He stated that the JIRs must eat in their rooms and could not eat in the main dining room with the other residents. He stated that visitation of anyone must be approved by US Attorney or Judge. On 07/11/2024 at 10:42 AM, Surveyor #1 observed Resident #5 and #6 from the hallway lying in bed guarded by 3 (three) detention officers, wearing metal ankle restraints that were chained to the bed. On 07/11/2024 at 10:43 AM, Surveyor #1 observed from the hallway Resident #8 and #9 being guarded to the room by 3 detention officers and chained with metal ankle restraints. On 07/11/2024 at 11:00 AM, Surveyor #1 and Surveyor #2 toured the 3rd floor Unit. The surveyor interviewed LPN #2 who stated that there were three (3) JIRs on the unit (Resident #1, #4 and #10). A supervisor of the U.S. Marshalls was interviewed and stated that all justice involved residents required approval by the U.S Attorney's office or judge to have interviews or visitation. On 07/11/24 at 11:05 AM, Surveyor #1 and Surveyor #2 were given permission from the detention officer to interview Resident #4 who was observed in bed. The surveyor observed that the Resident #4 was wearing plastic ankle restraints. The guard in the room indicated that the resident had medical issues and was required to wear the plastic restraints (ankle cuffs) instead of metal. The surveyors observed the plastic ankle cuffs were shackled with a metal chain to the bed. Resident #4 stated that they were in the facility due to heart and vascular problems. The resident stated that food was good, used disposable utensils to eat meals, and that they were not allowed to leave the room, only for a shower which was supervise by a prison guard. The resident stated that they were not allowed to intermingle with other residents and were only able to talk on the phone privately with their attorney. Resident #4 stated that otherwise there was no privacy when speaking on the phone. On 07/11/2024 at 11:12 AM, Surveyor #1 and Surveyor #2 were given permission from the detention guard to interview Resident #1, who was cognitively intact. The resident stated that he/she was admitted to the facility with the diagnoses of osteomyelitis and colitis and needed intravenous antibiotic therapy. Resident #1 stated that they received meals in the room but was able to pick his/her own meals and that the facility honored food preferences. The resident stated that he/she had not left the room except for showering. The resident stated that this was the only time that he/she could leave the room. On 07/11/2024 at 11:20 AM, Surveyor #1 and Surveyor #2 interviewed Licensed Practical Nurse Unit Manager (LPN/UM #1) who stated that Resident #3 resided on the 6th floor and had the diagnoses of Methicillin Resistant Staphylococci Aureus (MRSA) in the right axilla (armpit) and was on oral antibiotics. She also identified the resident as a prisoner. She stated that Resident #3 was not allowed to come out of the room unless it was to shower and had to eat meals in the room. She stated that the resident had activities in the room but was not allowed to attend activities in the main activity room because there was no intermingling with prisoners and LTC residents. LPN/UM #1 stated that Resident #7 also resided on the 6th floor and had a history of back pain. She stated that Resident #7's restrictions were the same as Resident #3. On 07/11/2024 at 11:35 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Recreation (DOR) who stated that she was informed by the Licensed Nursing Home Administrator (LNHA) that when the JIR were admitted to the facility that she was to have no interactions with them. She stated that she was told not to complete an activities assessment on admission. She stated that she provided the JIR residents with a basket of puzzles and cards on admission, however the residents were not to attend any activities out of their rooms. On 07/11/24 at 11:42 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Social Work (DSW) who stated that she had been employed by the facility for about 1 (one) year. She explained what her role was when residents were admitted to the facility and stated that during the admission process, she performed a social service assessment with the resident. Explained the process of completing an advanced directive, discharge planning and held Care Plan meetings. She stated that when the JIR were admitted to the facility she provided them with a list of resident rights, advanced directives, billing information and pain management. She stated that based on federal regulations in nursing homes keeping a resident in the room guarded and not being able to freely leave the room was a form of resident seclusion. She stated that the JIR residents were being isolated for safety reasons and that that was against the federal regulations. On 07/11/24 at 12:20 PM, during an interview with Surveyor # 1 the LNHA stated that shackles were considered a restraint. Further, he confirmed that seclusion, restriction of visitors, being served food with plastic and paper products and requiring supervision during activities of daily living were all violations of federal regulations for Long-Term Care. He concluded that if a long-term care resident was not able to intermingle with other residents, then that would be a form of seclusion. On 07/12/2024 at 9:15 AM, Surveyor #3, #4, and #5 toured the third floor and observed armed guards standing in the hallway near Resident #1, Resident #4 and Resident #10's rooms. Further observation revealed that there were armed guards standing inside the rooms. Surveyor # 4 observed residents #4 and #10 from the hallway, the names on the door were not the names of the residents identified as Resident #4 and #10 in the beds. The residents were observed to be covered with blankets and the guards prevented the surveyor from entering the rooms and from interviewing the residents. On 07/12/2024 at 9:18 AM, Surveyor #4 interviewed Licensed Practical Nurse #2 (LPN #2), who stated she could give the residents medication and the guards would identify the justice involved residents (JIR), and the guards would watch her give the medication to the residents. LPN #2 further stated that there were always two guards present, and one guard would observe the nursing care and staff was not allowed to pull the curtain to provide privacy. She further stated that she and all the staff are supervised by the Feds. On 07/12/2024 at 9:30 AM during an interview with Surveyor # 3 and # 5, Unit Manager # 3 confirmed that the JIRs stay in their rooms. Further, she confirmed that the JIRs received disposable trays for their meals. Lastly, she confirmed that they only come out of their rooms for showers on Tuesday and Thursday evenings. On 07/12/2024 at 9:30 AM, Surveyor #4 interviewed an unsampled resident who stated that they were aware there are prisoners at the facility and the prisoners do not come out of their rooms and do not participate in activities with other residents. On 07/12/2024 at 09:34 AM, Surveyor #1 and Surveyor #2 interviewed the LNHA who stated that the facility could accommodate the JIRs medical needs, however after he received the Centers for Medicare and Medicaid Services (CMS) memo S & C: 16-21-ALL, with a revised date 12/23/2016, he understood that it was against federal regulation to restrain or seclude the JIRs. He stated that he called the nursing home in New York to inform them to stop sending the JIRs to the facility, but they just kept sending them. He stated that he did not refuse to admit the residents to the facility because the JIR residents had nowhere else to go. He then stated that it was not the facility that was imposing these restrictions on the JIRs, it was the Bureau of Prisons that was imposing them. He added that the facility was aware that the JIRs were being treated differently by the facility than the regular facility residents and that it was not the facilities standard of practice, however he felt that the Department of Justice (DOJ) was a strong governing body and that he was between the Department of Health and the DOJ. On 07/12/24 at 09:40 AM, Surveyors #3 and #5 attempted resident interviews with Resident #8 and #9, but were told by the prison guard that interviews were not permitted but the surveyors could observe the JIRs through the doorway of their rooms. Surveyor #5 observed Resident #8's breakfast meal tray on the bedside table, the resident's meal was served on a disposable tray with paper plates, cups, and utensils. Resident #8 was observed in the room in wheelchair with an ankle restraint connected by a chain to the resident's bed. Resident #9 was observed in bed with an ankle restraint connected by a chain to the resident's bed. On 07/12/24 at 09:40 AM, Surveyors #3, #4, and #5 interviewed the 3rd floor Licensed Practical Nurse Unit Manager (LPN/UM), who stated the JIRs were served all their meals on disposable plates, utensils and cups as well as having their meals checked by the prison guards prior to serving. The LPN/UM further stated the JIR's shower schedule was Tuesday and Thursday in the evening and the prison guard stayed in the shower room with the JIR. On the same date at 9:43 AM while observing the fourth floor, Surveyor # 3 observed Resident # 5 and Resident # 6 from the hallway while they were in the room. The room contained two guards. No resident names were identified on the door placard. Resident # 6 was in bed. A metal chain was observed hanging below the sheet of the bed. On 07/12/2024 at 09:45 AM, Surveyor #5 interviewed the Licensed Practical Nurse (LPN #1) who is the nurse for both Resident #8 and #9. LPN #1 stated the JIRs stayed in their rooms all day except on shower days. LPN#1 stated the JIRs did not participate in group activities, go into the main dining area, and did not believe they were allowed visitors. On the same date at 9:50 AM, Surveyor # 3 interviewed an unsampled resident who stated that they had no interaction with the JIRs. On 07/12/2024 at 12:15 PM, Surveyor #1 and Surveyor #2 interviewed LNHA who stated that residents being secluded to their room, secluded from other residents, and not being able to attend activities or eat in the main dining rooms were all a form of seclusion, however it was not the LNHA that was enforcing this on the JIR residents, it was the Bureau of Prisoners. On 07/12/24 at 1:24 PM, Surveyors #1, #2, #3, #4, and #5 conducted a phone interview with the Medical Director (MD)who stated that he had been on vacation when the 11 JIRs were admitted to the facility. He stated he was not aware that the 11 JIRs were secluded to their rooms or that they were all restrained with ankle shackles. The MD further stated that he did not write physician orders for restraints for any of the 11 JIRs. On 07/12/24 at 3:40 PM, Surveyors #2, #3, #4 and #5 met with the LNHA, Regional DON, and the DON and were notified of the IJ and were provided with the IJ template. On 07/15/2024 at 8:45 AM, while on the third floor, Surveyor # 3 observed Resident # 4 from the hallway. The guard would not allow the surveyor to enter the room. At that time, Surveyor # 3 observed a metal shackle affixed to the resident's leg and to the bed. One guard was observed within the room. Also at that time, Surveyor # 3 observed Resident # 10 in bed. A metal shackle was observed affixed to the bed. Also, one guard was present in that room. On the same date at 8:51 AM, while on the fourth floor, Surveyor # 3 observed Resident # 6 and Resident # 5 in their rooms. They had metal chains hanging from their beds. On 07/15/24 at 09:44 AM, Surveyor #2, #3 and #5 interviewed the LNHA who stated until he met with or heard from the New Jersey Department of Health (NJDOH), Centers of Medicare and Medicaid (CMS), and the [contracted company] that he could not submit a removal plan for any of the deficiencies because the prisoners could not be released into the facility and would have to be removed from the facility. On 07/15/24 at 9:45 AM during an interview with the Surveyor #2 and #3, the Licensed Nursing Home Administrator confirmed that the 11 JIRs involved residents were still being secluded and still being restrained. NJAC 8:39-4.1 <b [TRUNCATED]

Complaint # NJ 175415 Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to promote and facilitate 11 of 11 Justice Involved Residents' (JIR) (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) right to: 1) make their own choices regarding aspects of their life and care; 2) participate in activities and 3) interact with members of the community both inside and outside the facility. The failure to promote and facilitate a resident's self-determination had the likelihood to cause serious psychological harm. On 07/11/24 at 09:00 AM, Surveyor #1 and #2 interviewed the Director of Nursing (DON) who stated that she was notified by the facility's Corporate Office (CO) that JIRs were entering the facility. The DON stated that the CO instructed the facility's administration (DON, Administrator (LNHA), Admission Coordinator, Social Services, Activities Director, and Unit Managers) that all JIRs would be shackled, guarded by law enforcement officers from the Bureau of Prison [BOP], and were not to interact with other residents. On 07/11/24 at 11:35 AM, Surveyor #1 interviewed the Director of Recreation who stated that she was informed by the Interdisciplinary Team and the LNHA that no activity assessment had to be completed for the JIRs because the JIRs would not be attending any activities. On 07/12/24 at 9:30 AM, Surveyor #3 and #5 interviewed Unit Manager (UM) #3 who stated that the JIRs stayed in their rooms. UM3 stated that the JIRs only come out of their rooms for showers on Tuesday and Thursday evenings. The facility's LNHA was informed of the Immediate Jeopardy (IJ) situation on 07/12/24 at 3:49 PM which also constituted Substandard Quality of Care (SQC) for 42 Code of Federal Regulations (CFR) S483.10(f)(1)(2)(3)(8). The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility. An acceptable removal plan was received on 7/29/24 at 9:59 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: All Justice Involved Residents were discharged from the facility as of 7/26/24. The facility will no longer admit Justice Involved Residents. The survey team verified the removal plan on-site on 7/29/24 and determined the IJ was removed as of 7/26/2024. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) Updated Guideline to Surveyors on Federal Requirements for Providing Services to Justice Involved Individuals, revised 12/23/16, S&C 16-21 ALL, documented that Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. The facility policy dated 02/2024 and titled, Resident Rights indicated that all residents would be treated equally regardless of age, race, sex, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The resident has a right to be treated with dignity and respect including being free from any physical or chemical restraints imposed for the purposes of discipline or convenience. The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility . the right to receive visitors of his or her own choosing subject to the resident's right to deny visitation when applicable .right to participate in family groups .the right for personal privacy includes accommodations, medical treatment, telephone communications, personal care, visits and meetings of family and residents groups. Review of a facility policy titled Care Plan with a review date of April 2024 revealed under, Policy that, It is the policy of [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. Review of a facility policy titled, Activity Programs with a revised date of February 2024 revealed under, Policy Interpretation and Implementation that, 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. On 07/11/24 at 11:05 AM, Surveyor #1 and #2 were given permission from the law enforcement officer to interview Resident #4. Resident #4 stated they could only leave the room to shower, could not intermingle with other residents and were only able to talk on the phone privately with their attorney. Resident #4 stated that otherwise there was no privacy when speaking on the phone. The surveyors attempted to interview other JIRs but were denied by the law enforcement officers. The survey reviewed the medical records. 1. According to the Admission Record (AR), Resident #1 was admitted with diagnoses which included but not limited; to Osteomylitis (an infection of the bone) of the right hand. Review of an admission progress note dated 07/02/24 at 3:20 PM, revealed Resident #1 was alert and oriented. 2. According to the AR, Resident #2 was admitted with the diagnoses which included but not limited to; Multiple Sclerosis (an autoimmune disease). 3. According to the AR, Resident #3 was admitted with diagnoses which included but not limited to polyneuropathy (peripheral nerve damage). Review of a progress note dated 07/05/24, revealed Resident # 3 was alert and verbally responsive. 4. According to the AR, Resident #4 was admitted with diagnoses which included but not limited to; polyneuropathy. The admission assessment documented Resident #4 was independent in decision-making. 5. According to the AR, Resident #5 was admitted with diagnoses which included but not limited to; local infection of the skin and subcutaneous tissue. Review of an Interdisciplinary progress note dated 07/10/24, revealed Resident #5 was alert and verbally responsive. 6. According to the AR, Resident #6 was admitted with diagnoses which included but not limited to; polyneuropathy. Review of a Social Service progress note dated 07/03/24 at 9:45 PM, revealed Resident #6 was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15 at of 15 indicating that the resident's cognition was intact. 7. According to the AR, Resident #7 was admitted with diagnoses which included but not limited to; low back pain. Review of an Admission summary note dated 07/04/24 at 11:12 AM, revealed Resident #7 was alert, and able to verbalize their needs to staff. 8. According to the AR, Resident #8 was admitted with diagnoses which included but not limited to; dilated cardiomyopathy (a disease of the heart muscle). Review of an Admission progress note dated 07/09/24 at 2:04 PM, revealed Resident #8 was alert, responsive and able to make their needs known. 9. According to the AR, Resident #9 was admitted with diagnoses which included but not limited to; dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). Review of a progress admission note dated 07/10/24 at 1:36 PM, revealed Resident #9 was alert with periods of forgetfulness. 10. According to the AR, Resident #10 was admitted with diagnoses which included but not limited to; Clostridium Difficile Colitis (C. diff; a bacterial infection of the colon). Review of the admission summary progress note dated 07/02/24 at 2:40 PM, revealed Resident #10 was alert and oriented x 3 and able to make their own decisions. 11. According to the AR, Resident #11 was admitted with diagnoses which included but not limited to; polyneuropathy. Review of a progress note date 07/08/24 at 4:08 PM, Resident #11 was alert, verbally responsive and able to make their needs known. A review of the Individualized Care Plans (ICP) for Resident #1 through #11 revealed no CPs were initiated addressing the resident's choices regarding the aspects of their life that were significant to the residents. Further review of the medical record revealed that Resident #1 through #11 did not sign the facility Admission Agreement. The comprehensive Minimum Data Sets (MDS) were in progress and unavailable for review. NJAC 8:39-27.1(a)

Complaint # NJ 175415 Based on observation, interview, review of resident medical records and other pertinent facility documentation it was determined that the facility failed to ensure that 11 of 11 Justice Involved Residents (JIRs) (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) were free from involuntary seclusion. The JIR were secluded from having autonomy and to make choices to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. The failure to allow JIRs autonomy posed the likelihood to cause serious injury, psychological harm, and severe mental anguish which resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 07/02/2024, the date that the first JIR (Resident #1) was admitted to the facility and was secluded to the room by law enforcement officers of the Bureau of Prison [BOP]. The IJ situation was identified on 07/12/2024 when Residents #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 were observed being secluded to their rooms and guarded by law enforcement officers. The facility Licensed Nursing Home Administrator (LNHA) was informed of the IJ situation on 07/12/2024 at 3:49 PM which also constituted Substandard Quality of Care (SQC) for 42 Code of Federal Regulations (CFR) 483.12(a)(1). The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. An acceptable removal plan was received on 7/29/24 at 9:59 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: All Justice Involved Residents were discharged from the facility as of 7/26/24. The facility will no longer admit Justice Involved Residents. The survey team verified the removal plan on-site on 7/29/24, and determined the IJ was removed as of 7/26/24. The findings are as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016, S & C 16-21-ALL, documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. The facility policy dated 02/2024 and titled, Resident Rights indicated that all residents would be treated equally regardless of age, race, sex, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The resident has a right to be treated with dignity and respect including being free from any physical or chemical restraints imposed for the purposes of discipline or convenience. The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility . the right to receive visitors of his or her own choosing subject to the resident's right to deny visitation when applicable .right to participate in family groups .the right for personal privacy includes accommodations, medical treatment, telephone communications, personal care, visits and meetings of family and residents groups. On 07/11/2024 at 09:00 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Nursing (DON) who stated that she was notified by the facilities Cooperate Offices (CO) that JIRs were entering the facility. She stated that the facilities CO instructed the facilities administration (DON, Administrator, Admission Coordinator, Social Services, Activities Director, and Unit Managers) not to mix the JIR with other residents and that they needed to be roomed together. She stated that the JIRs would be guarded by law enforcement and their ankles would be shackled with metal cuffs. She stated that the CO also instructed the facility not to mix or intermingle the JIR with other residents in the facility, no community activities or outside visitation. On 07/11/2024 at 10:20 AM, Surveyor #1 and Surveyor #2 toured the fourth floor and interviewed Licensed Practical Nurse (LPN#1) who stated that he worked for an agency and that it was his first time working at the facility. LPN #1 stated that there were 6 (six) JIRs residing on his unit (Resident #2, #5, #6, #8, #9, and #11). He stated that there were police officers guarding the residents and that the residents wore metal ankle cuffs. He continued to explain that he was not sure what the residents' limitations were and was not aware of any behaviors that the JIRs had. He also added that he was not aware of any complaints about these residents from other residents that resided on his unit. On 07/11/2024 at 10:25 AM, Surveyor #1 observed the JIRs from the hallway. Residents #2, #5, #6, #8, #9 and #11, that resided on the fourth floor were observed in their rooms being guarded by law enforcement officers. On 07/11/2024 at 10:30 AM, Surveyor #1 and Surveyor #2 interviewed a gentleman outside in the hallway who identified himself as a contracted Supervisor of the United States Marshals (SUSM) (federal law enforcement agency in the United States, enforcing the federal courts). He stated that the surveyors were not allowed to enter the JIRs rooms and would not allow the surveyors to interview the JIRs on the 4 (four) [NAME] Unit (Resident #2, #5, #6, #8, #9, and #11). The SUSM explained to the surveyors that the JIRs were at the facility for rehabilitation services. He stated that all JIRs were to wear metal ankle restraints, and all were to be chained to the bed. He explained that the wearing of ankle restraints depended on the resident's medical condition. He stated that all residents could not attend facility activities and could not intermingle with other residents and could only talk amongst other JIR residents. He stated that the JIR residents could only leave their rooms with escorts for showering or any other reason which was approved by the U.S Marshals. He stated that the JIRs must eat in their rooms and could not eat in the main dining room with the other residents. He stated that visitation of anyone must be approved by US Attorney or Judge. On 07/11/2024 at 10:42 AM, Surveyor #1 observed Resident #5 and #6 from the hallway lying in bed guarded by 3 (three) detention officers, wearing metal ankle restraints that were affixed to the bed. On 07/11/2024 at 10:43 AM, Surveyor #1 observed Resident #8 and #9 from the hall, being guarded to the room by 3 detention officers and chained to the bed with metal ankle restraints. On 07/11/2024 at 11:00 AM, Surveyor #1 and Surveyor #2 toured the 3rd floor Unit. The surveyor interviewed LPN #2 who stated that there were three (3) JIRs on the unit (Resident #1, #4 and #10). On 07/11/2024 at 11:05 AM, Surveyor #1 and Surveyor #2 were given permission from the detention officer to interview Resident #4 who was observed in bed with glasses and was pleasant and cooperative. The surveyor observed that Resident #4 was wearing plastic ankle restraints. The guard in the room indicated that the resident had medical issues and was required to wear the plastic restraints (ankle cuffs) instead of metal. The surveyors observed the plastic ankle cuffs were shackled with a metal chain to the bed. Resident #4 stated that [Resident #4] was in the facility due to heart and vascular problems. Resident #4 stated that the food was good and that they were not allowed to leave the room, only for a shower. The resident stated that they were not allowed to intermingle with other residents and were only able to talk on the phone privately with his/her attorney. Resident #4 stated that otherwise there was no privacy when speaking on the phone. Resident #4 also stated that [he/she] was not allowed to attend community dining or community activities. On 07/11/2024 at 11:12 AM, Surveyor #1 and Surveyor #2 were given permission from the detention guard to interview Resident #1, who was cognitively intact . The resident stated that they were admitted to the facility with the diagnoses of osteomyelitis and colitis and needed intravenous antibiotic therapy. The resident indicated that they did not have any open wounds. Resident #4 stated that they received meals in the room but was able to pick their own meals and that the facility honored food preferences. The resident stated that they had not left the room except for showering. The resident stated that this was the only time that they could leave the room . On 07/11/2024 at 11:20 AM, Surveyor #1 and Surveyor #2 interviewed Licensed Practical Nurse Unit Manager (LPN/UM #1) who stated that Resident #3 resided on the 6th floor and had the diagnoses of Methicillin Resistant Staphylococci Aureus (MRSA) in the right axilla (armpit) and was on oral antibiotics. She also identified the resident as a prisoner. She stated that Resident #3 was not allowed to come out of the room unless it was to shower and had to eat meals in the room. She stated that the resident had activities in the room but was not allowed to attend activities in the main activity room because there was no intermingling with prisoners and LTC residents. LPN/UM #1 stated that Resident #7 also resided on the 6th floor and had a history of back pain. She stated that Resident #7's restrictions were the same for Resident #3. On 07/11/2024 at 11:35 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Recreation (DOR) who stated that she was informed by the Licensed Nursing Home Administrator (LNHA) that when the JIRs were admitted to the facility that she was to have no interactions with them. She stated that she was told not to complete an activities assessment on admission and that resident were not to attend any activities out of their rooms. She stated that she provided the JIR residents with a basket of puzzles and cards on admission. On 07/11/2024 at 11:42 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Social Work (DSW) who stated that she had been employed by the facility for about 1 (one) year. She explained what her role was when residents were admitted to the facility and stated that during the admission process, she performed a social service assessment with the resident. She explained the process of completing an advanced directive, discharge planning and held care plan meetings. She stated that when the JIR were admitted to the facility she provided them with a list of resident rights, advanced directives, billing information, and pain management. She stated that based on federal regulations in nursing homes keeping a resident in the room guarded and not being able to freely leave the room was a form of resident seclusion. She stated that the JIR residents were being isolated for safety reasons and that was against the federal regulations. On 07/12/2024 at 9:15 am, Surveyor #3, Surveyor #4, and Surveyor #5 toured the third floor and observed armed guards standing in the hallway near Resident #1, Resident #4, and Resident #10's room. Further observation revealed that there were armed guards standing inside the rooms. Surveyor # 4 observed Residents #4 and #10 from the hallway and were observed to be covered with blankets and the guards prevented the surveyor from entering the rooms and from interviewing the residents. On 07/12/2024 at 9:18 am, Surveyor #4 interviewed Licensed Practical Nurse #2 (LPN #2), who stated she could give the residents medication and the guards would identify the justice involved residents (JIR), and the guards would watch her give the medication to the residents. LPN #2 further stated that there were always two guards present, and one guard would observe the nursing care and staff were not allowed to pull the curtain to provide privacy. She further stated that she and all the staff were supervised by the Feds. On 07/12/2024 at 9:30 AM, Surveyor #4 interviewed an unsampled resident who stated that they are aware there are prisoners at the facility and the prisoners do not come out of their rooms and do not participate in activities with other residents. On 07/12/2024 at 09:34 AM, Surveyor #1 and Surveyor #2 interviewed the LNHA who stated that the facility could accommodate the JIRs medical needs, however after he received the Centers for Medicare and Medicaid Services (CMS) memo S & C: 16-21-ALL, with a revised date 12/23/2016, he understood that it was against federal regulation to restrain or seclude the JIRs. He stated that he called the nursing home in New York to inform them to stop sending the JIRs to the facility, but they just kept sending them. He stated that he did not refuse to admit the resident to the facility because the JIR residents had nowhere else to go. He then stated that it was not the facility that was imposing the restrictions on the JIRs, it was the Bureau of Prisons that was imposing them. He added that the facility was aware that the JIRs were being treated differently by the facility than the regular facility residents and that it was not the facilities standard of practice, however he felt that the Department of Justice (DOJ) was a strong governing body and that he was between the Department of Health and the DOJ. On 07/12/2024 at 9:40 AM, Surveyor #3, Surveyor #4, and Surveyor #5 interviewed the 3rd-floor Unit Manager (UM), who stated that the JIR were served all their meals on disposable plates, utensils, and cups, and the prison guards check their meals before serving. The UM further stated that the JIR's shower schedule was Tuesday and Thursday in the evening, and the prison guard would stay in the shower room with the JIR. On 07/12/2024 at 09:40 AM, Surveyor #3 and Surveyor #5 attempted resident interviews with Resident #8 and #9 but were told by the prison guard that interviews were not permitted but we could observe the JIR through the doorway of their rooms. Surveyor #5 observed Resident #8's breakfast meal tray on the bedside table, the resident's meal was served on a disposable tray, plates, cups, and utensils. Resident #8 was observed in the room in a wheelchair with an ankle restraint affixed by a chain to the resident's bed. Resident #9 was observed in bed with an ankle restraint affixed by a chain to the resident's bed. On 07/12/2024 at 09:45 AM, Surveyor #5 interviewed LPN #1 who was the nurse for both Resident #8 and #9. LPN #1 stated the JIRs stayed in their rooms all day except on shower days. LPN#1 stated the JIRs do not participate in group activities, go into the main dining area, and does not believe they were allowed visitors. On 07/12/2024 at 12:15 PM, Surveyor #1 and Surveyor #2 interviewed the LNHA who stated that residents being secluded to their room, secluded from other residents, and not being able to attend activities or eat in the main dining rooms were all a form of seclusion, however it was not the LNHA that was enforcing that on the JIR residents, it was the Bureau of Prisoners. 1. According to the Admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but was not limited to osteomyelitis (infection of the bone) of the right hand. According to the Admission progress note dated 07/02/2024 at 3:20 PM, the resident was alert and oriented. Review of the Admission Assessment (AA) dated 07/02/2024, Resident #1 was assessed as not having any behaviors and utilized no physical or chemical restraints, however Resident #1 was observed by Surveyor #1 (S1) and Surveyor #2 (S2) on 07/11/24 at 11:04 AM, wearing metal ankle cuffs. Review of the physician's orders (PO) reflected that there were no orders for the use of metal ankle cuffs, however a PO order dated 07/02/24, reflected an order to monitor skin integrity under the cuff area every shift. There was no consent signed for the use of the metal ankle cuffs. Review of the resident's Individualized Care Plans (CP) dated 07/02/24, revealed that a CP was not implemented for the use of restraints. The CP did not address that the resident required constant supervision from the detention guards for all aspects of activities of daily living (ADLs). The CP did not address that the resident was not permitted to leave the room unless for showering and accompanied by the detention guards and there was no documentation on the CP to address restrictions from attending community activities and community dining. 2. According to the AR, Resident #2 was admitted to the facility with the diagnoses which included but was not limited to multiple sclerosis (autoimmune disease). A comprehensive MDS was in progress and unavailable for review. Resident #1 did not sign the facility AA. Review of the AA dated 07/05/2024, Resident #2 was assessed as not having any behaviors and utilized no physical or chemical restraints, however Resident #2 was observed by Surveyor #1 and Surveyor #2 on 07/11/24 at 10:44 AM, wearing metal ankle cuffs. Review of the physician's orders (PO) reflected that there were no orders for the use of metal ankle cuffs, however the Treatment Administration Record (TAR) reflected an order dated 07/11/24, to check skin integrity under on bilateral ankle cuffs every shift. There was no consent signed for the use of the metal ankle cuffs. Review of the resident's CP dated 07/05/24, revealed that a CP was not implemented for the use of restraints. The CP did not address that the resident required constant supervision from the detention guards for all aspects of activities of daily living (ADLs). The CP did not address that the resident was not permitted to leave the room unless for showering and accompanied by the detention guards and there was no documentation on the CP to address restrictions from attending community activities and community dining. 3. According to the AR, Resident #3 was admitted to the facility on [DATE] with diagnoses which included but not limited to polyneuropathy. Review of the AA dated 07/05/24, revealed that Resident # 3 was assessed as not having any behaviors or requiring physical or chemical restraints. Review of a Progress Note (PN) dated 07/05/24, revealed Resident # 3 was alert and verbally responsive. Review of the CP initiated on 07/05/24, revealed no CPs were initiated regarding supervision with ADLs, restraints, activities, or seclusion. 4. According to the AR, Resident #4 was admitted into the facility July 2, 2024, with diagnoses which included but not limited; to Polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body causes pain, tingling or burning sensations on the body), hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone), hypertension (elevated blood pressure), Atrial Fibrillation (irregular, rapid heart rate) and dysphagia (difficulty swallowing). Review of the Order Summary Report revealed a physician order (PO) dated 7/11/24, to check the skin integrity on bilateral ankle cuffs every shift. Further review revealed that there were no orders for restraints and seclusion from the rest of the facility with continuous monitoring from law enforcement. Review of the AA dated 07/02/2024, the resident was assessed as not having any behavior problems, was independent with their decision-making, and not requiring physical or chemical restraints. Review of the resident's CP dated 07/02/24, did not include focus areas that would address supervision from law enforcement with Activities of daily living, restraints, activities, or seclusion. Review of the admission summary progress note dated 07/02/24 at 01:37 PM, revealed the resident was alert and oriented. 5. According to the AR, Resident #5 revealed was admitted to the facility on [DATE], with diagnoses which included but not limited to local infection of the skin and subcutaneous tissue. Review of the PN dated 07/10/24, revealed that Resident # 5 was alert and verbally responsive. Review of the AA dated 07/03/24, the resident was assessed as not having any behaviors or requiring physical or chemical restraints. Review of the CP initiated on 07/03/24, revealed no CPs were initiated regarding supervision with ADLs, restraints, activities, or seclusion. 6. According to the AR, Resident # 6 was admitted to the facility on [DATE]. Review of Resident # 6's AR revealed the resident was admitted to the facility with diagnoses which included but not limited to; polyneuropathy. Review of the AA dated 07/03/24, the resident was not assessed as having any behaviors or requiring physical or chemical restraints. Review of the CP initiated on 07/03/24, revealed no CPs were initiated regarding supervision with ADLs, restraints, activities, or seclusion. 7. According to the AR, Resident #7 was admitted to the facility on [DATE], with diagnoses which included but not limited to; low back pain. Review of a PN dated 07/04/24, revealed that Resident # 7 was alert and oriented. The AA dated 07/04/24, indicated that resident was assessed as not having any behaviors or requiring physical or chemical restraints. Review of the CP initiated 07/04/24, revealed no CPs were initiated regarding supervision with ADLs, restraints, activities, or seclusion. 8. According to the AR, Resident #8 was admitted [DATE], to the facility with diagnoses which included but not limited to dilated cardiomyopathy (disease of the heart muscle). Review of the AA dated 07/08/24, revealed that the resident was assessed as not having any behaviors or requiring physical or chemical restraints. Review of a PN dated 07/09/24, revealed that Resident # 8 was alert and verbally responsive. Review of the Care Plan initiated on 07/08/24, revealed no CPs were initiated regarding supervision with ADLs, restraints, activities, or seclusion. 9. According to the AR, Resident #9 was admitted to the facility with diagnoses which included but was not limited to dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). Review of a PN dated 07/10/2024 at 1:36 PM, revealed that the resident was alert with periods of forgetfulness. Review of the AA dated 7/5/2024, included that the resident was assessed as not having any behaviors or requiring physical or chemical restraints, however on 07/11/24 at 10:43 AM, Surveyor #1 and Surveyor #2 observed the resident in the room with metal cuff affixed to both ankles. Review of the physician's orders (PO) reflected that there were no orders for the use of metal ankle cuffs, however the PO reflected an order dated 07/11/24, to check skin integrity under on bilateral ankle cuffs every shift. There were no consents found in the medical record regarding the use of ankle restraints. Review of the CP dated 07/05/24, revealed that a CP was not implemented for the use of restraints. The CP did not address that the resident required constant supervision from law enforcement officers for all aspects of activities of daily living (ADLs). The CP did not address that the resident was not permitted to leave the room unless for showering and accompanied by law enforcement officers and there was no documentation on the CP to address restrictions from attending community activities and community dining. 10. According to the AR, Resident #10 had diagnoses which included but not limited to; enterocolitis due to clostridium Difficile (inflammation of the digestive tract due to an infection), depression, anxiety disorder, and diverticulitis (inflammation or infection in digestive tract). Review of the PO dated 07/02/24, revealed no order for restraints or seclusion from the rest of the facility with continuous monitoring from law enforcement. Review of the resident's CP dated 07/02/24, did not include focus areas that would address supervision of law enforcement with Activities of daily living, restraints, activities, or seclusion. Review of the PN dated 07/02/24 at 2:40 PM, revealed the resident was alert and oriented x 3 and was able to make their own decisions. 11. According the the AR, Resident #11 was admitted to the facility with diagnoses which but was not limited to; polyneuropathy (Damage to multiple peripheral nerves). Review of a progress note (PN) dated 07/08/24 at 4:08 PM, revealed that the resident was alert verbally responsive and able to make their needs known. Review the AA dated 07/03/24, the resident was assessed as not having any behaviors or requiring physical or chemical restraints, however Resident #11 was observed by Surveyor #1 and Surveyor #2 on 07/11/24 at 10:44 AM, wearing metal ankle cuffs. Review of the PO reflected that there were no orders for the use of metal ankle cuffs, however Treatment Administration Record (TAR) reflected an order dated 07/11/24, to check skin integrity under on bilateral ankle cuffs every shift. Review of the CP dated 07/03/24, revealed that a CP was not implemented for the use of restraints. The CP did not address that the resident required constant supervision from the detention guards for all aspects of ADLs. The CP did not address that the resident was not permitted to leave the room unless for showering and accompanied by law enforcement officers and there was no documentation on the CP to address restrictions from attending community activities and community dining. The comprehensive Minimum Data Set (MDS), an assessment tool that facilitates a resident's care, was in progress for Residents #1 though #11, and unable to be reviewed. The facility Admission Agreement (a contract which included all documents that a resident or responsible person must sign at the time of, or as a condition of, admission) was not signed by Residents #1 through #11. 8:39-4.1 (a)

COMPLAINT # NJ 175415 Based on observation, interview, review of resident medical records and other pertinent facility documentation it was determined the facility failed to ensure that 11 of 11 residents involved in the Justice System [Justice Involved Residents] (JIRs) (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) were free from physical restraints. The failure to treat residents respectfully and in a dignified manner had the likelihood to cause serious injury, psychological harm and mental anguish. These residents were restrained with ankle shackles that were attached to the beds with metal chains. This was cited as a pattern that immediately jeopardizes the health and safety of the JIRs, as well as all other residents that reside in the facility which resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 07/02/24, the date that the first JIR (Resident #1) was admitted to the facility and was restrained with metal shackles by law enforcement officers of the Bureau of Prison [BOP]. The IJ situation was identified on 7/12/24 when Residents #1, 2, 3, 4, 5, 6, 7, 8, 9,10, and 11 were observed being restrained with ankle shackles attached to their beds with metal chains guarded by law enforcement officers. The facility's Licensed Nursing Home Administrator (LNHA) was informed of the IJ situation on 07/12/24 at 3:49 PM, that an immediate jeopardy situation existed which also constituted Substandard Quality of Care (SQC) for 42 CFR 483.10 (e) (1) Free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. An acceptable removal plan was received on 7/29/24 at 9:59 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: All Justice Involved Residents were discharged from the facility as of 7/26/24. The facility will no longer admit Justice Involved Residents. The survey team verified the removal plan on-site on 7/29/24, and determined the was removed as of 7/26/24. The findings as are follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016, S & C 16-21-ALL, documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. The facility policy dated 02/2024 and titled, Resident Rights indicated that all residents would be treated equally regardless of age, race, sex, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The resident has a right to be treated with dignity and respect including being free from any physical or chemical restraints imposed for the purposes of discipline or convenience. The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility . the right to receive visitors of his or her own choosing subject to the resident's right to deny visitation when applicable .right to participate in family groups .the right for personal privacy includes accommodations, medical treatment, telephone communications, personal care, visits and meetings of family and residents groups. The facility policy dated 12/2010, revised 4/2024 and titled, Physical Restraints indicated that restraints should only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline of staff convenience. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms. Restraints should only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. The order shall include the specific reason for the restraint; how the restraint will be used to benefit the resident's medical symptom; and the type of restraint, and period of time for the use of the restraint. 1. According to the Admission Record (AR), Resident # 1 was admitted to the facility with diagnoses which included osteomyelitis (infection of the bone) of the right hand . Review of the Admission Assessment (AA) dated 07/02/24, revealed Resident #1 was assessed as not having any behaviors, or requiring physical or chemical restraints. According to the admission progress note dated 07/02/24 at 3:20 PM, the resident was alert and oriented. A review of the Individualized Care Plans (CP) revealed no CPs were implemented for the use of physical restraints. Further review of the medical record revealed that Resident #1 did not sign the facility Admission Agreement (AA) or consent for the use of physical restraints. The comprehensive Minimum Data Set (MDS) was in progress and not yet completed. 2. According to the AR, Resident #2 was admitted to the facility with diagnoses which included multiple sclerosis (autoimmune disease). Review of the AA dated 07/05/24, revealed Resident #2 was assessed as not having any behaviors, or requiring physical or chemical restraints. A review of the Individualized Care Plans (CP) revealed no CPs were implemented for the use of physical restraints. Further review of the medical record revealed that Resident #2 did not sign the facility AA or consent for the use of physical restraints. The comprehensive Minimum Data Set (MDS) was in progress and not yet completed. 3. According to the AR, Resident #3 was admitted to the facility with diagnoses which included polyneuropathy (peripheral nerve damage). Review of the AA dated 07/05/24, revealed Resident #3 was assessed as not having any behaviors, or requiring physical or chemical restraints. A review of the Individualized Care Plans (CP) revealed no CPs were implemented for the use of physical restraints. Further review of the medical record revealed that Resident #3 did not sign the facility AA or consent for the use of physical restraints. The comprehensive Minimum Data Set (MDS) was in progress and not yet completed. 4. According to the AR, Resident #4 was admitted to the facility with diagnoses which included polyneuropathy. Review of the AA dated 07/02/24, revealed Resident #4 was assessed as not having any behaviors, or requiring physical or chemical restraints. The AA indicated the resident was independent in their decision-making. According to the admission summary progress note dated 07/02/24 at 1:37 PM, the resident was alert and oriented. A review of the Individualized Care Plans (CP) revealed no CPs were implemented for the use of physical restraints. Further review of the medical record revealed that Resident #4 did not sign the facility AA or consent for the use of physical restraints. The comprehensive Minimum Data Set (MDS) was in progress and not yet completed. 5. According to the AR, Resident #5 was admitted to the facility with diagnoses which included local infection of the skin and subcutaneous tissue. Review of the AA dated 07/03/24, revealed Resident #5 was assessed as not having any behaviors, or requiring physical or chemical restraints. According to an Interdisciplinary progress note dated 07/10/24, the resident was alert and verbally responsive. A review of the Individualized Care Plans (CP) revealed no CPs were implemented for the use of physical restraints. Further review of the medical record revealed that Resident #5 did not sign the facility AA or consent for the use of physical restraints. The comprehensive Minimum Data Set (MDS) was in progress and not yet completed. 6. According to the AR, Resident #6 was admitted to the facility with diagnoses which included polyneuropathy. Review of the AA dated 07/03/24, revealed Resident #6 was assessed as not having any behaviors, or requiring physical or chemical restraints. According to the Social Service progress note dated 07/03/24 at 9:45 PM, resident #6 was assessed as alert and oriented with a Basic Interview for Mental Status (BIMS)of 15 out of 15 which indicated that the resident's cognition was intact. A review of the Individualized Care Plans (CP) revealed no CPs were implemented for the use of physical restraints. Further review of the medical record revealed that Resident #6 did not sign the facility AA or consent for the use of physical restraints. The comprehensive Minimum Data Set (MDS) was in progress and not yet completed 7. According to the Admission Record Resident #7 was admitted to the facility with diagnoses which included low back pain. Review of the AA dated 07/04/24, revealed Resident #7 was assessed as not having any behaviors, or requiring physical or chemical restraints. According to the admission summary note dated 07/04/24 at 11:12 AM, the resident was alert, and able to verbalize his/her needs to staff. A review of the Individualized Care Plans (CP) revealed no CPs were implemented for the use of physical restraints. Further review of the medical record revealed that Resident #7 did not sign the facility AA or consent for the use of physical restraints. The comprehensive Minimum Data Set (MDS) was in progress and not yet completed. 8. According to the AR, Resident #8 was admitted to the facility with diagnoses which included dilated cardiomyopathy (disease of the heart muscle). Review of the AA dated 07/08/24, revealed Resident #8 was assessed as not having any behaviors, or requiring physical or chemical restraints. According to the Admission progress note dated 07/09/24 at 2:40 PM, the resident was alert, responsive and able to make his/her needs known. A review of the Individualized Care Plans (CP) revealed no CPs were implemented for the use of physical. Further review of the medical record revealed that Resident #8 did not sign the facility AA or consent for the use of physical restraints. The comprehensive Minimum Data Set (MDS) was in progress and not yet completed. 9. According to the AR, Resident #9 was admitted to the facility with diagnoses which included dementia. Review of the AA dated 7/5/24, revealed Resident #9 was assessed as not having any behaviors, or requiring physical or chemical restraints. According to the progress admission note dated 07/10/24 at 1:36 PM, the resident was alert with periods of forgetfulness. A review of the Individualized Care Plans (CP) revealed no CPs were implemented for the use of physical restraints. Further review of the medical record revealed that Resident #9 did not sign the facility AA or consent for the use of physical restraints. The comprehensive Minimum Data Set (MDS) was in progress and not yet completed. 10. According to the AR, Resident #10 was admitted to the facility with diagnoses which included clostridium difficile colitis (C.diff) (bacterial infection of the colon). Review of the AA dated 07/02/24, revealed Resident #10 was assessed as not having any behaviors, or requiring physical or chemical restraints. The admission summary progress note dated 07/02/24 at 2:40 PM, resident was alert and oriented x3 and able to make their own decisions. A review of the Individualized Care Plans (CP) revealed no CPs were implemented for the use of physical restraints. Further review of the medical record revealed that Resident #1 did not sign the facility AA or consent for the use of physical restraints. The comprehensive Minimum Data Set (MDS) was in progress and not yet completed. 11. According to the Admission Record Resident #11 was admitted to the facility with diagnoses which included polyneuropathy. Review of the AA dated 07/03/24, revealed Resident #11 was assessed as not having any behaviors, or requiring physical or chemical restraints. According to the progress note dated 07/08/24 at 4:08 PM, the resident was alert verbally responsive and able to make their needs known. A review of the Individualized Care Plans (CP) revealed no CPs were implemented for the use of physical restraints. Further review of the medical record revealed that Resident #11 did not sign the facility AA or consent for the use of physical restraints. The comprehensive Minimum Data Set (MDS) was in progress and not yet completed. On 07/11/24 at 09:00 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Nursing (DON) who stated that she was notified by the facilities Corporate Offices (CO) that JIRs were entering the facility. She stated that the facility's CO instructed the facility's administration (DON, Administrator, Admission Coordinator, Social Services, Activities Director, and Unit Managers) not to mix the JIR with other residents and that they needed to be roomed together. She stated that the JIRs would be guarded by law enforcement and their ankles would be shackled with metal cuffs. She stated that the CO also instructed the facility not to mix or intermingle the JIR with other residents in the facility. On 07/11/24 at 09:35 AM, Surveyor #1 and #2 interviewed the Minimum Data Set Coordinator (MDSC) who stated that the eleven (11) JIRs had entry MDSs completed, however comprehensive MDSs were not completed until day 14 of admission. The MDSC provided the surveyors with the entry MDSs for all 11 JIRs. On 07/11/24 at 10:20 AM, Surveyor #1 and Surveyor #2 toured the fourth floor and interviewed Licensed Practical Nurse (LPN#1) who stated that he worked for an agency and that it was his first time working at the facility. LPN #1 stated that there were 6 (six) JIRs. On 07/11/24 at 10:25 AM, Surveyor #1 observed the JIRs from the hallway. The six residents that resided on the fourth floor were observed in their rooms being guarded by law enforcement officers. On 07/11/24 at 10:30 AM, Surveyor #1 and Surveyor #2 interviewed a gentleman outside in the hallway who identified himself as a contracted Supervisor of the United States Marshalls (SUSM). He stated that the surveyors were not allowed to enter the JIRs rooms and would not allow the surveyors to interview the JIR on the 4 (four) [NAME] (Resident #2, 5, 6, 8, 9, and 11). The SUSM explained to Surveyor #1 and Surveyor #2 that the JIRs were at the facility for rehabilitation services. He stated that all JIRs were to wear metal ankle restraints, and all were to be chained to the bed. He explained that wearing of ankle restraints depended on the resident's medical condition. He stated that the JIRs could not attend facility activities and could not intermingle with other residents and could only talk amongst other JIR residents. He stated that the JIR residents could only leave their rooms with escorts for showering or any other reason which was approved by the U.S Marshall. He stated that the JIRs must eat in their rooms and could not eat in the main dining room with the other residents. He stated that visitation of anyone must be approved US Attorney or Judge. On 07/11/24 at 10:42 AM, Surveyor #1 observed Resident #5 and #6 from the hallway lying in bed wearing metal ankle restraints that were chained to the bed and guarded by 3 detention officers. On 07/11/24 at 10:43 AM, Surveyor #1 observed from the hallway Resident #8 and #9 in their room chained with metal ankle restraints and guarded by 3 detention officers. At 07/11/24 at 11:00 AM, Surveyor #1 and Surveyor #2 toured the 3rd floor Unit. The surveyors interviewed LPN #2 who stated that there were 3 JIRs on the unit (Resident #1, #4 and #10). On 07/11/24 at 11:05 AM, Surveyor #1 and Surveyor #2 were given permission from the detention guard to interview Resident #4 who was observed in bed with glasses and was pleasant and cooperative. The surveyor observed that the Resident #4 was wearing plastic ankle restraints. The guard in the room indicated that the resident had medical issues and was required to wear the plastic restraints (ankle cuffs) instead of metal. The surveyors observed the plastic ankle cuffs were shackled with a metal chain to the bed. Resident #4 stated that they were in the facility due to heart and vascular problems. Resident #4 stated that the food was good and that they were not allowed to leave the room, only for a shower. The resident stated that they were not allowed to intermingle with other residents and were only able to talk on the phone privately with their attorney. Resident #4 stated that otherwise there was no privacy when speaking on the phone. On 07/11/24 at 11:12 AM, Surveyor #1 and Surveyor #2 were given permission from the detention guard to interview Resident # 1 who was cognitively intact. The resident stated that they were admitted to the facility with the diagnoses of osteomyelitis and colitis and needed intravenous antibiotic therapy. Resident #4 stated that they received meals in the room but was able to pick their own meals and that the facility honored food preferences. The resident stated that they had not left the room except for showering. The resident stated that that was the only time that they could leave the room. On 07/11/24 at 11:20 AM, Surveyor #1 and Surveyor #2 interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #1) who stated that Resident #3 resided on the 6th floor and had the diagnoses of Methicillin Resistant Staphylococci Aureus (MRSA) in the right axilla (armpit) and was on oral antibiotics. She also identified the resident as a prisoner. She stated that Resident #3 was not allowed to come out of the room unless for a shower and had to eat meals in the room. She stated that the resident had activities in the room but was not allowed to attend activities in the main activity room because there was no intermingling of prisoners with LTC residents. LPN/UM #1 stated that Resident #7 also resided on the 6th floor and had a history of back pain. She stated that Resident #7's restrictions were the same and Resident #3. On 07/11/24 at 11:35 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Recreation (DOR) who stated that she was informed by the Licensed Nursing Home Administrator (LNHA) that when the JIR were admitted to the facility that she was to have no interaction with them. She stated that she was told not to complete an activities assessment on admission. She stated that she provided the JIR residents with a basket of puzzles and cards on admission, however the residents were not to attend any activities out of their rooms. On 07/11/24 at 11:42 AM, Surveyor #1 and Surveyor #2 interviewed the Director of Social Work (DSW) who stated that she had been employed by the facility for about 1 (one) year. She explained what her role was when residents were admitted to the facility and stated that during the admission process, she performed a social service assessment with the resident. She explained the process of completing an advanced directive, discharge planning and held Care Plan meetings. She stated that when the JIR were admitted to the facility she provided them with a list of resident rights, advanced directives, billing information and pain management. She stated that based on federal regulations in nursing homes keeping a resident in the room guarded and not being able to freely leave the room was a form a resident seclusion. She stated that the JIR residents were being isolated for safety reasons and that that was against the federal regulations. On 07/12/24 at 09:34 AM, Surveyor #1 and Surveyor #2 interviewed the LNHA who stated that the facility could accommodate the JIRs medical needs, however after he received the Centers for Medicare and Medicaid Services (CMS) memo S & C: 16-21-ALL, with revised date 12/23/2016, he understood that it was against federal regulation to restrain or seclude the JIRs. He stated that he called the nursing home in New York to inform them to stop sending the JIRs to the facility, but they just kept sending them. He stated that he did not refuse to admit the residents to the facility because the JIRs had nowhere else to go. He then stated that it was not the facility that was imposing the restrictions on the JIRs, it's the Bureau of Prisons that was imposing them. He added that the facility was aware that the JIRs were being treated differently by the facility than other residents and that it was not the facility's standard of practice however he felt that the Department of Justice (DOJ) was a strong governing body and that he was between the Department of Health and the DOJ. On 07/12/24 at 9:40 AM, Surveyors #3 and #5 attempted resident interviews with Resident #8 and #9 but were told by the prison guard interviews were not permitted but could be observed through the doorway of their rooms. The surveyors observed Resident #8 in their room in a wheelchair with an ankle restraint connected by a metal chain to the resident's bed. Resident #9 was observed in bed with an ankle restraint connected by a chain to the resident's bed. On 07/12/24 at 9:45 AM, Surveyor #5 interviewed the Licensed Practical Nurse (LPN #1) who was the nurse for Residents #8 and #9. LPN #1 stated that the JIRs stay shackled in their rooms all day except on shower days. On 07/12/24 at 12:15 PM, Surveyor #1 and Surveyor #2 interviewed the LNHA who stated that resident being secluded to their room, seclusion from other residents and not being able to attend activities or eat in the main dining rooms were all a form of seclusion, however it was not the LNHA that was enforcing this on the JIR residents, it was the Bureau of Prisoners. On 07/12/24 at 1:24 PM, Surveyors conducted a phone interview with the Medical Director (MD)who stated that he had been on vacation when the 11 JIRs were admitted to the facility. He was not aware that the 11 JIRs were secluded to their rooms or that they were all restrained with ankle shackles. The MD further stated that he did not write physician orders for restraints for any of the 11 JIRs. On 07/15/24 at 08:45 AM, Surveyors #2 and #3 together toured the 3rd floor 300 unit and observed Residents #4 and #10 in their rooms with ankle shackles attached to their beds with metal chains. On 07/15/24 at 08:51 AM, Surveyors #2 and #3 toured the 4th floor 400 unit and observed Resident #11 in hallway of the 400 unit in a wheelchair escorted by 3 prison guards with hand cuffs and ankle shackles in place. At 08:54 AM, the surveyors observed Residents #6, #5 and #8 in their rooms with ankle shackles attached to their beds with metal chains. On 07/15/24 at 09:44 AM, Surveyor #2, #3 and #5 together interviewed the LNHA who stated that until he met with or was contacted by the New Jersey Department of Health (NJDOH), Centers for Medicare and Medicaid (CMS), and [contracted complany] he could not submit a removal plan for any of the Immediate Jeopardize because the JIRs would have to be removed from the facility and that was not possible at this time. 8:39-4.1 (6)

C # NJ Based on interviews and record review, as well as review of pertinent facility documents on 12/13/16, it was determined that the facility staff failed to ensure the safety and well-being, as well as follow the facility policy for Wandering/Elopement, for 1 of 3 sampled residents (Resident #1). On 11/23/16, Resident #1, with cognitive deficit, was expected to return from the Dialysis Center between 7:30 p.m. and 8:30 p.m. The Certified Nursing Assistant (CNA #1) told Licensed Practical Nurse (LPN #1) that Resident #1 had not returned from the Dialysis Center at 8:30 p.m. The facility did not initiate the search for the Resident until 11:45 p.m. on 11/23/16, and were unable to locate the resident. The local Police notified the facility that Resident #1 had been found at approximately 6:20 a.m. on 11/24/16. This deficient practice placed Resident #1, as well as all other residents, at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified on 12/13/16 at 2:57 p.m., when Administration was alerted. The IJ was lifted on 12/13/16 at 4:30 p.m., when the facility provided and implemented an acceptable plan of correction (POC). This deficient practice is evidenced by the following : 1. According to the Admission Record, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 11/5/16, showed that the Resident had a Brief Interview for Mental Status (BIMS) score of 5/15, which indicated that the Resident was cognitively impaired. The MDS also indicated that the Resident required extensive assistance from staff with Activities of Daily Living (ADLs). According to Resident #1's Care Plan (CP), initiated on 10/29/16, and revised on 11/15/16, Resident #1 had impaired cognitive function or impaired thought process related to Dementia. The CP goal for the Resident was to Maintain Safety. In addition, the Resident was at risk for Falls related to gait and/or balance problems. On 11/25/16, the New Jersey Department of Health (NJDOH) received a Facility Reportable Event (FRE) from the facility. According to the FRE, on 11/23/16 at approximately 1:00 p.m., Resident #1 was picked up by the Transportation Company for Dialysis treatment and expected to return to the facility between 7:30 p.m. and 8:30 p.m. The FRE showed that at 8:30 p.m. CNA #1 notified LPN #1 that Resident #1 did not return from the Dialysis Center. The FRE further indicated: At end of shift, supervisor was again made aware that the Resident did not return. Room to room check initiated .Security confirmed that the (Resident) did not return. Director of Nursing (DON) was notified. The FRE also included two Elopement Risk Assessment documents dated 10/29/16 and 11/24/16. Both documents indicated that Resident is not at risk for elopement. Attached with the FRE a form titled, Summary of Investigation, dated 11/25/16, written by the Director of Nursing (DON) showed that the Nursing Supervisor (NS #2) called the Dialysis Center and Resident #1's family but the NS #2 was not able to get in touch with anyone. On 11/24/16 at 6:20 a.m., the Police came and assisted the facility to find Resident #1. The FRE revealed that the Police were able to locate the Owner of the Transportation Company (OTC). Subsequently, the OTC reached out to the Driver who transported Resident #1 from the Dialysis Center on 11/23/16. According to the Investigation, the driver had dropped off the Resident to his/her son's house (who was not included on the list for Emergency contact). The Investigation also revealed that this Son's telephone number was not provided to the facility. Furthermore, the Police together with the Resident #1's son and daughter (listed Emergency contacts), went to pick up the Resident and brought the Resident back to the facility with no injury noted. Further review of the FRE dated 11/23/16, under the section Interventions, included but were not limited to the following: Assessed of any injury-No apparent injury, and in-service staff to confirm (Name of Transport) that picks up the Resident prior to sending Resident out for appointments/dialysis. On 12/13/16, the Assistant Director of Nursing (ADON), explained that LPN #2 worked 11 p.m. to 7 a.m. on 11/23/16. The surveyor reviewed the facility form titled, Progress Notes (PN), dated 11/24/16 at 8:31 a.m., written by LPN #2. The PN indicated that on 11/23/16, during room rounds at 11:15 p.m., Resident #1 was not in their room. LPN #2 informed the 3 p.m.-11 p.m. shift who was unaware of Resident #1's location. The PN also showed that I informed my night supervisor of the situation at around 11:45 p.m., we immediately stared (sic) {started} a search. At 11:15 p.m. I check the notes on the computer from the previous shift along with reading the 24 HR (hour) report. Rounds was made on the entire until (sic) {unit} on all 3 wings at around 11:45 p.m. I notified my supervisor. During an interview with Resident #1 on 12/13/16 at 10:16 a.m., the Resident indicated (unable to recall the exact date), that after the Dialysis Treatment, the Resident requested the Transportation Driver to drop him/her off to his/her son's house. The Resident further revealed that the Driver did not indicate the Resident was not allowed to do that. In an interview with the Unit Manager (UM) on 12/13/16 at 10:40 a.m., the UM indicated that on 11/23/16, Resident #1 was expected to return from the Dialysis Center between 7:30 p.m. and 8:30 p.m. The UM stated that he/she worked as the 3 p.m.-11 p.m. Nursing Supervisor (NS #1) on 11/23/16. The UM also indicated that at 4 p.m. on 11/23/16, he/she received a telephone call from Resident #1's daughter and wanted to know if the Resident returned from the Dialysis Center. The UM stated that he/she told the Resident's daughter that the Resident was expected to return at 8 p.m. During a subsequent interview with the UM on 12/13/16 at 10:43 a.m., the UM indicated that CNA #1 and LPN #1 did not notify him/her that Resident #1 had not returned from the Dialysis Center on 11/23/16. The UM went on to state If only LPN #1 and CNA #1 told me that the Resident did not return, we could have done what we needed to do before the end of our shift (3 p.m.-11 p.m.). The UM further indicated that he/she was already home at 11:45 p.m. on 11/23/16, when he/she received a telephone call from the 11 p.m.- 7 a.m. Nursing Supervisor (NS #2) and was notified that Resident #1 had not returned from the Dialysis Center. Further interview with the UM on 12/13/16 at 10:49 a.m., indicated that CNA #1 had insisted that he/she told LPN #1 at approximately 8 p.m. to 8:30 p.m. on 11/23/16, that the Resident had not returned from the Dialysis Center. The UM also stated that Resident #1's family came here and spoke to the Police and they were worried because they did not know where the Resident was. During an interview with CNA #1 on 12/13/16 at 11:54 a.m., CNA #1 indicated that Resident #1 usually returned from Dialysis between 7:30 p.m. and 8:30 p.m. The CNA stated I normally see Resident #1 on the North Wing sitting in her wheelchair after Dialysis treatment. When I did not see the Resident where he/she was, I went to check his/her room but the Resident was not there. I told LPN #1 that the Resident did not return from Dialysis at approximately 8 p.m. to 8:30 p.m. CNA #1 continued to state that after he/she told LPN #1 that Resident #1 did not return from Dialysis Center, the response he/she got from LPN #1 was He/she is giving out medications. The surveyor asked the CNA if he/she told anyone aside from LPN #1. The CNA stated I don't know what else to do. I told the nurse. I did my job. I did not tell my Supervisor. I left my shift and the Resident still was not back. I kept hearing from the Resident that he/she wanted to go home. I went home and I got a call from the Supervisor and the DON asking me about Resident #1. The CNA further explained that he/she told both the DON and the Nurse Supervisor that the CNA mentioned to LPN #1, that Resident #1 did not return from the Dialysis Center at approximately 8 p.m. to 8:30 p.m. CNA #1 verified that Resident #1 verbalized about going home, but the Resident did not exhibit an exit seeking behavior. During an interview with LPN #1 on 12/13/16 at 12:01 p.m., LPN #1 indicated that no one told him/her verbal or written that Resident #1 went out for Dialysis and did not return after that. The LPN also indicated that the nurse (LPN #3) who was first assigned for Resident #1 left early at 7:30 p.m. on 11/23/16. The LPN stated that when LPN #3 left, he/she was assigned to Resident #1, including giving the Resident's medications. The surveyor asked about the medications that Resident #1 had to receive after 7:30 p.m. on 11/23/16. The LPN #1 stated I did not pay attention on the Medication Administration Record (MAR) because the room was empty. I did not know that the Resident went out for Dialysis and did not return. I only came to know about the Resident not returning from the Dialysis when the night nurse (LPN #2) was doing his/her rounds. LPN #1 indicated that when LPN #2 did not see Resident #1 in his/her room, LPN #2 asked LPN #1 where Resident #1 was. LPN #1 went on to state I told LPN #2, I do not know where the Resident was, so the 11 p.m. to 7 a.m. shift started calling the DON and the Dialysis Center. A review of the form titled, Medication Administration Record (MAR) for Resident #1, dated 11/2016, indicated that the following medications were due at 9 p.m. on 11/23/16 : Insulin Aspart 100 units/milliliter (ml) inject as per sliding scale, subcutaneously before meals and at bedtime related to Type 1 Diabetes Mellitus Without Complications (7:30 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m.). Sodium Bicarbonate 650 milligrams (mg), give 1 tablet by mouth every 12 hours for Antacids (9 a.m. and 9 p.m.). The MAR showed that the aforementioned medications were left unsigned and/or not documented as having been administered on 11/23/16, at 9 p.m. In a telephone interview with the Owner of the Transportation Company (OTC) on 12/13/16 at 12:13 p.m., the OTC confirmed that Resident #1 was picked up from the Dialysis Center and was dropped off at the address provided by the Resident to the Driver on 11/23/16. The OTC stated that the Driver knew that Resident #1 had to be dropped off back to the facility and could not explain why the Driver had taken the Resident to a different address. The OTC indicated that a disciplinary action was issued to the Driver for not following their protocol. In an interview with the LPN #3 on 12/13/16 at 12:27 p.m., LPN #3 indicated that he/she worked on the same floor with LPN #1, on 11/23/16. LPN #3 stated that he/she worked until 6 p.m. on 11/23/16, and that he/she had not mentioned to the UM that Resident #1 did not return from Dialysis, because the Resident was not due to return at 6 p.m. however, LPN #3 went on to state that he/she documented on the 24 hour report that Resident #1 was out for Dialysis Treatment. During a telephone interview with the Charge Nurse (CN) and Nurse Manager (NM) at the Dialysis Center on 12/13/16 at 12:28 p.m., they indicated that Resident #1 started his/her Dialysis Treatment at 2:56 p.m., and ended at 5:57 p.m. on 11/23/16. The NM stated On 11/23/16, all of our Dialysis Treatments were completed early so we don't have to call facilities and transportations for late pick-up. A review of the PN dated 11/23/16 at 6:30 p.m., signed by LPN #3, documented that the Resident #1 was at Dialysis. On 12/13/16, LPN #2 and Nursing Supervisor #2 were not available for interview. In an interview with the Assistant Director of Nursing (ADON) on 12/13/16 at 2:34 p.m., the ADON indicated that the DON was not available to be interviewed and was on vacation. The surveyor reviewed the form titled, Sign In Sheet, dated 11/24/16, signed by the staff including LPN #1. The form under the section of Topic showed: Transportation arrangements done with (a different Transportation Company) as much as possible. The ADON explained that the aforementioned Topic was the inservice/education provided to the staff following the incident involving Resident #1. The ADON further explained that there was no other inservice/re-education provided to the staff, particularly to LPN #1, about What to do when the Resident was reported missing or did not return from Dialysis/Appointments on time. On 12/14/16, a post survey review of the the form titled, Dialysis Center Post Treatment, for Resident #1, dated 11/23/16, showed: Pre-Treatment time at 2:56 p.m. and Post-Treatment time at 5:57 p.m. A post survey review on 12/14/16, of the form titled, New Jersey Daily Trip Log, for Resident #1, dated 11/23/16, revealed: Pick- Up Time 6:30 p.m. and Drop-Off Time 7:00 p.m. A review of the facility's policy titled, Wandering/Elopement Policy, revision date August 2014, revealed under Definition: Elopement- act of running away without permission . Policy included: The facility will make every effort to prevent a resident from leaving the nursing home premises unsupervised, without permission or without the knowledge of any staff member. It will also ensure the safety of residents, to the degree possible, whenever they leave the premises of the nursing home without appropriate discharge orders or instructions A protocol will be implemented in the event an elopement occurs or a resident is reported missing. Policy protocols included: Calling a Code Gray 'E'-emergency, to notify the security staff that a resident is unaccounted for. and start a thorough search of the area for the missing resident. On 12/13/16 at 2:45 p.m., the Administrator and the ADON were notified that an IJ for Resident #1 had occurred on 11/23/16, for failure to ensure resident safety and well-being when Resident #1 did not return from Dialysis Treatment between 7:30 p.m. and 8:30 p.m. The IJ was corrected on 12/13/16 at 4:30 p.m., when the facility implemented an acceptable POC that included staff education. The acceptable POC was documented as follows: 1. Resident #1 went for a dialyses (sic) treatment and didn't return at scheduled time, Nurse didn't call Dialyses (sic) center to find out what location of Resident is and why (the Resident) has not returned on time. This incident was reported to DOH on 11-25-16. Nurse in question was suspended 12-13-16 until proper investigation is completed. 2. All residents that go out of facility for dialyses (sic) or other md appointments have the potential to be affected by this practice. 3. All Nursing staff in the facility on 12-13-16 were in serviced on the importance of notifying Nurse/Supervisor or designee immediately when resident don't return from outside appointments at their appropriate return time and should immediately call Dialyses (sic) center or md office to find the disposition of the resident. All other staff that is not here today will be in serviced on this topic before the start of the shift. 4. A log created 12-13-16, for each unit, for any resident that goes on an outside appointment with the approximate time they should be returning and if they didn't return we will immediately follow up with a phone call to the center. Audits of such logs will be done by the DON or designee weekly until 100% compliance for 3 months and then monthly. Reports will be reviewed by the QA committee quarterly. 5. Completion 12-13-16 at 3:45 p.m. NJAC 8:39-27.1 (a)

Complaint #: NJ & NJ Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to immediately search for and/or conduct an investigation of a resident who was missing for the noon meal and 1:00 p.m. medication administration on 6/17/14, for 1 of 3 residents reviewed (Resident #1). In accordance with the facility's own "Wandering/Elopement Policy," that reflected upon establishing that a resident is not in the building, the security personnel must start a search of the building grounds, including the perimeter, the patio and parking area. There was no indication that the facility's policy was followed until approximately 4:00 p.m. when the 3:00 p.m.-11:00 p.m. staff also noted Resident #1 was missing. According to the facility's undated Summary of Investigation, faxed to the New Jersey Department of Health (DOH) on 6/19/14, the 7:00 a.m.-3:00 p.m. nurse, a Licensed Practical Nurse (LPN) #1, was aware that Resident #1 was not present for the noon meal or for the 1:00 p.m. medication administration. LPN #1 had assumed the resident had gone on a field trip. Even after LPN #1 discovered that Resident #1 had not gone on the field trip, LPN #1 did not report to the Nursing Supervisor or Administration that the resident was missing. Resident #1 was missing from the facility for approximately 4 hours without staff initiating a search for the resident and/or the Nursing Supervisor and/or the facility administration being made aware. The police were notified; however, the resident was not located until 2 days later when the resident checked his/herself into the hospital and informed hospital staff that he/she had escaped from the address where the facility was located. The resident did not return to the facility. The immediate jeopardy to Resident #1 began on 6/17/14 at approximately 12:00 p.m. and was corrected on 6/23/14 at 4:58 p.m. when the facility implemented an acceptable (POC). This deficient practice was evidenced by: All interviews were conducted on the day of the survey, 6/23/14, unless otherwise stated. 1. According to an Admission Record Face Sheet, Resident #1 was admitted to the facility in August 2013, with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 8/30/13, reflected Resident #1 had a score of 11 on the Brief Interview for Mental Status (BIMS), which indicated the resident had a moderate cognitive impairment. Resident #1 required assistance with all activities of daily living, including ambulation. An MDS dated [DATE], reflected that Resident #1 was unable to complete the BIMS interview and had short/long-term memory problems. In the area of cognitive skills for Daily Decision Making the resident had some difficulty in new situations. In addition, Resident #1 ambulated with a cane and supervision. A Psychiatric Evaluation Form dated 5/24/14, reflected Resident #1 had a [DIAGNOSES REDACTED]. A review of a New Jersey Universal Transfer Form (NJUTF), dated 8/30/13, indicated Resident #1 was at risk for elopement. However, the facility Nursing Admission Assessment, dated 8/30/13, reflected that Resident #1 was not an elopement risk. There was no indication that an elopement risk assessment was not completed from 8/30/13 to 6/17/14. A review of a Risk Management/Incident Note completed by a Registered Nurse (RN) dated 6/17/14 at 16:30 (4:30 p.m.) reflected, "At around 4:30 p.m." the district nurse reported that during her last rounds she was "unable to locate" the resident. After not locating resident on the 6th floor, the RN noted that Resident #1 had not been signed out of the building on pass by the resident's family and did not have a doctor's appointment. The Nursing Supervisor was made aware and called a Code Gray (missing person.) The elopement protocol was initiated. All staff were alerted and administrative staff made aware. The incident was reported to the police department. At 9:10 p.m. a police officer arrived to the facility and did a thorough investigation of the incident. A Missing Person Report was filed and the resident's family and doctor were made aware. According to a Facility Reportable Event Record (FRE) dated, 6/18/14 and faxed to the New Jersey Department of Health on 6/19/14, at approximately 4:00 p.m. it was reported by the Registered Nurse Supervisor, that Resident #1 was not in their room and was unable to be located. Resident #1 was "alert and oriented." The FRE further documented, a complete and thorough search of the building was done, and an elopement checklist was completed. All surrounding areas were searched, including all known previous addresses, the local train station and surrounding hospitals. Resident #1's family and attending physician were notified including the police. Furthermore, the 7:00 a.m. -3:00 p.m. nurse was suspended pending investigation. A review of a facility incident report dated 6/17/14 at 15:20 (3:20 p.m.) and revised on 6/17/14 at 23:31 (11:31 p.m.) confirmed that Resident #1 had eloped. At 4:00 p.m. the district nurse reported during her last rounds she was unable to locate Resident #1. They noted that the resident had not signed out on pass by the family and did not have a doctor's appointment. At 4:30 p.m. Resident #1's family members and physician were made aware. In addition, at 9:10 p.m. a Police Officer arrived and did a "thorough" investigation of the incident and reflected a "missing complaint report" was filed. In addition, the undated Summary of Investigation (part of the facility's investigation) reflected that security cameras were reviewed by the Administrator, Director of Nursing (DON) and Security. There was no documentation that indicated when the security camera footage was viewed by the Administrative staff. On 6/23/13 at 1:22 p.m., the surveyor reviewed current time security camera footage with the Administrator. The Administrator was unable to access and review prior footage. The Administrator then stated "I am positive" Resident #1 got out of the front door, "there is a lot of activity that goes on there." The Administrator later stated at 2:30 p.m. that the camera footage only stores 5 days for review. In addition, he would not be able to obtain the footage from 6/17/13 and could only go back to 6/18/14. The Administrator did not indicate the date he viewed the security camera footage. During the course of the Facility's Investigation a statement was obtained from Certified Nursing Assistant (CNA) #2 dated 6/19/14, that reflected after 9:00 a.m. Resident #1 was walking in the hallway doing his/her usual exercise. At lunch time after 12:00 p.m., CNA #2 did not see Resident #1 and asked LPN #1 where Resident #1 was. LPN #1 told CNA #2 that Resident #1 "went out on the field trip to the park." Another statement obtained during the course of the facility's investigation written by LPN #1, reflected she administered the morning medications to Resident #1. At 10:00 a.m. she observed Resident #1 ambulating from North Wing to South Wing. Normally after Resident #1 ambulated from North/South Wing, Resident #1 sits in dining room. The statement further reflected that lunch was served and the resident's meal tray was put in Resident #1's room. After Resident #1 "did not eat," LPN #1 "thought" Resident #1 had attended the recreational trip to the park. LPN #1 also documented that there was another resident that attended the trip and their tray was still in their room. During last rounds both trays were still in the resident's rooms. She then asked "recreation" if the residents had returned from the trip and was told yes. She was then informed that Resident #1 did not attend the trip. LPN #1 then went to the patio area and Resident #1 was not on the patio. LPN #1 then returned to the floor and made the Unit Manager (UM) aware, who then made the supervisor aware. In addition LPN #1 documented that elopement procedures were followed. It was further documented that the 1:00 p.m. medication was not given and Resident #1 was not in their room. There was no documentation that reflected at what time LPN #1 made the UM aware she could not locate Resident #1 and/or Resident #1 was not present for the 1:00 p.m. medication administration. A statement dated 6/17/14 completed by a CNA documented, at 3:25 p.m. while making rounds the CNA observed an untouched tray in Resident #1's room. The resident was not observed in the room. In addition the CNA documented "I reported it to the nurse in the wing." An undated, untitled staff statement reflected, "While I am in the 6th floor to make my rounds," LPN #1 reported that she cannot locate Resident #1 after searching the room and the patio. "It was noted also that resident has no appointment" and was not signed out on pass by the family today. The "Undersigned" asked other staff members to search again within the 6th floor. Security was informed and the nursing supervisor was called and notified that Resident #1 was missing. The aforementioned statement was not signed by the untitled staff member. A review of an undated written summary completed by the Director of Nursing (DON) reflected on 6/18/14, Resident #1's friend called and notified the facility that Resident #1 had called the facility and informed them that Resident #1 had some business to attend with a lawyer and will return to the facility "today." There was no further documentation as to the whereabouts of Resident #1. At 9:10 a.m., the surveyor conducted a tour of the facility and grounds with the Director of Maintenance (DM). The DM stated that all doors will alarm (sound) if opened without entering a code into the keypad first. In addition, that will trigger an alarm on the security camera screens located by the receptionist area. The DM stated that the receptionist should observe the cameras and report any triggered alarms to Administration. At 10:00 a.m. on 6/23/14, the surveyor conducted an interview with LPN #1, who was on duty on 6/17/14 during the 7:00 a.m.-3:00 p.m. (the day of Resident #1's elopement). LPN #1 stated that Resident #1 would normally eat lunch at 12:30 p.m. in the 6th floor dining room, then plays a card game in his/her room. She stated that she didn't remember what Resident #1 did that day. She revealed she didn't see Resident #1 after lunch and the resident was not in his/her room for 1:00 p.m. moisturizing eye drop medication on 6/17/14. She stated "Actually, I didn't look" for the resident to administer the 1:00 p.m. medications. LPN #1 further stated that Resident #1 had not verbalized that he/she wanted to leave and Resident #1 would go out on pass with family members periodically. LPN #1 also indicated that Resident #1 had a wheelchair initially, but attended therapy and progressed to ambulating with a cane. At 10:38 a.m., the surveyor conducted an interview with CNA #1 who was assigned to pass out the lunch trays on 6/17/14. CNA #1 stated that "I assumed" Resident #1 went to the park with the recreation department that morning. She confirmed that she left the lunch tray in Resident #1's room "at around 12:00 p.m." At 10:42 a.m., the surveyor conducted an interview with CNA #2 who was assigned to provide care on the 7:00 a.m.-3:00 p.m. shift on 6/17/14. CNA #2 stated that she gave Resident #1 a shower and helped him/her get dressed. Later Resident #1 was "walking in hallway." She revealed that Resident #1 "did not have lunch" and she told LPN #1 that Resident #1 did not eat lunch and LPN #1 told her that Resident #1 went out on the field trip. CNA #2 revealed "I didn't check the field trip list." CNA #2 stated that she couldn't remember the last time she saw Resident #1 after breakfast. In addition she stated "I assumed" the resident went to the park that morning and revealed "Now I know I am to follow up when someone is not here, the DON told me." During a subsequent interview with LPN #1 at 10:52 p.m., the surveyor asked LPN #1 what residents were on the list for the field trip the morning of 6/17/14. LPN #1 revealed that Resident #1 was not on the list and stated, that when she went to recreation, they told her that Resident #1 "didn't go on the trip." At 10:58 a.m., the surveyor conducted an interview with the Director of Recreation (DR) and asked about the communication process between staff when residents went out on field trips. The DR replied, "The nurses get a list the day before." The DR confirmed that Resident #1 "was not on the list" and no one came to him to ask if Resident #1 was on the list. He revealed that the residents who go out on field trips always return before lunch except on 6/17/14, they went to the park at 10:30 a.m. with lunch and returned "about 1:00 p.m." At 12:15 p.m., the surveyor conducted an interview with the front desk Security Guard (SG) #1, who was off duty day of the elopement. SG #1 was asked what the facility process was to ensure that residents do not leave the building unaccompanied. SG #1 stated that they look at everyone's wrist for a name bracelet when they are leaving. Residents wearing Wanderguards (an elopement alert device), will cause the door to alarm when attempting to leave. SG #1 confirmed that the front door opens freely when approached. SG #1 also stated, if SGs have to leave the area for any reason, they are to tell the receptionist, so that the receptionist can keep an eye on the front door. He stated that from 12:00 p.m. - 1:00 p.m. he will go to the patio (which adjoined the lobby) and bring in all the residents for lunch. The patio is closed between 12:00 p.m. and 1:00 p.m. for lunch. At 12:25 p.m., the surveyor conducted an interview with the receptionist who worked the day of the elopement on 6/17/14. The receptionist stated that no door alarms sounded the day of the elopement. In addition, the receptionist could not remember if the security guard left the desk for any reason that day. At 1:15 p.m., the surveyor conducted a telephone interview with the Security Supervisor (SS) who worked the security desk the day of the elopement. The SS stated that she went out to the patio sometime before or after lunch because a family member reported an occurrence between 2 other residents. The SS could not specify a time. The SS stated that the patio is closed between 12:00 p.m. and 1:00 p.m. In addition, the SS stated, "If I leave the desk for any reason I tell the receptionist to keep an eye out for the front door." At 3:20 p.m., the surveyor conducted an interview with the Administrator, DON and Assistant Director of Nursing (ADON) and reviewed Resident #1's NJUTF, dated 8/30/13 with them. The surveyor asked who was responsible for reviewing the NJUTF on admission. The DON and ADON both agreed that it was the responsibility of the DON, ADON, and the admitting nurse on the unit the resident was assigned to. Section 20 of the 8/30/13 NJUTF documented that Resident #1 was at risk for elopement. The ADON revealed that the facility did not assess Resident #1 as an elopement risk since he/she was wheelchair dependent, did not have exit seeking and/or wandering behavior. The ADON and DON were asked about the facility policy on re-assessment of residents for elopement risk. The ADON stated that it is only done on admission and re-admission unless a resident exhibits exit seeking behavior. The DON further stated, based on the transfer form (NJUTF) we should have made Resident #1 "a wander risk" at least until we observed that he/she was not "an elopement risk." The Administrator stated "We are re-doing the Elopement Risk Assessment Form" and we will be doing them quarterly on all residents. The Administrator stated "We started them last week after this incident." The surveyor asked the the DON why there was approximately a 4 hour delay in searching for a missing resident. The DON replied that LPN #1 was suspended pending the investigation and was given education regarding notification of supervisors if a resident is not noticed within a reasonable period of time. A review of a Warning Notice for LPN #1, dated 6/17/14 revealed LPN #1 "failed to notify supervisor" that Resident #1 was missing. LPN #1 was suspended pending the investigation. LPN #1 was "educated on the importance of notifying supervisor and following elopement policy." A review of a sign in sheet dated 1/28 to 2/1/13, reflected that LPN #1 had received prior education on Fire Safety and Disaster Preparedness/Code Gray procedures that included but not limited to resident elopement. On 6/23/14 at 5:27 p.m., during an interview with the surveyor, the DON stated that Resident #1's family came to the facility yesterday (6/22/14) to pick up Resident #1's belongings. The family had informed them that the resident had gone to a local hospital under an alias, 2 days after leaving the facility. The emergency room (ER) nurse observed the resident identification bracelet on Resident #1's wrist with the resident's name and address of the facility. The ER nurse then contacted Resident #1's significant other. A review of the facility Wandering/Elopement Policy, revised June 2005 reflected "Once it has been established that a resident is missing from his/her unit and there is reasonable risk that he/she may have left the building, the District Manager or District Nurse will contact the operator, who will be directed to call a Code Gray "E" - emergency, to notify the security staff that a resident is unaccounted for." There was no evidence that the facility implemented their own policy. The Immediate Jeopardy to the resident's health and safety was brought to the attention of the facility administration on 6/23/14 at 3:20 p.m. The immediate jeopardy to Resident #1 began on 6/17/14 at approximately 12:00 p.m. and was corrected on 6/23/14 at 4:58 p.m. based on an acceptable POC which was implemented by the facility. The POC is as follows: 1. Resident #1's family and physician were made aware. 2. The facility notified the Department of Health on 6/19/14. 3. Resident #1 did not return to the facility. 4. Nursing staff and CNA re-education began on 6/17/14 during the 3:00 p.m. to 11:00 p.m. shift on the facility's Wandering/Elopement Policy and will continue until all nursing staff and security/receptionist staff has been re-educated. 5. The lobby area near the doorway was cleared on 6/20/14 of large sofas to ensure a clear unobstructed view of the doorway. 6. All residents will be assessed for elopement risk. 7. Immediate re-education on the Wandering/Elopement Policy for all facility staff was started on 6/23/14. 8. All resident transfer sheets were reviewed for elopement risk. 9. Residents at risk for elopement will be sent out with facility staff to appointments. 10. The policy for Elopement/Wandering was revised and will include elopement assessments to be completed quarterly and upon significant change. 11. A new elopement assessment form was created to be utilized by facility staff. 12. All resident transfer forms will be reviewed to ensure elopement careplan is implemented if needed. 13. All nursing/CNA staff were re-educated beginning 6/23/14 about notifying supervisor immediately about missing resident as well as the general elopement policy. 14. Visitor tags were introduced to security/reception on 6/18/14 to differentiate between residents and visitors. 15. Security staff were re-educated on 6/23/14 to notify the receptionist when they need to leave their post and the receptionist will take the place of the security guard until his/her return. 16. The Administrator ordered a lock system for the front door which will be opened by security/receptionist. 17. The DON or designee will review 5 new admissions monthly for 6 months for accuracy of elopement assessment and transfer form. DON will audit 5 random charts monthly for 6 months to ensure that elopement assessment is complete and accurate and the careplans are complete, and will report findings at the quarterly Quality Assurance (QA) meeting. 18. The Administrator will check front doorway monthly for 6 months to ensure that it is secure and the view of the doorway is clear, and will report findings at the quarterly QA meeting. NJAC 8:39-13.4 (c) 2 (i-vi)

Complaint # NJ 876 Based on interview and record review it was determined the facility failed to notify a family member when a resident's status significantly changed. This deficient practice was observed for 1 of 4 residents reviewed for status change, Resident #15. The resident sustained [REDACTED]. This deficient practice was evidenced by the following: Resident #15 was admitted to the facility in 2006. The resident had [DIAGNOSES REDACTED]. The resident was only able to express needs using nonverbal cues, such as grimacing. According to the most current annual Minimum Data Set (MDS- an assessment tool) dated 1/1/13 Resident #15 was assessed by the facility to need extensive assistance of two staff for all Activities of Daily Living (ADLs). On 1/8/13 at 12:42 p.m. the surveyor interviewed a family member of Resident #15 who stated that she visited the resident on 8/27/12 at 6:00 p.m. and observed that the resident's right leg was swollen and painful. According to the family member, she was not notified by the facility that the resident had an injury. The surveyor reviewed the "Progress Notes" dated 8/27/12 timed 12:17 p.m. which indicated that Resident #15 was noted to have swelling to the right side of the lower extremity and the physician ..."was called, left message , awaiting call back to make aware." At 16:53 the "Progress Notes" indicated that the facility was waiting for the physician to come to the facility, at 18:26 the physician was again called and a voice message was left and the facility was awaiting a call back. The "Progress Notes" timed at 18:51 indicated that Resident #15's family member was visiting and had concerns about the resident's condition. On 1/11/2013 at 11:02 a.m. the surveyor interviewed the Charge Nurse who stated that the family member had not been called because the facility was waiting for a call back from the physician. The Charge Nurse further stated that normally the facility would have called the family. The surveyor reviewed the facility's policy and procedure titled "Change in Resident's Condition or Status" which indicated ...the Nursing Supervisor/ RN/LPN/ Designee will notify the resident's next of kin or representative when: The resident is involved in any accident or incident that results in an injury including injuries of unknown source..." On 1/14/2013 at 1:34 p.m. during surveyor interview with the Director of Nursing she stated that the resident's family should be informed as soon as an injury is found. Refer to F-323 N.J.A.C. 8:39-13.1(c)

Complaint number NJ 876 Based on interview and record review it was determined the facility failed to ensure that a physician's order was obtained prior to initiating a treatment. The unordered treatment resulted in a fracture requiring surgical repair and pain to a resident. This deficient practice was noted in 1, Resident #15, of 26 residents reviewed for care issues and was evidenced by the following: Resident #15 was admitted to the facility in 2006 and had [DIAGNOSES REDACTED]. According to the most current annual Minimum Data Set (MDS- an assessment tool) dated 1/1/13, Resident #15 was assessed by the facility to need extensive assistance of two staff for Activities of Daily Living (ADLs). On 1/8/13 at 12:42 p.m. the surveyor interviewed a family member of Resident #15 who stated that she visited the resident on 8/27/12 at 6:00 p.m. and observed that the resident's right leg was swollen and painful. According to surveyor review of the facility's "SUMMARY OF INVESTIGATION" report, the regularly assigned day shift Certified Nurses Assistant (CNA) applied a leg brace that was brought from home by Resident#15's family member on 8/26/12 to the resident's right leg. On 1/14/13 at approximately 9:30 a.m. the surveyor reviewed the Physician Orders for the month of August 2012. There was no order for the use of a knee brace. Later that day at 9:45 a.m. the surveyor interviewed the Director Of Nurses (DON) who stated "The CNA put the knee brace on the resident without a physician's order." According to surveyor review of the facility's the current policy and procedure titled "Assistive Devices," "A Physician Order is obtained for all assistive devices ..." The "SUMMARY OF INVESTIGATION" further indicated that on 8/27/12 at approximately 12:17 p.m. the assigned CNA observed and reported swelling of Resident #15's "lower extremity" and at approximately 6:51 p.m. an order for [REDACTED]. On 1/9/2013 at 10:36 a.m. the surveyor reviewed the "Progress Notes" dated 8/27/2012 and timed 9:13 p.m. which indicated that Resident #15 was sent out to the local hospital per the family member's request. Surveyor review of a "Progress Note" dated 8/30/12 and timed 11:13 p.m. indicated that Resident #15 was admitted to the hospital with [REDACTED]. Resident #15 had an open reduction and internal fixation, a surgical procedure, to repair the fracture. According to the "SUMMARY OF INVESTIGATION" report, the facility concluded that ..."due to resident's [DIAGNOSES REDACTED]. N.J.A.C. 8:39-27.1(a), 11.2(b)