Every finding on record at Whiting Gardens Rehabilitation and Nursing Center

Complaint #2967432 Based on observation, interviews, review of medical records, and review of other pertinent facility documents, it was determined that the facility failed to accurately assess and provide adequate monitoring and supervision to a moderately cognitively impaired resident (Resident #9) with a known history of confusion, exit-seeking behavior, and threats of elopement, who eloped from the facility on 3/27/2026. The deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident #9). Resident #9, who wore a wanderguard (security bracelet), had history of exit seeking and elopement, and was assessed as a high risk for wandering/elopement, was transferred to another facility on 2/3/2026, secondary to an emergency evacuation. Upon re-admission to the facility, the facility assessed Resident #9 with no risk for elopement and discontinued the resident's wanderguard on 3/19/2026. On 3/27/2026 at 8:45 PM, the Licensed Practical Nurse (LPN #1) went to administer Resident #9 their medication, but they could not be located. The resident was last seen at 7:30 PM, returning their meal tray to the nursing station. Upon investigation, it was determined that the resident used the door code to exit through a door to the courtyard where they used a metal outdoor chair to scale a six-foot fence. LPN #1 had taken their car to search for the resident in the dark, and found the resident at 9:53 PM, standing on the property of an adjacent assisted living facility that was located through the woods from the long-term care facility. The resident was assessed and transferred to the emergency room (ER) for evaluation. Interview with Resident #9 on 7/1/2026, confirmed that they had climbed over the fence using a patio chair because they had wanted to go to the store to get cigars. The facility's failure to accurately assess and provide adequate supervision to a cognitively impaired resident who was a risk for elopement and eloped, placed Resident #9 as well as other residents, at risk for elopement. This posed a likelihood of serious harm, injury, impairment, or death and resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 3/27/2026 at 7:30 PM, after Resident #9 was last seen by staff in the facility. The facility Administration was notified of the IJ on 7/6/2026 at 3:27 PM. The facility submitted an acceptable Removal Plan (RP) on 7/7/2026 at 3:53 PM. The survey team verified the implementation of the RP during the continuation of the onsite survey on 7/8/2026. The evidence was as follows: A review of the facility's policy titled Elopement Prevention & Response, dated 2/4/2026, included the Purpose: To identify residents at risk for elopement, implement preventive interventions, and outline a clear response process to protect resident safety.residents may be at increased risk of elopement if they have the following: cognitive impairment, dementia, or confusion; history of wandering or elopement; poor safety awareness or impaired judgement; and behavioral symptoms such as restlessness or exit-seeking behavior. A review of the Facility Reportable Event (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 3/27/2026, included an Investigation Summary and Conclusion (ISC) with a date of incident of 3/27/2026. The ISC indicated that Resident #9 was assessed as moderately cognitively impaired but was not found to be an elopement risk based on their admission assessment on 3/19/2026. On 3/27/2026 at 8:45 PM, the resident was not in their room. Staff reported last seeing the resident at 7:30 PM. On 3/27/2026 at 9:00 PM, the resident was unable to be located throughout the facility, and at 9:30 PM, LPN #1 got in a vehicle to search the area surrounding the facility. On 3/27/2026 at 9:53 PM, Resident #9 was found standing on the assisted living facility property that was located through the woods from the long-term care facility in which they resided. The resident was returned to the facility and sent to the hospital for evaluation. The resident was discharged from the hospital and returned to the facility the next day with no issues identified and no new orders. Further review of the FRE revealed under Investigation Resident #9's account of what happened. Resident #9 exited the locked door from the unit to the courtyard area by entering a numerical code that they obtained by watching staff and others enter the code on the unit in which they resided. Resident #9 had remembered the numerical code. Resident #9 stated that they wanted to go to their [family member's] house. When the resident exited the unit and entered the courtyard, they took a chair and climbed over the locked six-foot fence. The facility review of the camera footage confirmed Resident #9's version of events. The surveyor reviewed Resident #9's electronic medical record (EMR). A review of the admission Record face sheet (an admission summary) revealed Resident #9 was admitted to the facility with diagnoses that included but were not limited to; dementia, Parkinson's disease without dyskinesia (a progressive disorder of the nervous system without involuntary movements), and psychosis (a collection of symptoms indicating a person has lost touch with reality). A review of the Elopement/Wandering Risk Assessment dated effective 9/29/2025, revealed that the resident had scored an eleven, and was classified as a high risk for wandering. There was no additional Elopement/Wandering Risk Assessment completed for Resident #9 upon their return to the facility. A Nursing Note dated 9/29/2025 at 8:29 AM, indicated that the Psychiatric Nurse Practitioner (Psych NP) saw the resident today due to episode of lingering in lobby and the resident exited with a group of visitors but was kept in line of sight the entire time and was not an elopement. The resident is fixated on cigars, has short term memory loss, and asks the same questions. The resident's short term memory impairment and poor insight was significant. Per the Psych NP's consult, the resident was not realistic about their condition and stated that they could leave and take care of themselves. The resident can only ambulate a few feet unassisted and has tremors related to their Parkinson's disease. The resident stated that they would not leave again, but stated they wanted their cigars and was going to get them. A wanderguard was placed on the resident's left ankle with placement to be checked every shift. A review of the Psychiatric Consultation dated 1/8/2026, indicated that the reasons for the consult was the resident's exit-seeking and verbally aggressive behavior. The consultation also revealed that the resident stated that they wanted to leave the facility and had made attempts several times. Individual Psychotherapy Progress Notes dated 1/20/2026 and 1/29/2026, both included that the resident expressed wanting to leave that facility. A Social Service note dated 2/3/2026 at 10:26 AM, indicated that the Social Worker called the resident's first emergency contact who did not pick up, so they called the second emergency contact. The Social Worker notified them that resident is being transferred today to another facility [name redacted]. Explained to [them] the reason why and that the expectation is for the placement to be temporary. A Nursing Note dated 3/19/2026 at 8:06 PM, indicated that the resident returned to the facility via a wheelchair. There resident's vital signs were stable and the resident had no complaints. A review of the Nursing admission Assessment dated effective 3/19/2026, included Section N. Elopement, and completed by LPN #3, indicated that if yes is answered for any the above risk factors, a careplace MUST be developed to prevent elopement. LPN #3 assessed the resident as no to all questions including no history of actual or attempted elopement from home or another facility. LPN #3 also indicated no for the resident repetitively expressing a desire to leave, tendency to wander, and confused and able to ambulate or wheel self independently. This assessment contradicted the resident's past history at the facility. A Social Service note dated 3/20/2026 at 9:47 AM, revealed that the resident returned to the facility from [facility name redacted] and the resident stated they were happy to be back and felt like they never left. The resident enjoyed going out to smoke cigars and hangout with their peers and staff. The resident was not able to be discharged to the community at this time due to not being safe to live alone. A review of the History and Physical dated 3/20/2026 at 10:41 AM, indicated that the resident was a long term resident at the facility that had returned from a transfer from [facility name redacted]. A Nursing Note dated 3/22/2026 at 2:37 PM, that the resident had been adjusting well to the unit and navigated well in their wheelchair. The resident was being monitored for safety throughout the shift. A Nursing Note dated 3/23/2026 at 3:03 PM, that the resident had been self-propelling in a wheelchair around the unit and attended activities. A Nursing Note dated 3/23/2026 at 10:23 PM, reflected that the resident was noted to have periods of forgetfulness. A review of the admission Minimum Data Set (MDS), an assessment tool dated 3/27/2026, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated the resident had moderate cognitive impairment. Section GG of the MDS indicated that Resident #9 had no functional limitation on all extremities and was able to transfer and walk 10 feet with supervision. The section also indicated that the resident was capable of wheeling with two turns up to 50 feet on wheelchair independently and that Resident #9 was also capable of wheeling self in wheelchair up to 150 feet independently. A review of Section P titled Alarms, revealed the resident had no wander device used daily. A Nursing Note dated 3/28/2026 at 7:46 PM, authored by the Assistant Director of Nursing (ADON), and indicated the note was a late entry for 3/27/2026. The ADON wrote that they were notified by the supervisor that the resident was located by a nurse outside adjacent to the property at 9:53 PM. There were no apparent injuries and the resident was sent to the ER for physical evaluation. The resident returned to the facility with a wanderguard. A Nursing Note dated 3/28/2026 at 2:22 PM, that the resident returned from [hospital] with wanderguard placed on their right ankle. The resident was awake, alert, and forgetful. A review of the February and March 2026 Treatment Administration Records (TAR), included a physician's order (PO) dated 9/29/2025, and discontinued 3/19/2026, for a wander guard to left ankle; to check placement every shift. A review of the Individualized Comprehensive Care Plan (ICCP) did not include an active focus area for the resident's risk of elopement due to exit-seeking behavior, attempts to leave the facility, repeated expressed desire to leave the facility, and confusion prior to the resident's elopement on 3/27/2026. A further review of the ICCP revealed a cancelled care plan with a focus for an increased risk of exit-seeking behavior and elopement with a date initiated of 7/23/2024. Interventions initiated on 9/29/2025, included monitor the resident in the lobby area. The interventions also documented that the resident had exit-seeking behavior into the parking lot (sic) to seek out selected staff to ask for cigars and included the use of a wander device placed to the resident's left ankle and to check the placement every shift. On 7/1/2026 at 11:06 AM, the surveyor observed Resident #9 self-propelling in a wheelchair to and from the bathroom. The resident had a wanderguard secured on their left ankle. The surveyor inquired about the incident when they had climbed over the fence in the courtyard, and Resident #9 stated that they had went over the fence using one chair because they had wanted to get cigars. Resident #9 stated that when they were at the store, a lady pulled up and told me I have to get back to [the] facility. The resident denied remembering the numerical code they used to get out of the unit. On 7/2/2026 at 10:20 AM, the surveyor requested from the Director of Nursing (DON) Resident #9's discharge records from [facility name redacted] where the resident was transferred back to the facility on 3/19/2026. On 7/2/2026 at 11:17 AM, the surveyor asked the ADON for the resident's discharge records from the facility where the resident was transferred from on 3/19/2026, and the ADON stated that the facility only received a verbal report via telephone from [facility name redacted]. On 7/2/2026 at 1:11 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and DON. The LNHA confirmed there was no transfer paperwork from [facility name redacted] where Resident #9 was transferred back from. At that time, the DON stated that the facility obtained the resident's physician's orders from the discharge summary. The surveyor requested a copy of the discharge summary, and no summary was provided during the survey. On 7/6/2026 at 8:15 AM, the surveyor requested from the LNHA the video footage of the incident on 3/27/2026, and he stated that they did not save the video footage of the incident. On 7/6/2026 at 8:36 AM, the surveyor interviewed the DON and ADON. The DON stated that Resident #9 used a code that the resident obtained by watching staff enter it, to exit a locked door to the courtyard where the resident smoked. The DON continued that the resident used their wheelchair to ambulate, and the resident's mobility seemed better than they thought. The resident transferred themself to another chair that they used to climb the fence. The ADON then stated that he had watched the video and the resident who was screened as unable to walk, was able to stand, move a metal outdoor chair, and used it to climb a six-foot fence. The ADON stated the resident climbed the fence and landed on their two feet on the other side. The ADON stated that when they had found the resident, the resident had reported to him that they saw the lights on at the assisted living facility and thought it was a store where they could buy cigars. The ADON reported that was where LPN #1 had found the resident. During that interview, the surveyor had asked the DON and ADON three times if the resident had ever worn a wanderguard at the facility prior to this elopement, and they both denied it all three times. At that time, the surveyor informed them that the resident had a PO for a wanderguard that was discontinued on 3/19/2026, upon transfer back to the facility. On 7/6/2026 at 8:50 AM, the surveyor asked both the DON and the ADON whether the LPNs could assess the residents upon admission to the facility, and they both answered yes. The ADON further stated that they (DON and ADON) looked at the assessments along with the charge nurse. When the surveyor asked for any documentation that they had reviewed the resident's elopement screening, the ADON stated he could not say where it was documented. On 7/6/2026 at 11:23 AM, the surveyor reinterviewed the ADON, who stated that prior to Resident #9 being transferred to the facility, they wore a wanderguard. The ADON continued that the facility treated the resident's return to the facility as a new admission and not a re-admission, and the resident had a decreased ability to ambulate upon return. The ADON stated that the resident had returned to a different unit since that was the only available bed, and that unit did not have access to the front door. The ADON stated that they could only guess that the resident observed staff punching the code. The ADON acknowledged that the facility was previously cited for a recent elopement, and that their plan of correction put in place including locked door codes had failed. On 7/6/2026 at 11:45 AM, 11:55 AM, and at 12:06 PM, the surveyor attempted to interview LPN #1, who was Resident #9's primary nurse. LPN #1 did not answer or return the surveyor's calls. On 7/6/2026 at 11:51 AM and at 11:54 AM, the surveyor attempted to conduct a telephone interview with the Certified Nursing Aide (CNA #1), who cared for Resident #9 at the time of the elopement. CNA #1 did not answer or return the surveyor's calls. On 7/6/2026 at 2:59 PM and on 7/7/2026 at 12:05 PM, the surveyor attempted to conduct a telephone interview with LPN #3, who completed Resident #9's admission assessment on 3/19/2026. LPN #3 did not answer or return the surveyor's calls. On 7/7/2026 at 8:51 AM, during an interview with the surveyor, the Charge Nurse (CN) stated that the supervisors completed the admission assessments when the primary nurses were administering medications to the residents. The surveyor asked the CN whether the supervisors were all RNs, and the CN stated that there were supervisors who were LPNs. On 7/7/2026 at 10:36 AM, during an interview with the surveyor, LPN/UM #2 stated that when the nurse was doing medication pass, the supervisors completed the admission assessments. LPN/UM #2 stated that they initiated care plans which the MDS Coordinator reviewed. On 7/7/2026 at 10:46 AM, the surveyor interviewed CNA #2, who stated that Resident #9 could both walk and propel themself in the wheelchair. An acceptable Removal Plan (RP) was received on 7/7/2026 at 3:53 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the immediacy including; on 3/27/2026 at 9:53 PM, Resident #9 was located, assessed, transferred to the ER, and returned to the facility. On 3/28/2026, Resident #9 received a wanderguard, had a nursing assessment, a follow-up with the physician and Social Worker for emotional support, and the care plan was updated with interventions including increased monitoring for safety. On 7/6/2026, a wandering/risk assessment was completed for the resident accurately reflecting the resident's history of exit-seeking behavior. The DON initiated a review of residents with a history of elopements and exit seeking behaviors and risk assessments and care plans were updated as needed. Photos and face sheets of residents at risk for elopement were placed at nursing stations and the reception area, and education was provided to Licensed Nurses on elopement assessing upon admission. On 7/7/2026, the facility's elopement prevention and response policy was updated and all staff were educated. Privacy protectors were placed on exit door keypads and staff were educated on being discreet with door codes and changing the code if it was compromised. The survey team verified the implementation of the Removal Plan on-site and determined the immediacy was removed as of 7/8/26 at 10:40 AM. NJAC 8:39-27.1

Complaint #2967432 Based on interviews, review of medical records and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure himself as well as staff a.) implemented policies and procedures to ensure residents were provided adequate supervision to prevent elopement; b.) implement corrective actions to prevent elopement after previously cited; and c.) ensure appropriate licensed staff conducted accurate assessments. This deficient practice had the potential to affect all residents and was evidenced by the following: Refer to F 658 and F 689 A review of the undated facility Job Description Administrator revealed the following:The primary purpose of the Administrator position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to the residents at all times. As the Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and responsibilities included but were not limited to; plan, develop, organize, implement, evaluate and direct programs and activities. Review policies and procedures that govern the operation of the facility. Meet with department directors to discuss use of departmental policies and procedures and establish rapport in and among departments so that each can realize the importance of teamwork. Interpret the facility's policies and procedures to employees, residents, family members, visitors, government agencies, etc., as necessary. Review the facility's policies and procedures periodically, at least annually, and make changes as necessary to ensure continued compliance with current regulations. Review and develop a plan of correction for deficiencies noted during survey inspection. Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed. Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility. Miscellaneous: assure that all residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents. Assure that each resident receives the necessary nursing, medical and physical functional status, as defined by the comprehensive assessment and care plan. Assist the Quality Assurance Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Assure compliance related policies and procedures are followed and the facility remains compliant with all federal, state and local laws, and serve as the facility's Corporate Compliance liaison for compliance issues to the Compliance Officer. A review of the facility's policy titled Elopement Prevention & Response, dated 2/4/2026, included the Purpose: To identify residents at risk for elopement, implement preventive interventions, and outline a clear response process to protect resident safety.residents may be at increased risk of elopement if they have the following: cognitive impairment, dementia, or confusion; history of wandering or elopement; poor safety awareness or impaired judgement; and behavioral symptoms such as restlessness or exit-seeking behavior. A review of the Statement of Deficiencies (SOD) from a survey conducted by the New Jersey Department of Health (NJDOH) on 2/5/2026, revealed that the facility was cited for failing to provide adequate supervision to a resident with a known history of wandering and wore a wanderguard (security bracelet), who eloped from the facility on 2/1/2026. The resident eloped from the [NAME] Unit which was a secured unit and required a code to be entered to unlock the doors. The facility submitted a Plan of Corrections (POC) alleging the corrective actions put in place to ensure adequate supervision and safety devices to all residents at risk for elopement, care plans for residents at risk are reviewed, and education on the [NAME] Unit Locked Door Memo was provided to staff. The facility alleged compliance on 2/18/2026. A review of the Facility Reportable Event (FRE) submitted by the facility to the NJDOH on 3/27/2026, included an Investigation Summary and Conclusion (ISC) with a date of incident of 3/27/2026. The ISC indicated that Resident #9 was assessed as moderately cognitively impaired but was not found to be an elopement risk based on their admission assessment on 3/19/2026. On 3/27/2026 at 8:45 PM, the resident was not in their room. Staff reported last seeing the resident at 7:30 PM. On 3/27/2026 at 9:00 PM, the resident was unable to be located throughout the facility, and at 9:30 PM, the Licensed Practical Nurse (LPN #1) got in a vehicle to search the area surrounding the facility. On 3/27/2026 at 9:53 PM, Resident #9 was found standing on the assisted living facility property that was located through the woods from the long-term care facility in which they resided. The resident was returned to the facility and sent to the hospital for evaluation. The resident was discharged from the hospital and returned to the facility the same evening with no issues identified and no new orders. Further review of the FRE revealed under Investigation Resident #9's account of what happened. Resident #9 exited the locked door from the [West Unit] to the courtyard area by entering a numerical code that they obtained by watching staff and others enter the code on the unit in which they resided. Resident #9 had remembered the numerical code. Resident #9 stated that they wanted to go to their [family member's] house. When the resident exited the unit and entered the courtyard, they took a chair and climbed over the locked six-foot fence. The facility review of the camera footage confirmed Resident #9's version of events. A review of Resident #9's medical record revealed that on 9/29/2025, the resident was assessed as a high risk for wandering and elopement and was ordered a wanderguard placed on their left ankle after being evaluated by the Psychiatric Nurse Practitioner (Psych NP) for lingering in the facility lobby and exiting with a group of visitors. It was documented multiple times that the resident expressed wanting to leave the facility. On 2/3/2026, the resident was transferred temporarily to [facility name redacted] due to an emergency evacuation. The resident was re-admitted to the facility on [DATE], was assessed by an LPN for no risk of wandering/elopement despite the contradicting assessment and documentation in the resident's medical record, and the resident's wanderguard was discontinued. On 7/2/2026 at 11:17 AM, the surveyor asked the Assistant Director of Nursing (ADON) for the resident's discharge records from the facility where the resident was transferred from on 3/19/2026, and the ADON stated that the facility only received a verbal report via telephone from [facility name redacted]. On 7/2/2026 at 1:11 PM, the surveyor interviewed the LNHA and Director of Nursing (DON). The LNHA confirmed there was no transfer paperwork from [facility name redacted] where Resident #9 was transferred back from. At that time, the DON stated that the facility obtained the resident's physician's orders from the discharge summary. The surveyor requested a copy of the discharge summary, and no summary was provided during the survey. On 7/6/2026 at 8:15 AM, the surveyor requested from the LNHA the video footage of the incident on 3/27/2026, and he stated that they did not save the video footage of the incident. On 7/6/2026 at 8:50 AM, the surveyor asked both the DON and the ADON whether the LPNs could assess the residents upon admission to the facility, and they both answered yes. The ADON further stated that they (DON and ADON) looked at the assessments along with the charge nurse. When the surveyor asked for any documentation that they had reviewed the resident's elopement screening, the ADON stated he could not say where it was documented. On 7/6/2026 at 11:23 AM, the surveyor reinterviewed the ADON, who stated that prior to Resident #9 being transferred to the facility, they wore a wanderguard. The ADON continued that the facility treated the resident's return to the facility as a new admission and not a re-admission, and the resident had a decreased ability to ambulate upon return. The ADON stated that the resident had returned to a different unit since that was the only available bed, and that unit did not have access to the front door. The ADON stated that they could only guess that the resident observed staff punching the code. The ADON acknowledged that the facility was previously cited for a recent elopement, and that their plan of correction put in place including locked door codes had failed. On 7/7/2026 at 8:51 AM, during an interview with the surveyor, the Charge Nurse (CN) stated that the supervisors completed the admission assessments when the primary nurses were administering medications to the residents. The surveyor asked the CN whether the supervisors were all Registered Nurses (RNs), and the CN stated that there were supervisors who were LPNs. On 7/7/2026 at 10:36 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM #2) stated that when the nurse was doing medication pass, the supervisors completed the admission assessments. LPN/UM #2 stated that they initiated care plans which the Minimum Data Set (MDS) Coordinator reviewed. A review of the undated facility document titled Job Description - Registered Nurse, included under Departmental Duties the following: interviews and assesses new admissions and initiates new admissions care plans. A review of the undated facility document titled Job Description - Licensed Practical Nurse did not include any duty or responsibility to do admission assessments and initiation of care plans. NJAC 8:39-9.2(a)NJAC 8:39-9.3(a)NJAC 8:39-27.1(a)

Based on observation, interviews, review of medical records and review of other facility documents, it was determined that the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being of residents by ensuring accurate elopement assessment completed by a Registered Nurse (RN) of a moderately cognitively impaired resident (Resident #9) with a known history of confusion, exit-seeking behavior, and threats of elopement which resulted in the resident eloping on 3/27/2026, in accordance with professional standards of practice. This deficient practice was identified for 1 of 3 residents (Resident #9) reviewed for elopement.The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 7/1/2026 at 11:06 AM, the surveyor observed Resident #9 wheeling themselves independently to and from the bathroom. They had a wandering device secured on the left ankle. When Resident #9 had finished using the bathroom, the surveyor inquired about the incident when he/she had climbed over the fence in the courtyard. Resident #9 stated that he/she wanted to get cigars. Resident #9 could not remember the numerical code they used to get out of the unit when asked by the surveyor.The surveyor reviewed Resident #9's electronic medical record (EMR).A review of the admission Record revealed Resident #9 was admitted to the facility with diagnoses that included but were not limited to; dementia, Parkinson's disease without dyskinesia (a progressive disorder of the nervous system without involuntary movements), and psychosis (a collection of symptoms indicating a person has lost touch with reality).A review of the admission Minimum Data Set MDS), an assessment tool, dated 3/27/2026, revealed Resident #9 had a Brief Interview for Mental Status score (BIMS) of 9 out of 15, meaning Resident #9 had moderate cognitive impairment. Section GG of the MDS indicated that Resident #9 had no functional limitation on all extremities and was able to transfer and walk 10 feet with supervision. The section also indicated that the resident was capable of wheeling with 2 turns up to 50 feet on wheelchair independently and that Resident #9 was also capable of wheeling self in wheelchair up to 150 feet independently. A review of Section P titled Alarms, revealed the resident had no wander device used daily.A review of the Order Summary Report with orders active as of 3/19/2026, revealed a physician order (PO) for a wander management device [name redacted] to the left ankle started on 9/29/2025. The order was discontinued on 3/19/2026, upon readmission to the facility.A review of the Individualized Comprehensive Care Plan (ICCP) did not include a Focus with interventions for Resident #9's risk of elopement due to exit-seeking behavior, attempts to leave the facility, repeated expressed desire to leave the facility, and confusion prior to the resident's elopement on 3/27/2026.Further review of the ICCP revealed a cancelled care plan with a Focus for an increased risk of exit-seeking behavior and elopement with a date initiated of 7/23/2024. Interventions initiated on 9/29/2025, included monitor the resident in the lobby area. The interventions also documented that the resident had exit-seeking behavior into the parking lot (sic) to seek out selected staff to ask for cigars and included the use of a wander device placed to the resident's left ankle and to check the placement every shift.A review of the Progress Notes (PN) dated 9/29/2025 entered at 8:27 PM by Licensed Practical Nurse (LPN #2), revealed that Resident #9 was seen by the psychiatry nurse practitioner after an incident when Resident #9 lingered in the lobby and exited the facility with a group of visitors but was kept in line of sight of staff. The note also documented that the resident was fixed on cigars and had significant short term memory loss and poor insight. Resident #9 was given an order for a wander device to be placed on the left ankle and placement to be checked every shift started on 9/29/2025.A PN by the social worker dated 2/3/2026 and entered at 8:28 PM, indicated that Resident #9 was transferred to another facility [name of facility redacted] due to an emergency evacuation of the facility.A PN by Nursing Supervisor/ Licensed Practical Nurse (NS/LPN #3) dated 3/19/2026 and entered at 8:07 PM, indicated that Resident #9 was readmitted back to the facility on 3/19/2027.A review of the Elopement/ Wandering Risk assessment dated [DATE] entered at an unspecified time by LPN #2, indicated that Resident #9 was forgetful with early dementia. The assessment also specified that Resident #9 was a known wanderer and had history of wandering.A review of the psychiatry consultation with the psychiatry nurse practitioner dated 1/8/2026, indicated that the reasons for the consult were the resident's exit-seeking and verbally aggressive behavior. The consultation also revealed that the resident stated that he/she wanted to leave the facility and had made attempts several times.A review of the Nursing admission assessment dated [DATE], (Resident #9's readmission to the facility) and signed by NS/LPN #3 at an unspecified time, reflected an elopement risk assessment completed that did not indicate any risk for elopement. The assessment specified that the resident had no history of actual or attempted elopement from home or another facility, that the resident did not repeatedly express a desire to leave. The assessment further revealed that Resident #9 had no tendency to wander, and that he/she was not confused and he/ she was not able to ambulate or wheel self independently.A review of the Facility Reportable Event (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 3/27/2026, included an Investigation Summary and Conclusion (ISC) with date of incident of 3/27/2026. The ISC indicated that Resident #9 was assessed as moderately cognitively impaired but was not found to be an elopement risk based on their admission assessment on 3/19/2026. On 3/27/2026 at 8:45 PM, the resident was not in their room. Staff reported last seeing the resident at 7:30 PM. At 9:00 AM, on the same night, the resident was unable to be located throughout the facility. At 9:30 PM, Licensed Practical Nurse (LPN #1) got in a vehicle to search the area surrounding the facility. At 9:53 PM, Resident #9 was standing on the assisted living facility property that was located through the woods from the long-term care facility in which he/she resided. The resident was returned to the facility and sent to the hospital for evaluation. The resident was returned to the facility the same evening with no issues identified and no new orders.Further review of the FRE revealed under Investigation Resident #9's account of what happened. Resident #9 exited the locked door from the unit to the courtyard area by entering a numerical code that he/she obtained by watching staff and others enter the code on the unit in which they resided. Resident #9 had remembered the numerical code. Resident #9 stated that he/she wanted to go to their sister's house. When the resident exited the unit and entered the courtyard, they took a chair and climbed over the locked 6-foot fence. The facility review of the camera footage confirmed Resident #9's version of events.On 7/2/2026 at 10:20 AM, the surveyor asked the facility Director of Nursing (DON) for Resident #9's discharge records from [name of facility redacted] where the resident was transferred from on 3/19/2026.On 7/2/2026 at 11:17 AM, the surveyor asked the Assistant Director of Nursing (ADON) for the resident's discharge records from the facility where the resident was transferred from on 3/19/2026. The ADON stated that they got reports from the facility by telephone.On 7/2/2026 at 1:11 PM, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that there was no paperwork from the facility where Resident #9 was transferred from.On 7/2/2026 at 1:11, the DON informed the surveyor that the facility got orders from [name of facility redacted] the discharge summary. The surveyor asked for the discharge summary. No discharge summary was provided to the surveyor.On 7/6/2026 at 8:15 AM, the surveyor requested for the video footage of the resident's elopement on 3/27/2026 from the LNHA. The LNHA stated that they did not save the video footage of the incident on 3/27/2026.On 7/6/2026 at 8:36 AM, during an interview with the surveyor, the DON stated that Resident #9 exited the unit through a locked and coded door to the courtyard where resident #9 smoked using their wheelchair to ambulate. The DON also stated that the resident's mobility seemed better than they thought.On 7/6/2026 at 8:43 AM, during an interview with the surveyor, the ADON stated that they watched the video footage of the incident, but it was not saved. The ADON stated that from the footage, Resident #9 was seen landing on their feet. The ADON stated that Resident #9 was not wearing a wander device at the time of the incident. The ADON stated that they were not sure if Resident #9 had ever worn a wander device. The ADON denied that law enforcement was called during the incident. On 7/6/2026 at 8:46 AM, during an interview with the surveyor, the surveyor asked both the DON and the ADON three (3) times if Resident #9 had ever worn a wander device in the past. Both the DON and the ADON replied no three (3) times.On 7/6/2026 at 8:50 AM, the surveyor asked both the DON and the ADON whether the LPNs can assess the residents upon admission to the facility. The DON and ADON answered that the LPNs can assess the residents. The ADON further stated that they (DON and ADON) look at the assessments along with the charge nurse. When the surveyor asked for any documentation that the DON and ADON, along with the charge nurse looked at the assessments of the LPNs, the ADON answered they could not say where it was documented. The ADON stated that the RNs do not sign off the assessments they look at. The surveyor also asked the DON and the ADON whether the LPNs can initiate care plans. The DON stated that the LPNs can initiate the care plans, along with the MDS Coordinator (MDSC). The surveyor asked the DON whether the MDSC was an LPN or RN. The DON answered, LPN but they had an RN overseeing the MDS.On 7/6/2026 at 9:08 AM, during an interview with the surveyor, the Director of Maintenance (DOM) stated that they test the exit doors with the capability of responding to wander devices weekly. The DOM provided the surveyor test logs for exit doors.On 7/6/2026 at 9:13 AM, during an interview with the surveyor, Licensed Practical Nurse/ Unit Manager (LPN/ UM#1) stated that RNs and LPNs can assess newly admitted residents. The unit manager stated that RNs checked their work. LPN/UM#1 further stated that they initiated care plans which were checked by the MDSC. LPN/ UM #1 stated that the MDSC was also an LPN.On 7/6/2026 at 9:19 AM, during an interview with the surveyor, LPN #4 stated that they did admission assessments for long-term care residents. LPN #4 also stated that rehabilitation admissions were assessed by RNs. LPN #4 stated that he/she had initiated care plans. The nurse stated that they would have to look when asked to confirm if they had initiated care plans.On 7/6/2026 at 11:45 AM, 11:55 AM, and at 12:06 PM, the surveyor made several attempts to conduct a telephone interview with LPN #1 who was Resident #9's primary nurse and who located the resident from another property at the time of the elopement. Several messages were left. The calls were not returned.On 7/6/2026 at 11:51 AM and at 11:54 AM, the surveyor made attempts to conduct a telephone interview with CNA #1 who cared for Resident #9 at the time of the elopement. A message was left, and the calls were not returned.On 7/6/2026 at 2:59 PM and on 7/7/2026 at 12:05 PM, the surveyor attempted to conduct a telephone interview with LPN #3, who did Resident #9's admission assessment on 3/19/2026. Several messages were left, and the calls were not returned.On 7/7/2026 at 8:51 AM, during an interview with the surveyor, the Charge Nurse (CN) stated that the supervisors do the admission assessments when the primary nurses are administering medications to the residents. The surveyor asked the CN whether the supervisors were all RNs. The CN stated that there were supervisors who are LPNs.On 7/7/2026 at 10:36 AM, during an interview with the surveyor, LPN/ UM #2 stated that when the nurse is doing medication pass, the supervisors do the admission assessments. The unit manager stated that they initiated care plans which the MDSC checked.On 7/7/2026 at 10:46 AM, CNA #2 stated that they were familiar with Resident #9 since the resident was admitted last March 2026. CNA #2 stated that the resident could both walk and wheel themselves in the wheelchair.A review of the facility policy titled Elopement Prevention & Response dated February 4, 2026, included the following under Purpose: To identify residents at risk for elopement, implement preventive interventions, and outline a clear response process to protect resident safety. The policy also indicated that residents may be at increased risk of elopement if they have the following: Cognitive impairment, dementia, or confusion; history of wandering or elopement; poor safety awareness or impaired judgement; and behavioral symptoms such as restlessness or exit-seeking behavior.A review of the undated facility document provided by the DON to the surveyor on 7/2/2026 at 8:30 AM, titled Job Description - Registered Nurse included under Departmental Duties the following; Interviews and assesses new admissions and initiates new admissions care plans.A review of the undated facility document provided by the DON to the surveyor on 7/2/2026 at 8:30 AM, titled Job Description - Licensed Practical Nurse did not include any duty or responsibility to do admission assessments and initiation of care plans. N.J.A.C. 8:39 - 27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure pressure-relieving interventions were in place according to the physician's order. This deficient practice was identified for 1 of 2 residents (Resident #158) reviewed for pressure ulcers/injuries.This deficient practice was evidenced by the following: On 07/01/26 at 9:52 AM, Surveyor #1 observed the resident lying in bed. The resident was not wearing heel lift boots.On 07/02/26 at 11:55AM, Surveyor #1 observed the resident lying in bed. The resident was not observed wearing heel lift boots as ordered. The resident indicated that the boots had not been put on. The electronic medical record (EMR) for Resident #158 was reviewed.A review of the admission Record (AR), an admission summary, revealed diagnoses which included, but were not limited to, muscle weakness, difficulty in walking, presence of other vascular implants and graft, and need for assistance with personal care.A review of the resident's most recent Minimum Data Set (MDS), an assessment tool, dated 06/29/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. The MDS also revealed the resident was at risk for pressure ulcers.A review of the resident's individual comprehensive care plan (ICCP) initiated 06/26/26, included a focus area; potential for an alteration in skin integrity related to incontinence, decreased mobility, and deconditioning. Interventions included pressure ulcer to right heel and left heel, use pillows and wedges for positioning as needed, and follow facility protocols for treatment of injury. A review of the Order Summary Report (OSR) included the following physician orders (PO):A PO dated 06/25/26 Offload heels when in bed every shift for prevention.A PO dated 06/25/26 Heel lift boots while in bed every shift. A review of the Treatment Administration Record (TAR) for July 2026 verified a nurse signed the order for heel lift boots while in bed on both 07/01/26 and 07/02/26 day shift, which indicated the resident was wearing the heel boots.On 07/02/26 at 12:00PM, Surveyor #1 interviewed the Certified Nursing Assistant (CNA#1) who stated the resident was non-ambulatory and was dependent for all aspects of care. CNA#1 further stated the resident did not wear heel boots but did receive treatments to the lower legs and had dressings.On 07/02/26 at 12:04PM, Surveyor #1 interviewed the Licensed Practical Nurse (LPN#1), who stated Resident #158 had wounds to both feet. LPN#1 stated the resident was supposed to wear bilateral heel boots to decrease pressure on the heels. LPN#1 further stated she did sign on the TAR that she applied the heel boots and admitted she did not document that the resident refused the heel boots on the TAR because she was going to go back and offer to reapply them. LPN#1 stated if the resident decided to allow the nurse to apply the heel boots, then she would strike out the documentation in the TAR and document the heel boots were applied. LPN#1 finally stated this was not the normal process for documentation of application of a preventative device. On 07/06/26 at 11:16 AM, Surveyor #2 interviewed the Director of Nursing (DON), who stated the purpose of pressure relieving devices was to help decrease the risk of a wound that is associated with pressure to the skin. The DON further stated the nurse would sign the order within the ordered time frame. The DON stated if a resident refused a treatment, Right then and there you would document they refused and document the attempts and interventions to educate, or why they didn't tolerate it. The DON finally stated, The assumption is that if it was signed off without any disclaimer of being refused with no reason why, the conclusion was that it was done.A review of the facility provided Skin & Pressure Relieving Devices policy revealed: Procedure: 2. Pressure-relieving devices may include but are not limited to .Heel offloading devices or heel protectors .4. Nursing staff will: Ensure devices are properly applied and functioning correctly .Document the use of pressure-relieving devices and any changes in skin condition. NJAC 8:39-27.1(a)(e)

Based on observation and interviews, it was determined that the facility failed to ensure controlled medications were stored within a double lock system. This deficient practice was identified on 1 of 3 units inspected (East Wing), and was evidenced by the following:On 2/10/26 at 10:30 AM, during a tour of the East Wing, the surveyor, accompanied by the Licensed Nursing Home Administrator (LNHA), observed the door to the medication room was propped open with an industrial floor fan. The LNHA stated that a small pipe broke yesterday in the medication room which flooded the area, and the area was being dried. Upon further observation, with the Licensed Practical Nurse (LPN), the surveyor observed that the medication refrigerator was not locked. The LPN opened the refrigerator, and a locked box was noted. The LPN opened the locked box to reveal two boxes each containing a 30 milliliter (mL) bottle of liquid Lorazepam (a Schedule 4 controlled substance used to treat anxiety). Upon further investigation, one bottle was sealed, and the other one had one dose of 0.5 mL removed. The LPN was asked how the Lorazepam should be stored, and she stated that usually the medication room door was closed (locked) and acknowledged that the door was not locked now, and it should be. The LPN further stated that if the door had to be propped open, the medications should have been moved to another unit's locked box. On 2/10/25, the surveyor interviewed the Director of Nursing (DON), who was aware of the East Wing's medication room's door being propped open and the DON stated that it was important for controlled substances to be double locked as required by regulation. On 2/10/26 at 2:15 PM, the surveyor met with the LNHA, and no further information was provided by the facility. NJAC 8:39- 29.7(c)

Complaint # 2731929 Based on observation, interviews, review of medical records, and review of other pertinent facility documents, it was determined that the facility failed to provide adequate supervision to a moderately cognitively impaired resident (Resident #1) with a known history of wandering and wore a wanderguard (security bracelet), who eloped from the facility on 2/1/26. The deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident #1). Interviews on 2/4/26, revealed on 2/1/26 between 4:20 and 5:00 PM, the Licensed Practical Nurse (LPN #1) observed Resident #1 dressed in a winter coat and hat on [a unit the resident did not reside on] pushing a wheelchair that was holding a bag of personal belongings. Resident #1 informed LPN #1 that they were visiting their sister and were bringing home their sister's laundry to wash and could not find the front door exit. LPN #1 stated that they brought Resident #1 to the front lobby and entered the code into the keypad, and Resident #1 exited the facility. On 2/1/26 at approximately 6:00 PM, Resident #1's Representative (RR #1) called the facility to inform them Resident #1 had left the facility and RR #1 was contacted by RR #2, who was Resident #1's roommate in the community, and told them that Resident #1 was at their home. RR #1 called the police and emergency medical services (EMS), but Resident #1 refused to go to the emergency room (ER) and was brought back to the facility on 2/1/26 at 8:30 PM, by RR #2. The facility's failure to provide adequate supervision to a cognitively impaired resident who was at risk for elopement and eloped, placed Resident #1 as well as all residents, at risk for elopement. This posed a likelihood of serious harm, injury, impairment, or death and resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 2/1/26 at approximately 4:20 PM, after Resident #1 was last seen by staff in the facility. The facility Administration was notified of the IJ on 2/4/26 at 5:13 PM. The facility submitted an acceptable Removal Plan (RP) on 2/5/26 at 2:00 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 2/5/26. The evidence was as follows: A review of the facility's undated Elopements policy, indicated that the staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or the Director of Nursing. A review of the Exit Seeking incident report dated 2/1/26, indicated at approximately 6:40 PM, the Nursing Supervisor (NS #1) informed the Director of Nursing (DON) that the Receptionist on duty received a phone call from RR #1, that Resident #1 was at a local private home. Local police went to the residence and located Resident #1 and informed the facility the resident was uninjured and safe. Resident #1 declined emergency medical services (EMS), and the resident's emergency contact [RR #2] transported the resident back to the facility. It was not until the resident exited the lobby door, the aide stated to reception she was familiar with the individual that she assisted to exit. A further review of the incident report included Resident Description; that the resident approached the [LPN #1] and [the Certified Nursing Aide (CNA #1)] on [a different unit than the resident resided on] at about 6:00 PM, appropriately dressed for winter in a coat and hat. [Resident #1] identified self to staff as a visitor dropping off items. [Resident #1] presented self articulately and asked for assistance with the exit. Staff from [the other unit] offered assistance and [LPN #1] and [CNA #1] punched in the code to the front door. The Receptionist stated he left the desk for a brief moment to perform a task, but observed the area as [Resident #1] exited. The Receptionist explained to staff in interview [Resident #1] got a ride and frequently hitches rides. Resident #1 has experience with telephone apps and has experience with [Ride Share name redacted] to obtain rides to the community. Resident #1 was assisted off the unit by the police department due to the police department were on the unit for another emergency. The surveyor reviewed Resident #1's medical record. A review of the admission Record revealed Resident #1 was admitted to the facility with diagnoses that included but were not limited to; alcohol dependence, hypertension (high blood pressure), dementia, and depression. A review of the admission Minimum Data Set (MDS), an assessment tool dated 12/11/25, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) of 12 out of 15, meaning Resident #1 had moderate cognitive impairment. A review of Section GG titled Functional Status, indicated the resident was able to ambulate independently with little supervision. A review of Section P titled Alarms, revealed the resident had a wander guard used daily. A review of the Individualized Comprehensive Care Plan (ICCP) included a focus area dated 12/8/25, for a risk for elopement related to new admission, verbalization of leaving and packing bags, and non-compliant with keeping wanderguard on. The goals initiated on 12/8/25, with a target date of 3/6/26, include the resident will not leave the facility unattended; the resident's safety will be maintained through the review date; the resident will demonstrate happiness with daily routine. Interventions initiated 12/8/25, included wanderguard on wrist, to check placement every shift; disguise exits: cover door knobs and handles, tape floor; distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; frequently monitor my whereabouts; document wandering behavior; and identify pattern of wandering. A review of the physician's orders (PO) dated 12/7/25, for a wanderguard to the left wrist, and the placement was changed on 12/8/25, to the resident's right wrist. On 1/29/26, the PO was changed to a wanderguard to the left ankle. A review of Resident #1's Elopement Risk Assessment completed on 1/28/26, indicated the resident was disoriented to time and place and did not understand surroundings. The resident had a diagnosis of dementia and was at a moderate risk for wandering. A review of the following Progress Notes included Resident #1 exhibiting wandering behaviors or expressing to leave the facility: A Physician's Progress Note on 1/6/26 at 9:04 AM, that the resident was examined today upon their request. The resident wanted to know when they would be discharged . The resident was forgetful, alert and oriented to self, but not time and place. A Nursing Note dated 1/13/26 at 10:17 PM, that the resident was alert to self with forgetfulness, and continued to question when they would be discharged even after a care meeting was held today.The resident needs reminding and redirection. A Nursing Note dated 1/23/26 at 2:16 PM, the resident was [alert and oriented to person and place] with forgetfulness. The resident was able to make needs known and was continuously asking to go home. The resident was not happy here, and their wanderguard was in place to their right wrist. A Nursing Note dated 1/25/26 at 9:18 PM, that the resident was alert with confusion and forgetfulness. The resident was found self-propelling [in a wheelchair] down the hallway with all their belongings packed and stating I am leaving. I booked an [Ride Share name redacted] and I am going home. This writer provided emotional support and redirection. The resident was verbally combative and using negative language to this writer. [F***] you [NAME]. You can't [f***ing] keep me here. The writer ensured safety of the resident and the situation was de-escalated without incident. The resident agreed to remain in their room for the night, but they verbalized a plan to leave tomorrow. The resident was assisted back to their room and was resting with eyes closed at that time. No further behaviors were noted at that time. A Physician's Progress Note dated 1/27/26 at 10:09 AM, revealed that the resident was examined today for a follow-up. The resident did not remember their recent hospitalization. A Nursing Note dated 1/28/26 at 4:45 PM, that the resident was observed pushing their wheelchair in the hallway. The resident had their clothes and personal material on their wheelchair seat. The resident had their coat on, and they were carrying their [handbag]. The resident was adamant that they wanted to be discharged right now. The staff were able to convince the resident to wait until tomorrow. The staff shared the current outside temperature and suggested the resident wait until tomorrow to plan their discharge. The resident agreed to wait until tomorrow. A Nursing Note dated 1/29/26 at 7:36 AM, indicated the resident had their wanderguard in hand. [The nurse] explained why the [wanderguard] was on, and the resident refused to wear it on their wrist. The resident agreed to have it on their left ankle. Emotional support and [tender love and care] and was effective. A Nursing Note marked Late Entry, dated 2/1/26 at 6:00 PM, for a late entry on 2/1/26 at 6:35 PM, for notification by supervisor that the resident exited the facility to the outside returning to their own residence in the community. There were no physical injuries, and the resident declined evaluation at the ER. The resident was returned to the facility by [RR #2], and [RR #1] and the Nurse Practitioner were notified. On 2/4/26 at 10:02 AM, the surveyor observed Resident #1 lying in bed. The surveyor interviewed Resident #1 regarding the elopement incident, and the resident could not recall the elopement incident. Resident #1 continued to ask the surveyor why the resident was in the facility. On 2/4/26 at 12:45 PM, the surveyor interviewed RR #2, who stated Resident #1 made themself look like a visitor that day. RR #2 continued that Resident #1 had been planning their escape from the facility since they were admitted and had a bag hidden. RR #2 stated that Resident #1 had cut off their wanderguard with a plastic knife and put their belongings on their wheelchair that they pushed out. RR #2 stated when they arrived at their home at approximately 6:00 PM, Resident #1 was there. RR #2 stated the resident must have taken a ride share and had a house key to enter the home. RR #2 stated Resident #1 had left the facility between 4:00 PM and 5:00 PM, that it was on camera that a nurse let them out. RR #2 stated when they saw Resident #1 at home, they immediately called RR #1, who then called the local police, EMS, and the facility. On 2/4/26 at 12:50 PM, the surveyor attempted to conduct a telephone interview with the Agency CNA, who was caring for Resident #1 on the day of the elopement. A message was left, and the call was not returned. On 2/4/26 at 1:15 PM, the surveyor conducted a telephone interview with NS #1, who was on duty at the time of the elopement. NS 31 stated he became aware of the elopement when RR #1 called the facility and said the resident was at home in the community. NS #1 stated that he did not see the resident on the day of the elopement. NS #1 stated that the CNA interacted with the resident between 3:00 PM and 4:00 PM that day. The surveyor asked who was working at the reception desk in the main lobby on the day of elopement and was told the Maintenance Technician (MT) was at the desk that day. On 2/4/26 at 1:40 PM, the surveyor interviewed the Maintenance Technician (MT), who confirmed he was assigned the reception desk on 2/1/26. The MT stated there was a leak on the East Unit and he had to leave to empty a bucket of water. The MT stated he witnessed someone let the resident out of the locked unit, through the [NAME] door, and hallway door. [Resident #1] told the nurse they were visiting their sister and bringing their [sister's] laundry home to wash. The MT stated another nurse on [a different unit] recognized the resident, but at that time the resident was gone. I saw her let [Resident #1] out between 4:30 PM and 5:00 PM. The MT stated RR #1 called the facility at 6:00 PM. The MT stated there were no pictures at the front desk of residents who were at risk for elopement, and he did not hear Resident #1's wanderguard go off. The MT stated someone called the facility at 5:30 PM, and told them there was a person hitch-hiking with a wheelchair, and he did not think anything of it. On 2/4/26 at 1:50 PM, the surveyor interviewed the DON, who stated NS #1 notified her at 6:30 PM, that Resident #1 was home. The DON stated that the resident got out of the front lobby door. The resident was wearing winter clothing, and the resident told LPN #1 they were a visitor visiting at the facility. The DON stated Resident #1 asked where the exit was, and LPN #1 entered the door code for the resident to exit. The DON stated that wandergaurds only went off at the front door, and Resident #1 had cut off their wanderguard. On 2/4/25 at 2:40 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the elopement. The surveyor asked how the resident was able to get out of the secured unit they resided on. The LNHA stated that at the time of the elopement, there was an emergency on Resident #1's nursing unit. The Police Officer, who was on that unit, thought Resident #1 was a visitor and held the door open. The LNHA continued that Resident #1 told staff that they dropped off clothing to their sister. On 2/4/26 at 3:53 PM, the surveyor interviewed LPN #1, who stated on 2/1/26, a [gender redacted (Resident #1)] came up to her and said that they could not find the front door. LPN #1 said [Resident #1] stated they were visiting their sister and brought the sister some things and [Resident #1] could not find the front door. [Resident #1] was pushing a wheelchair. LPN #1 stated she walked [Resident #1] off the nursing unit and let [Resident #1] out the front door. LPN #1 stated she did not know where [Resident #1] went from there. An acceptable Removal Plan (RP) was received on 2/5/26 at 2:00 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the immediacy including; on 2/1/26 at 8:30 PM, Resident #1 returned to the facility, was assessed, and received a physical exam by the NP and Psychological NP on 2/3/26. On 2/4/26, the resident received a tamper resistant wanderguard and was placed on every fifteen-minute checks that changed to one-to-one monitoring on 2/5/26. The Maintenance Director conducted an audit of all exit and egress doors on the [NAME] Wing. On 2/2/26, Resident #1's photo and face sheet was placed at the reception area. On 2/2/26, CNA #1 and on 2/4/26, LPN #1 were educated on everyone must be signed out at reception area before providing assistance. On 2/2/26, the Interdisciplinary Team (IDT) and the Regional DON reviewed the elopement drill process and implemented new policies on visitor sign out and [NAME] Unit locked code door memo. The Assistant Director of Nursing (ADON) and designee conducted training to clinical staff, therapy staff, activity staff, reception staff, and housekeeping staff on elopement and the [NAME] locked code memo. The surveyor verified the implementation of the Removal Plan on-site and determined the immediacy was removed as of 2/5/26 at 2:39 PM. NJAC 8:39-27.1

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure himself as well as staff a.) implemented the facility's emergency preparedness plan including but not limit to; fire watch, availability of keys to first responders, notifying the New Jersey Department of Health (NJDOH) of the sprinkler system not operating or the relocation of residents, and properly tagging residents with identification during relocation; and b.) maintained the facility's fire sprinkler system to ensure all their residents attain their highest practicable physical, mental, and psychosocial well-being. This deficient practice had the potential to affect all residents and was evidenced by the following. Refer F 836A review of the undated Administrator Job Description included; the primary purpose of your position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times. As the Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties . Duties and Responsibilities included but were not limited to; plan, develop, organize, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the Regional Administrator, ensure all employees, residents, visitors, and the general public follow the facility's established policies and procedures, delegate a responsible staff member to act on your behalf when you are absent from the facility. Safety and Sanitation included but were not limited to; ensure that all facility personnel, residents, visitors, etc., follow established safety regulations, to include fire protection and prevention, smoking regulations, infection control, etc.; ensure that the building and grounds are maintained in good repair. A review of the facility's Comprehensive Emergency Preparedness Plan (EPP) dated updated 1/1/2026, included the following: Promulgation Statement by Administrator: I prepared this Emergency Plan which sets forth the general policies and procedures to be carried out in the event of an emergency. Policy Statement.The emergency preparedness plan shall be sent to municipal, county and state emergency management officials. The emergency preparedness planner shall request in writing an annual meeting with county and municipal emergency management coordinators to review the Emergency Preparedness Plan, and to ensure that the procedures of the emergency preparedness plan document are in coordination with the procedures of the county and municipal emergency management coordinators. Procedure: Should a fire or any other emergency occur within our facility or community area, our Emergency Preparedness shall be immediately implemented. Relocation Procedure.The State Department of Health shall be notified.all residents shall be properly tagged for identification. Availability of Keys.Should an emergency occur within our facility, keys to the locked rooms or areas shall be made available to first responders. Fire Watch Form.Fire Watch to include the following activities: 1. Fire watch must be continuously conducted by trained individuals performing no other duties in the affected areas until the impairment no longer exists. On 2/3/26 at 9:00 AM, the surveyor arrived to the facility and observed the Emergency Management Services (EMS) at the facility. At that time, the surveyor interviewed the Director of EMS, who stated last night, 2/2/26 at 10:30 PM, the [NAME] Wing nursing unit lost fire protection. The Director of EMS stated that the fire sprinkler system was not operating on that unit. The Director of EMS continued that at 2:45 AM, the South Wing nursing unit had a pipe burst, and the unit was flooded with contaminated water. The Director of EMS stated that the residents were being evacuated from the South Wing. On 2/3/26 at 9:12 AM, the surveyor interviewed the LNHA, who stated that he did not report the fire sprinkler system not working or the flooding to the NJDOH. The LNHA stated he was unaware that he had to. On 2/3/26 at 9:46 AM, the surveyor interviewed the EMS Coordinator, who stated that last night at 10:30 PM, the sprinkler was leaking on the [NAME] Wing, and the fire protection system was shutdown. The EMS Coordinator continued at 2:30 AM, that morning, the fire sprinkler flooded the South Wing. The EMS Coordinator stated there were 59 residents who resided on the South Wing that were being evacuated with 13 residents being relocated in the facility and 46 were being evacuated to another facility. On 2/3/26 at 10:00 AM, the surveyor observed the Office of Emergency Management (OEM) triaging residents for an evacuation. On 2/3/26 at 11:09 AM, the surveyor interviewed the Fire Marshall, who stated this was the nineth time the Fire Department had been called out to the facility for the sprinkler system since December 2025. On 2/3/26 at 1:24 PM, the surveyor met with the LNHA, Chief EMS Coordinator, and the Fire Marshall. The surveyor asked the LNHA what the facility put in place from their EPP. The LNHA responded that he did not put anything into place, that OEM had taken control and they were doing everything. The surveyor then asked if the facility set up an incident command, and the LNHA replied, no. The surveyor asked who was the facility's scribe, and the LNHA asked what? The surveyor stated the person who was taking down the residents' names as they were evacuated, and the LNHA stated that OEM was taking care of that including a head count. At that time, the Chief EMS Coordinator stated that the first alarm activation took place on 2/2/26 at 10:30 PM, and the fire department responded and found a broken sprinkler pipe in the outside soffit of the [NAME] Wing. The facility contacted the Fire Sprinkler Vendor (SFV) who was on-site prior to the emergency officials leaving. The facility was placed on fire watch. The Chief EMS Coordinator stated that on 2/3/26 at 2:30 AM, a sprinkler pipe burst in the South Wing shower, the same emergency response team arrived at the facility and the SFV was no longer at the facility and the fire sprinkler system on the [NAME] Wing was still not repaired. The Chief EMS Coordinator continued that the LNHA was not on-site and there was no one from maintenance present. The Chief EMS Coordinator stated that they were concerned that the water had entered residents' rooms, nursing area, and hallway, and the facility did not provide the Fire Department (FD) with keys to the electrical panel. The FD shut the sprinkler system down and breached the Electrical Room door to access the fire panel. Upon entering, the FD found the cover to the electrical panel was down and leaning against a transformer on the opposite side of the room. The FD attempted to locate the breaker for the South Wing Shower Room, but the panel was labeled incorrectly and only the nursing staff was on-site and unable to identify breaker. The Chief EMS Coordinator stated that an electrician arrived on-site at 8:00 AM, and it took 30-40 minutes to determine where the appropriate shut off for the panel was. The Chief EMS Coordinator continued that EMS had taken over the EPP from the facility staff after staff were uncertain of what to do and looked at EMS for all guidance. The Chief EMS Coordinator stated that the South Wing was being evacuated, and staff were asking how to evacuate a bariatric resident from their bedroom. The Chief EMS Coordinator stated that staff were asked, Don't you have a plan for that? Do you have a lift? A plan to transfer the [resident] out of a bed to a safe zone? The Chief EMS Coordinator stated that staff gave blank stares. They asked nursing staff for their Fire Watch paperwork, and the South Staff Member writing times and initials when asked for paperwork, and nothing had been signed since the beginning of the initial leak at 10:30 PM. The Chief EMS Coordinator stated that it was reported that the [NAME] Wing had the Fire Watch paperwork when asked. The Chief EMS Coordinator stated that the LNHA arrived on-site on 2/3/26, between 4:00 AM and 4:30 AM. The Chief EMS Coordinator stated that the residents were being evacuated by EMS, and the facility did not have the emergency resident triage tags (resident identification). The Fire Marshall stated that he had made the call to evacuate the residents who were sheltering in place as well as offsite for; 1. Flooding and possible contaminated water, 2. No sprinkler system, and 3. Electrical hazards. A review of the Fire Watch dated 2/2/26, indicated when the fire alarm or automatic sprinkler system is out of service for more than four hours in a twenty-four period. Fire watch personnel shall consist of Maintenance or Nursing depending on availability of staff during day shift and security after hours. A room-by-room inspection will be done every sixty minutes in affected area. The form had a column for time, area of the building, and done by initials. The first row indicated the time was 10:38 PM, the area was South, and the initials KJ. The next row had the time 11:38 PM, with no area of the building inspected and the initials KJ. There were three additional times listed of 12:38 AM, 1:38 AM, and 2:38 AM, that did not include the area of the building inspected or initials for done by. On 2/5/26 at 1:00 PM, the surveyor interviewed the LNHA, who stated on 2/3/26, during the initial sprinkler emergency on the [NAME] Wing, the 3:00 PM to 11:00 PM (3-11) Supervisor was in charge. The 3-11 Supervisor called the LNHA, who called the Fire Sprinkler Vendor, and the LNHA was unsure who set the fire watch. The LNHA stated during the second fire sprinkler emergency on the South Wing, the 11:00 PM to 7:00 AM (11-7) Supervisor was in charge. The 11-7 Supervisor called 911 emergency services at 2:26 AM. The LNHA stated the Chief EMS Coordinator called him to alert the LNHA of the emergency that was occurring. The LNHA continued that the residents on the South Wing were sheltering in place at the time since no water had entered their rooms. The LNHA stated that around 5:00 AM, the Fire Marshall informed him that the Fire Marshall was calling an evacuation. The LNHA stated that they were told by EMS that the South Unit was condemned and they also used the term imminent hazard. On 2/5/26 at 1:26 PM, the surveyor interviewed the LNHA, who stated he was responsible for overseeing the facility and all the staff. NJAC 8:39-9.2(a)NJAC 8:39-9.3(a)NJAC 8:39-27.1(a)NJAC 8:39 31.6(j)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed operate in accordance with all state regulations to implement their emergency preparedness plan. This deficient practice has the potential to affect all residents, and was evidenced by the following:Reference: N.J.A.C. 8:39-31.6 Mandatory fire and emergency preparedness .(j) Any staff member who is designated as the acting administrator shall be knowledgeable about and authorized to implement the facility's plans in the event of an emergency. On 2/3/26 at 9:00 AM, the surveyor arrived to the facility and observed the Emergency Management Services (EMS) at the facility. At that time, the surveyor interviewed the Director of EMS, who stated last night, 2/2/26 at 10:30 PM, the [NAME] Wing nursing unit lost fire protection. The Director of EMS stated that the fire sprinkler system was not operating on that unit. The Director of EMS continued that at 2:45 AM, the South Wing nursing unit had a pipe burst, and the unit was flooded with contaminated water. The Director of EMS stated that the residents were being evacuated from the South Wing. On 2/3/26 at 9:12 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that he did not report the fire sprinkler system not working or the flooding to the New Jersey Department of Health (NJDOH). The LNHA stated he was unaware that he had to. On 2/3/26 at 9:46 AM, the surveyor interviewed the EMS Coordinator, who stated that last night at 10:30 PM, the sprinkler was leaking on the [NAME] Wing, and the fire protection system was shutdown. The EMS Coordinator continued at 2:30 AM, that morning, the fire sprinkler flooded the South Wing. The EMS Coordinator stated there were 59 residents who resided on the South Wing that were being evacuated with 13 residents being relocated in the facility and 46 were being evacuated to another facility. On 2/3/26 at 10:00 AM, the surveyor observed the Office of Emergency Management (OEM) triaging residents for an evacuation. On 2/3/26 at 11:09 AM, the surveyor interviewed the Fire Marshall, who stated this was the nineth time the Fire Department had been called out to the facility for the sprinkler system since December 2025. On 2/3/26 at 11:16 AM, the surveyor interviewed the Chief EMS Coordinator, who stated the plan at that time was that OEM was evacuating residents to two different facilities. The Chief EMS Coordinator stated that the OEM had people currently at the accepting facilities receiving the residents. A review of the facility's Comprehensive Emergency Preparedness Plan dated updated 1/1/2026, included the following: Promulgation Statement by Administrator: I prepared this Emergency Plan which sets forth the general policies and procedures to be carried out in the event of an emergency. Policy Statement.The emergency preparedness plan shall be sent to municipal, county and state emergency management officials. The emergency preparedness planner shall request in writing an annual meeting with county and municipal emergency management coordinators to review the Emergency Preparedness Plan, and to ensure that the procedures of the emergency preparedness plan document are in coordination with the procedures of the county and municipal emergency management coordinators. Procedure: Should a fire or any other emergency occur within our facility or community area, our Emergency Preparedness shall be immediately implemented. Relocation Procedure.The State Department of Health shall be notified.all residents shall be properly tagged for identification. Sprinkler/Fire Alarm Impairment: An impairment of any fire protection system or equipment occurs when that protection system, alarm or detection device is removed from service either partially or completely. This includes planned or emergency outages of the system or devices.An emergency impairment occurs when an unexpected event impairs the normal function of the protection system. Leakage, interruption of water supply, frozen or ruptured piping and equipment failure are examples.Policy: It is the policy of [the facility] to have a written fire protection impairment program. This program shall provide specific procedures to be followed in the event of a fire protection impairment.Procedure: The Administrator or designee shall act as the impairment coordinator. The impairment coordinator shall be responsible to ensure that these impairment procedures are being followed and completed. Emergency Impairments.all relevant procedures of the Preplanned Impairment section shall be followed.The fire watch from [page redacted] shall be noted with the time of restoration and shall be retained in the facility's records for at least twenty-four months. Availability of Keys.Should an emergency occur within our facility, keys to the locked rooms or areas shall be made available to first responders. Fire Watch Form.Fire Watch to include the following activities: 1. Fire watch must be continuously conducted by trained individuals performing no other duties in the affected areas until the impairment no longer exists. On 2/3/26 at 1:24 PM, the surveyor met with the LNHA, Chief EMS Coordinator, and the Fire Marshall. The surveyor asked the LNHA what the facility put in place from their EPP. The LNHA responded that he did not put anything into place, that OEM had taken control and they were doing everything. The surveyor then asked if the facility set up an incident command, and the LNHA replied, no. The surveyor asked who was the facility's scribe, and the LNHA asked what? The surveyor stated the person who was taking down the residents' names as they were evacuated, and the LNHA stated that OEM was taking care of that including a head count. At that time, the Chief EMS Coordinator stated that the first alarm activation took place on 2/2/26 at 10:30 PM, and the fire department responded and found a broken sprinkler pipe in the outside soffit of the [NAME] Wing. The facility contacted the Fire Sprinkler Vendor (SFV) who was on-site prior to the emergency officials leaving. The facility was placed on fire watch. The Chief EMS Coordinator stated that on 2/3/26 at 2:30 AM, a sprinkler pipe burst in the South Wing shower, the same emergency response team arrived at the facility and the SFV was no longer at the facility and the fire sprinkler system on the [NAME] Wing was still not repaired. The Chief EMS Coordinator continued that the LNHA was not on-site and there was no one from maintenance present. The Chief EMS Coordinator stated that they were concerned that the water had entered residents' rooms, nursing area, and hallway, and the facility did not provide the Fire Department (FD) with keys to the electrical panel. The FD shut the sprinkler system down and breached the Electrical Room door to access the fire panel. Upon entering, the FD found the cover to the electrical panel was down and leaning against a transformer on the opposite side of the room. The FD attempted to locate the breaker for the South Wing Shower Room, but the panel was labeled incorrectly and only the nursing staff was on-site and unable to identify breaker. The Chief EMS Coordinator stated that an electrician arrived on-site at 8:00 AM, and it took 30-40 minutes to determine where the appropriate shut off for the panel was. The Chief EMS Coordinator continued that EMS had taken over the EPP from the facility staff after staff were uncertain of what to do and looked at EMS for all guidance. The Chief EMS Coordinator stated that the South Wing was being evacuated, and staff were asking how to evacuate a bariatric resident from their bedroom. The Chief EMS Coordinator stated that staff were asked, Don't you have a plan for that? Do you have a lift? A plan to transfer the [resident] out of a bed to a safe zone? The Chief EMS Coordinator stated that staff gave blank stares. They asked nursing staff for their Fire Watch paperwork, and the South Staff Member writing times and initials when asked for paperwork, and nothing had been signed since the beginning of the initial leak at 10:30 PM. The Chief EMS Coordinator stated that it was reported that the [NAME] Wing had the Fire Watch paperwork when asked. The Chief EMS Coordinator stated that the LNHA arrived on-site on 2/3/26 between 4:00 AM and 4:30 AM. The Chief EMS Coordinator stated that the residents were being evacuated by EMS, and the facility did not have the emergency resident triage tags (resident identification). The Fire Marshall stated that he had made the call to evacuate the residents who were sheltering in place as well as offsite for; 1. Flooding and possible contaminated water, 2. No sprinkler system, and 3. Electrical hazards. A review of the Fire Watch dated 2/2/26, indicated when the fire alarm or automatic sprinkler system is out of service for more than four hours in a twenty-four period. Fire watch personnel shall consist of Maintenance or Nursing depending on availability of staff during day shift and security after hours. A room-by-room inspection will be done every sixty minutes in affected area. The form had a column for time, area of the building, and done by initials. The first row indicated the time was 10:38 PM, the area was South, and the initials KJ. The next row had the time 11:38 PM, with no area of the building inspected and the initials KJ. There were three additional times listed of 12:38 AM, 1:38 AM, and 2:38 AM, that did not include the area of the building inspected or initials for done by. A review of the NJ EMS Task Force Healthcare Facility Evacuation [County Redacted] - Facility Evacuation - Patient Tracking dated 2/3/26 at 1:47 PM, there were 40 residents evacuated to [name redacted], six residents to [name redacted] and thirteen residents were transferred to other rooms located within the facility. On 2/5/26 at 1:00 PM, the surveyor interviewed the LNHA, who stated on 2/3/26, during the initial sprinkler emergency on the [NAME] Wing, the 3:00 PM to 11:00 PM (3-11) Supervisor was in charge. The 3-11 Supervisor called the LNHA, who called the Fire Sprinkler Vendor, and the LNHA was unsure who set the fire watch. The LNHA stated during the second fire sprinkler emergency on the South Wing, the 11:00 PM to 7:00 AM (11-7) Supervisor was in charge. The 11-7 Supervisor called 911 emergency services at 2:26 AM. The LNHA stated the Chief EMS Coordinator called him to alert the LNHA of the emergency that was occurring. The LNHA continued that the residents on the South Wing were sheltering in place at the time since no water had entered their rooms. The LNHA stated that around 5:00 AM, the Fire Marshall informed him that the Fire Marshall was calling an evacuation. The LNHA stated that they were told by EMS that the South Unit was condemned and they also used the term imminent hazard. NJAC 8:39-31.6(j)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who was dependent on staff for transfers was safely and properly transferred with two staff members via mechanical lift. Instead, the resident was transferred by one staff member from their bed to a shower stretcher on 9/30/25, which resulted in the resident falling and sustaining a left upper extremity humeral fracture. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for accidents and was evidenced by the following:On 11/6/25 at 9:40 AM, the surveyor requested from the Licensed Nursing Home Administrator (LHNA), a copy of the Facility Reportable Event (FRE) that was reported to the New Jersey Department of Health (NJDOH) for Resident #2. On 11/6/25 at 9: 55 AM, the surveyor reviewed the FRE provided by the LHNA that indicated that on 9/30/25 at 9:10 AM, the Certified Nursing Assistant (CNA#1) was transferring the resident from the bed to a shower stretcher using a pull sheet without help of another staff member or the use of the mechanical lift as care planned. During transfer the resident fell to the ground when the shower stretcher moved away from the bed landing on their back. The resident was sent to the emergency room for an evaluation via 911 ambulance. The resident's Physician, Resident Representative, the Department of Health and the Ombudsman were notified. A follow up phone call on 9/30/25 by the Unit Manager to the emergency room revealed the resident sustained a humeral head (upper arm ball shaped bone which forms the shoulder joint) fracture. A review of the admission Record showed Resident #2 was admitted to the facility with medical diagnoses which included but were not limited to; heart disease, end stage renal disease, diabetes, and osteoporosis. A review of the admission Minimum Data Set (MDS), an assessment tool, dated 3/22/25 revealed under Section GG-functional abilities that the resident was dependent in tub/shower transfer meaning the helper does all the effort, resident does none of the effort to complete activity, or the assistance of two or more helpers is required for the resident to complete the activity. Resident #2 had a Brief Interview of Mental Status of 15/15, meaning the resident was cognitively intact. Review of the Nursing admission assessment dated [DATE] showed that the resident was extensive assistance for personal hygiene. Review of the Individualized Comprehensive Care Plan (ICCP) showed a focus of functional ability performance initiated on 12/30/24 and revised on 10/11/25. Interventions included but were not limited to Hoyer (mechanical) lift transfer, initiated on 7/11/25. A review of the progress notes dated 9/30/25, indicated that at 9:13 AM the nurse heard yelling from Resident #2 room. The nurse entered the room, and the resident was on the floor laying on their back next to the bed. CNA #1 was in the room. CNA #1 informed the nurse that he was transferring the resident from their bed to a shower bed and lowered the resident to the floor. The resident was unable to perform range of motion without complaints of pain. Vital signs were assessed and 911 called and the resident was sent to the hospital. A review of the radiology imaging from the hospital dated 9/30/25 at 10:17 AM, revealed the resident sustained a left proximal humerus fracture (left upper arm). A review of the FRE conclusion provided by the facility indicated that CNA#1 did not properly follow the resident's Plan of Care for transfer resulting in the increased risk for falls. CNA #1 accepted responsibility and was terminated from employment. On 11/6/25 at 12:15 PM, the surveyor interviewed Resident #2 regarding the fall. The resident told the surveyor that the aide lined up the shower stretcher next to the bed and when the aide pulled the resident with the sheet the stretcher moved away and I fell on the floor, I knew my arm was broke. The resident said they were transferred immediately to the hospital. On 11/6/25 at 12:10 PM, the surveyor observed a CNA (CNA#2) pushing a mechanical lift down the hallway. The surveyor asked about the procedure for use of the lift. CNA #2 said, You always need two people, if you don't have two people you don't use it until you do. On 11/6/25 at 12:25 PM, the surveyor interviewed a unit CNA (CNA#3) regarding assignments and resident needs. She told surveyor the assignment sheets have the resident's information and included if they were a one- or two-person assistance for transfer. The surveyor asked if they would ever have a problem getting a second person to help them for a two-person assistance resident and CNA#3 said never because the Unit Manager (UM) would always help. On 11/6/25 at 12:30 PM, the surveyor interviewed the unit Licensed Practical Nurse (LPN) regarding CNA assignments. She told the surveyor that before every shift the CNAs are handed an assignment sheet which included the resident assistance requirements for transfers. On 11/6/25 at 1:10 PM, the surveyor interviewed the UM of the South unit. The UM stated that the lead CNA or herself fill out the CNA assignment sheets, and it includes transfer assistance requirements for residents. All mechanical lift residents are a two-person assistance. She told the surveyor that Resident #2 was a mechanical lift resident, and the CNA (CNA#1) should have had two people in the room with him. The UM told surveyor, The CNA moved the resident with a sheet, and I don't know if the shower bed had the brakes on. The UM who was present on the unit, said the brakes were checked for function after the incident and they were in working order. On 11/6/25 at 1:45 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA). The surveyor asked the DON how a CNA would know if a resident was a one or two person transfer assist. The DON said besides assignment sheets the CNAs have access to a Kardex in the Electronic Medical Record (EMR) which would include that information. The surveyor asked if CNA#1 should have had a second person with him and she said, Yes, the resident was a mechanical lift transfer and help was available. He was educated that we don't attempt to maneuver unless they get help. He was agency and is no longer employed with us, and he accepted full responsibility. On 11/6/25 at 2:05 PM, the surveyor left a voice mail message for CNA #1 to return call. Surveyor reviewed the policy titled, Daily Work Assignments with a revision date of August 2006. Under policy interpretation and implementations, Certified Nursing Assistants are expected to carry out their daily assignments in a profession manner and in accordance with established nursing procedures. A review of the policy titled, Mechanical Lift (Hoyer) Transfers, an undated policy, the procedure was two staff were required. NJAC 8:39-27.1(a)

Complaint #: NJ00184635 Based on observations, interviews, review of medical records, and pertinent facility documentation on 03/26/25, the facility failed to: a.) ensure the safety of a moderately cognitively impaired resident with aggressive behaviors from a staff member who pepper sprayed the Resident in the face and b.) follow their, Abuse, Neglect, and Exploitation of Residents and Unmanageable Residents policies. The deficient practice resulted in Resident #6 being treated for chemical conjunctivitis and pain to the left eye. This deficient practice was identified for 1 out 2 residents (Resident #6) who were reviewed for abuse and was evidenced by the following: A review of the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by facilities to report incidents, revealed that on 3/19/25, Resident #6 was standing at the nurse's station grabbing at electronics/equipment, smashing it, and attempting to hit staff. The FRE further revealed that the Licensed Practical Nurse (LPN) #1 proceeded to get a bottle of pepper spray from her personal bag and sprayed Resident #6 to diffuse the situation. Additionally, the FRE revealed that the local police department was notified, and the Resident was transferred to the emergency room (ER) for treatment. On 03/26/25, at 11:33 A.M., during a tour of the dementia/locked unit, the surveyor observed Resident #6 sitting in a chair near the nurse's station. The surveyor asked Resident #6 questions and observed delayed responses for answers during this interview. The Resident was able to answer a few questions after much thought. Resident #6 reported that he/she felt ok. When asked if the Resident felt safe at the facility, the Resident responded, yes. According to the admission Record (AR), Resident #6 was admitted to the facility with diagnoses that included but were not limited to Dementia with severe mood disturbances and Major Depressive Disorder. According to the admission Minimum Data Set (MDS), an assessment tool dated 03/09/25, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the Resident was moderately cognitively impaired. The MDS further indicated that Resident #6 was experiencing delusions and had physical and verbal behaviors towards others. A review of Resident #6's Care Plan (CP) revealed a focus, initiated on 03/03/25, that indicated that the Resident could be verbally abusive towards others, combative towards the staff, had poor impulse control by throwing or destroying furniture, and lying down on the ground when upset. An intervention initiated on 03/03/25 included, If I become agitated, aggressive, or combative [,] maintain safety for all [,] keep at least 4 arm's length apart from me, decrease my stimuli and allow me to calm. During an interview on 03/26/25 at 12:01 P.M., the Certified Nursing Assistant (CNA) #1 stated that on 03/19/25, she worked a double shift [7 A.M. - 11 P.M.], and the Resident displayed no behaviors. She stated that although Resident #6 was not assigned to her, she was familiar with the Resident's behaviors. CNA #1 stated it was never appropriate to use pepper spray on a resident and that if she encountered an aggressive resident, she would step away and let them calm down. She further stated that she was educated on abuse and the prohibited use of pepper spray immediately post-incident. During an interview on 3/26/25, at 12:40 P.M., LPN #2 stated that she was assigned to Resident #6 on 03/19/25 for the day shift [7 A.M.- 3 P.M.] and that no behaviors were displayed during that time. She stated that using pepper spray on a resident was just wrong. During an interview with the surveyor on 03/26/25 at 1:23 P.M. with the DON and the Assistant Director of Nursing (ADON), they both stated that the camera footage was reviewed the next day, on 03/20/25, with the local police. They further stated that the police confiscated the footage, so it was not available for the surveyor to review. The DON and the ADON proceeded to describe the camera footage on 3/19/25. -Around 7:44 P.M., Resident #6 was seen at the nurse's station grabbing things and throwing them, and LPN #1 was behind the nurse's station. -Resident # 6 was then seen ripping the mouse from the computer and observed walking away from the nurse's station toward his/her room while twirling the mouse in the air. -LPN #1 was observed walking out of camera range and heading towards what they described as the med room [medication room]. -LPN #1 reappeared on camera at 8:04 P.M., running towards Resident #6 from behind. LPN #1 then ran in front of the Resident and sprayed the Resident with pepper spray three times. -Resident #6 was seen collapsing to the floor, holding his/her eyes, and appeared to be coughing. The facility provided Resident #6's hospital discharge paperwork for review, dated 03/19/25, that revealed that the Resident was treated for chemical conjunctivitis and pain to the left eye. The ADON stated that LPN #1 was suspended pending the outcome of the investigation. Upon the investigation, LPN #1 was terminated on 3/26/25, and a complaint form with the Board of Nursing was completed on the same date. Both the DON and the ADON stated that it was not acceptable for staff to use pepper spray on residents nor bring it into the facility. They further stated there was no policy reflecting this. A Police Report from the responding police department included a Supplement which documented their review of the surveillance footage of the event. The video spanned from 7:53 P.M. to 8:56 P.M. and captured key moments as follows: At approximately 8:07 P.M., the footage shows the victim, [Resident name], standing in the hallway of the west wing. Certified Nursing Assistant (CNA) [CNA name] is [was] seen engaging in conversation with [Resident name]. At this point, [Resident name] does not appear to pose any threat. As [Resident name] is standing, Licensed Practical Nurse (LPN) [LPN name] approaches [him/her] and proceeds to spray [him/her] directly in the face, mere inches from [his/her] eyes with her own personal Oleoresin Capsicum spray (OC spray) [Pepper Spray]. In response, [,] [Resident name] attempts to defend [him/herself] by swinging a computer mouse with [his/her] right hand to create distance from [LPN name]. Despite [Resident name] attempts to cover [his/her] face and posing no threat, [LPN name] continues spraying [him/her] multiple times. [Resident name] then collapses to the floor, visibly in pain and discomfort, covering [his/her] eyes. Both [CNA name] and [LPN name] walk away from [Resident name], [,] leaving him on the floor without any medical assistance. [He/she] remains there, in obvious distress as other employees pass by without offering help. At 8:14 [P.M.,] the video shows [Resident name] attempting to crawl to an adjacent room [Resident name] appearing disoriented, tries to enter [Room number], which is adjacent to his own. At this point, [CNA name] sees [him/her,] grabs [him/her,] and brings [him/her] to the ground The footage shows [CNA name] and [LPN name] dragging [Resident name] across the floor by [his/her] sweatshirt and sweatpants, with [CNA name] holding [his/her] right side and [LPN name] holding [his/her] left arm. They pull [him/her] back to [his/her] room at 8:15 P.M. and immediately leave, closing the door behind them. No care is provided to [Resident name] during the brief moment they are in the room. It appears no one else enters [Resident's name] room until [Police Department] and Emergency Medical Services arrive at 8:53 P.M. Review of the facility policy titled, Abuse, Neglect, and Exploitation of Residents, revised 04/03/21, revealed under the Policy Statement that, It is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents is absolutely prohibited. Additionally, under the Definitions section it revealed that, Physical abuse is the inappropriate physical contact with a resident which harms or is likely to harm the resident. A review of the undated Unmanageable Residents policy, revealed under section 2 of Policy Interpretations and Implementation, that, Should the resident pose an immediate danger, or become violent or beyond control of the facility, local law enforcement agencies may be called for assistance. The facility was notified of the Immediate Jeopardy (IJ) on 3/26/25 at 4:03 P.M. The Director of Nursing (DON) was presented with the IJ template. The Administrator was not able to attend. An acceptable removal plan was electronically mailed to the surveyor on 03/31/25 at 1:48 P.M. The facility implemented a corrective action plan to remediate the deficient practice. The surveyor verified the removal plan on-site and determined the IJ for F600 was removed as of 04/02/25. The Removal Plan was as follows: 1. The facility implemented a new policy, Weapons Prohibition Policy and Procedure, that included weapons are not permitted on the premises nor to be used against a resident. 2. The facility initiated in-services with the staff on Weapons Prohibition Policy and Procedure and placed signage at the staff entrance and the time clock regarding the prohibition of weapons. 3. The facility-initiated in-servicing for all staff departments on Managing Aggressive Behaviors and Responding to Challenging Behaviors. 4. The facility initiated audits on care plans and incident investigations. N.J.A.C. 8:39-4.1 (a)(5)

Complaint #NJ00183371 Based on observations, interviews, review of the medical record and other pertinent facility records on 3/6/25 and 3/7/25, it was determined on 3/7/25 that the facility failed to provide adequate supervision of a severely cognitively impaired resident with a known history of exit seeking which resulted in the resident eloping from the facility on 2/10/25 for 1 of 4 residents (Resident #1). The resident was located at an off-site location by an unidentified caller and returned to the facility on 2/10/25 at approximately 5:58 P.M. by the local police department. The facility's failure to provide adequate supervision to a cognitively impaired resident who was at risk for elopement posed a likelihood of serious harm, injury, impairment or death. This deficient practice placed Resident #1 and all other residents who were at risk or who had a known history of wandering or elopement in an Immediate Jeopardy (IJ) situation. The deficient practice was evidenced by the following: A Facility Reportable Event (FRE) sent to the New Jersey Department of Health dated 2/10/25, indicated that the nursing supervisor reported that the resident had been found outside of the facility after dinner at approximately 5:30 P.M. The nursing staff brought the resident back into the facility. The resident had no apparent physical injuries. The FRE did not indicate how the resident exited the facility. On 3/06/25 at 4:30 P.M. the surveyor observed Resident #1 awake, alert and fully dressed wearing a jacket. A wander guard was observed on resident's left wrist. The Resident was ambulating without the use of assistive devices. Resident #1 was socializing with another resident. The surveyor interviewed the resident who was able to state that he/she liked it at the facility. When the surveyor asked another question, the resident answered with a rambling response. It was determined he/she would not be able to continue the interview. On 3/7/25 at 9:50 A.M., during a tour of the Dementia/locked unit, the surveyor observed Resident #1 sitting in the dayroom watching television. The surveyor observed a wander guard on the resident's left wrist. According to the admission Record face sheet (an admission summary) Resident #1 was admitted with diagnoses that included but were not limited to, unspecified dementia (a group of symptoms that affect memory, thinking and social abilities), Schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges) and Schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder). A review of the admission Minimum Data Set (MDS), an assessment tool, dated 1/23/25, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated that the resident was severely cognitively impaired. Further review of the MDS record indicated that the resident was independent with ambulation without any assistive devices. A review of the Care Plans for Resident #1 indicated that an elopement care plan was initiated on 1/15/25. Interventions listed for the resident were: Wander guard to the left wrist; check for placement per order; Frequently monitor resident's whereabouts; Document wandering behavior and attempted diversional interventions in behavior log. A Progress Note dated 2/10/25, at 6:17 P.M., written by a Licensed Practical Nurse (LPN) caring for Resident # 1 indicated the resident was observed missing at 4:45 PM. All staff were told to look for the resident. The staff received a call that Resident #1 was observed at an offsite location. Two nurses from the facility drove to the offsite location to retreive the resident. According to this note, On arrival patient [sic] was in an Ambulance accompanied by 2 EMTs (Emergency Medical Technicians) and 2 Police Officers. Patient was received awake and alert, pleasantly confused. patient [sic] assisted into police car, patient was met at facility. During an interview with the Administrator on 3/7/25, at 1:40 P.M., he provided a map of the facility. He indicated on the map the exit door locations and stated that there are cameras both inside and outside of the facility, however, the resident was not captured exiting on any of the cameras. The Administrator did not indicate that there were any adjustments made to the cameras post incident. During an interview with the Director of Maintenance (DOM) on 3/7/25, at 2:02 P.M., he revealed that the wander guard system was on the front door, the west wing door and two other doors on the west unit. He indicated that he tested the system on Fridays. He stated that if a resident wearing a wander guard was close to the door, it still should not open. He further revealed that he was made aware of the elopement the following day, 2/11/25, during morning meeting. He stated that he did not check and wasn't asked by the administrative staff to check the wander guard system and/or the doors immediately after the incident. He did continue with his weekly check on Friday, 2/14/25. During the interview, the DOM provided a log documenting the doors being tested weekly. The DOM then explained the process of how he would check the operations of the door's magnetic locks, delayed egress doors, pin pad key locks, testing of the door's hardware for proper function and condition. He would then complete the log. A review of the documentation provided by the DOM revealed testing of the function of the doors were performed prior to the incident on 2/07/2025 and after the incident on 2/14/2025. When the surveyor asked the DOM why the doors were not tested at that time, he stated he was not asked to do so. The Director of Nursing (DON) during an interview on 3/7/25, at 2:38 P.M., revealed that she was made aware of the incident around 6:00 P.M. after the situation had been resolved. The Incident Report, which contradicts the FRE, provided by the facility dated 2/10/25 revealed that .initially the supervisor reported that no staff noticed that the resident was not on the floor until a phone call from an unidentified caller received that the resident was found. No alarms reported as sounding. All egress doors functional . The DON stated that she tried to get a timeline from the Nursing Supervisor but was unable. The DON further stated that other than the statements provided she did not interview any other staff on the unit. The DON revealed that the videos were viewed while trying to figure the root-cause analysis, but they were unable to see how the resident exited the facility. She stated that they did not test the doors or the wander guard system but rather relied on natural occurrence, which she explained as watching the staff to see how quickly they responded to door alarms. However, the DON stated that the root-cause analysis later revealed that Resident #1 left via an egress door, but the doors were not tested after the elopement. During an interview with the Administrator on 3/7/25, at 4:59 P.M., he stated that he was contacted via the phone by the DON after the incident occurred. He further stated that the Interdisciplinary Team met on 2/11/25 to collaborate but could not determine how Resident #1 exited the facility from the camera footage and the staff statements. He revealed that they still did not know how the resident got out of the facility. During an interview with CNA #2 on 3/7/25, at 5:43 P.M., she stated that she was familiar with the resident who wandered a lot and goes into other resident's rooms, and to the exit doors. She stated she did not see the resident when she entered the unit for the 3:00 P.M. to 11:00 P.M. shift on 2/10/25. I went to search for the resident and could not find him. I asked the other girls to help me look for the resident. When we were unable to locate the resident, I told the Nurse and the Nursing Supervisor who called the code. CNA #1 stated that other residents have tried to leave via the exit doors but that the alarm sounded, and they were stopped. She stated that she did not hear the alarm during the shift and is unsure of how Resident #1 exited the facility. During an interview with Unit Manager (UM) on 3/07/25 at 2:54 p.m., she stated that the UM's are responsible for care planning and that the DON and the Assistant Director of Nursing (ADON) oversee them. She stated that the CNAs were made aware of new interventions because she adds that information to the daily assignments. In the presence of the surveyor, the UM reviewed Resident #1's care plan intervention that read frequent monitoring of whereabouts and stated that it should be documented in the chart. She stated that the CNAs would not document anywhere it would be the nurse's responsibility. Review of the resident's electronic medical record did not reveal this documentation. According to CNA #3 during an interview with the surveyor on 3/7/25, at 6:16 P.M., he was working the evening of the incident. He did not recall seeing the resident nor hearing any alarm sounding during the shift. The Director of Social Services (DSS) during an interview with the surveyor on 3/8/2024 at 11:17 A.M., stated that she participated in elopement drills. She stated that her participation would be to contact the family regarding the incident if the staff were not able to. She revealed that she was made aware of the incident the next day 2/11/25, in morning meeting. The team discussed how the resident may have gotten out, however, she was unaware if it was identified. She revealed that she was not asked to meet with the resident for any follow up. She stated that if there was any follow up it would have been documented in the progress notes. A review of facility's undated document titled Elopement Drill Process revealed under #6 that when .the resident is located, the Social Service designee assesses the resident for emotional distress . In the presence of the surveyor, she reviewed the process and stated that she did not meet with or assess the resident, nor did she designate her co-worker to do so as indicated in step #6 of the protocol. Review of the progress notes did not indicate that a social service assessment was completed. During a follow-up interview with the DON and the ADON on 3/8/25, at 1:32 P.M., the ADON described the procedure for monitoring the wander guards. They both confirmed that the wander guard system was functioning during the weekly checks performed on 2/7/25 and 2/14/25. There was no documentation of the wander guard being tested after the incident. When asked why no post incident testing was performed the DON stated that there .was no failure with the doors. The ADON additionally stated that education for all staff was initiated after the incident. The surveyor reviewed facility in-service documents signed by facility staff dated 2/11, 2/12, 2/17, 2/19/25 titled Elopement Drill Practices. The surveyor reviewed sign-in sheets for the in-services completed and noted there were no 11-7 signatures. When surveyor questioned the ADON if the 11:00 P.M. to 7:00 A.M. shift was in-serviced his response was I was going to do it next month. During an interview with CNA #4 on 3/8/25, at 2:42 P.M., she stated we try to have the residents go to the dayroom where they can be watched but we can't force them. She further explained that staff are familiar with the resident. When asked what does frequent observation mean, the CNA stated staff sees the resident during rounds every 2 hours or if staff interact with them. She further stated that CNAs did not document this information anywhere. The CNA could not recall the last time was she saw Resident #1 on the day if the incident. During an interview on 3/8/25, at 2:46 P.M., with LPN #3 she stated she was familiar with the resident. She stated that the unit manager was responsible for initiating and updating care plans. She stated that frequent observation would be for residents at an increased risk for falls, behaviors or elopement. She stated frequent observation had no formal documentation or set time for how often to monitor. During a follow-up interview with the DON and ADON on 3/8/25, at 3:29 P.M., both stated that UMs were responsible for initiating the care plans and updating them. When asked what frequently monitor meant the ADON responded that it was subjective and then stated, I don't know. The DON stated that frequently was an alert word used to keep an eye out for the residents. It is a high alert word. The surveyor questioned the DON to clarify what the behavior log was and where information was documented. The DON responded, the behavior log is a progress note and the responsibility of the cart nurse. No documentation was noted in the progress notes nor was a behavior log provided. The surveyor attempted to reach the nursing supervisor and left a voice message; however, it was not returned. A review of the facility policy, titled Wander guard Policy dated 1/25, revealed under the policy statement that .it is the objective of the facility to ensure the safety and protection of wandering residents by preventing their exit from the building. Under the policy interpretation and implementation #5 a personalized care plan addressing the issue shall be developed for the identified resident. A review of the facility policy titled Care Plans Comprehensive, revised 2/01/18, revealed under the purpose of the care plan to incorporate identified problem areas and incorporate risk factors with identified problems. It revealed under the care plan intervention section that care plan interventions are designed after careful consideration of the relationship between the problem areas and their causes. When possible, interventions address then underlying source(s) of the problem area(s) rather than addressing only the symptoms or triggers. A review of Resident #1's care plan did not indicate any specific interventions to monitor the resident's whereabouts. The care plan did not indicate any specific interventions to distract Resident #1 from wandering or exit seeking behaviors. A review of the facility's undated C.N.A. job description stated under job expectations that the C.N.A. care rounds each shift every 2 hours. The facility was notified of the Immediate Jeopardy (IJ) on 3/7/25 at 5:43 P.M. The DON was presented with the IJ template. The Administrator was not able to attend. An acceptable removal plan was electronically mailed to the surveyor on 3/10/25 at 9:31 A.M. indicating that the action the facility would take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. The surveyor verified the removal plan on-site on 3/14/25 and determined the IJ was removed as of 3/14/25. The Removal Plan is as follows: 1. The ADON educated the CNA, Nurse, Supervisor, and DOM on the Elopement Drill Process. The facility provided an email which reflected the request for the agency nurse assigned to the resident not to return to the facility. 2. The facility implemented revised a protocol to include: Post an elopement maintenance or a designee will check all egress doors, window audit and wander guard function which will be documented in the facility's electronic record. 3. The facility initiated in-servicing for all staff on the facility's Elopement Drill Process. 4. The facility initiated in-servicing with all Nurses and Administrative staff the review of Incident Protocol and Care Plan Policy. 5. Facility initiated audits on wander guards, care plans, egress doors, elopement investigations. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and review of the Electronic Medical Record (EMR), and review of other facility documentation, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. This deficient practice continued over several months for 8 of 35 sampled residents (Resident #1, Resident #31, Resident #53, Resident #59, Resident #78, Resident # 79, Resident #120, and Resident#139) and was evidenced by the following: 1.) On 01/21/2025 at 09:01 AM, a review of the EMR for Resident # 139 revealed the following: According to the Admission Record, Resident #139 was admitted to the facility with diagnoses including but not limited to: Dementia with other behavioral disturbance, anxiety disorder. A review of the EMR revealed that there was no documentation to indicate Resident #139 was seen by attending physician at any time from 06/10/2024 thru 01/08/2025. Resident #139 was seen by the Advanced Practice Nurse (APN) on 11/20/2024, 12/16/2024, and 01/08/2025. 2.) On 01/16/2025 at 10:22 AM, a review of the EMR for Resident #79 revealed the following: According to the Admission Record, Resident #79 was admitted to facility with diagnoses including but not limited to Bipolar Disorder and Neuropathy. A review of the EMR for Resident #79 did not include documentation that Resident 379 was seen by the attending physician since 07/07/2024. Resident #79 was seen by the APN on 08/29/2024, 09/30/2024, 10/22/2024, 12/23/2024, and 01/14/2025. 3.) On 01/17/2025 at 09:41 AM, a review of the EMR for Resident #59 revealed the following: According to the Admission Record, Resident #59 was admitted to facility with diagnoses including but not limited to Bipolar Disorder (a mental illness that causes extreme shifts in mood) and Non-Alzheimer's Dementia (a variety of Dementia not caused by Alzheimer's Disease). A review of the EMR for Resident #59 did not include documentation that Resident #59 was seen by the attending physician in greater than the past 60 days Resident #59 was seen by the APN on 01/16/2024, 02/15/2024, 03/29/2024, 04/25/2024, 05/03/2024, 06/11/2024, 07/01/2024, 08/01/2024, 09/11/2024, 10/03/2024, 10/31/2024, 11/13/2024, 12/09/2024, and 01/08/2025. 51337 4.) On 01/15/2025 at 01:44 PM, a review of the EMR for Resident #120 revealed the following: According to the Admission Record, Resident #120 was admitted to facility with diagnoses including but not limited to Cauda Equina Syndrome (a serious condition that occurs when the nerves in the lower back are compressed) and Obstructive Uropathy (a condition that occurs when urine flow is blocked, causing urine to build up in the kidney). A review of the EMR for Resident #120 did not include documentation that Resident #120 was seen by the attending physician since 10/17/2024. Resident #120 was seen by the APN on 10/21/2024, 10/28/2024, 10/30/2024, 11/7/2024, 11/25/2024, 12/11/2024, 01/03/2025 and 01/06/2025. 5.) On 01/20/2025 at 09:23 AM, a review of the EMR for Resident #31 revealed the following: According to the Admission Record, Resident #31 was admitted to facility with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease (COPD), a lung disease causing restricted airflow and breathing problems, and Atrial Fibrillation (irregular heartbeat). A review of the EMR for Resident #31 did not include documentation that Resident #31 was seen by the attending physician from 10/23/2024 through 12/04/2024. Resident #31 was seen by the APN on 10/23/2024, 10/31/2024, 11/11/2024, 12/10/2024,12/26/2024, and 01/02/2025. 6.) On 01/20/2025 at 02:09 PM, a review of the EMR for Resident #1 revealed the following: According to the Admission Record, Resident #1 was admitted to facility with diagnoses including but not limited to Depression and Weakness. A review of the EMR for Resident #1 did not include documentation that Resident #1 was seen by the attending physician in greater than 60 days. Resident #31 was seen by the APN on 08/01/2024, 08/15/2024, 08/22/2024, 08/23/2024, 08/26/2024, 08/28/2024, 09/05/2024, 09/30/2024, 10/08/2024, 10/17/2024, 10/24/2024, 11/05/2024, 12/11/2024, 12/18,2024, and 01/17/2025. 7.) On 01/16/2025 at 12:39 PM, a review of the EMR for Resident #78 revealed the following: According to the Admission Record, Resident #78 was admitted to facility with diagnoses including but not limited to Cerebral Infarction (blood vessel blockage in the brain) and Major Depression (a mental health condition that involves a persistent low mood and loss of interest in activities). A review of the EMR for Resident #78 did not include documentation that Resident #78 was seen by the attending physician in greater than 60 days. Resident #78 was seen by the APN on 08/08/2024, 09/13/2024, 10/07/2024, 11/05/2024, 12/12/2024, and 01/06/2025. 8.) On 01/16/2025 at 11:58 AM, a review of the EMR for Resident #53 revealed the following: According to the Admission Record, Resident #53 was admitted to facility with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease (COPD), a lung disease causing restricted airflow and breathing problems and Atrial Fibrillation (condition where the heart's upper chamber beat irregularly and rapidly). A review of the EMR for Resident #53 did not include documentation that Resident #53 was seen by the attending physician in greater than 60 days. Resident #53 was seen by the APN on 08/05/2024, 08/14/2024, 08/16/2024, 08/22/2024, 09/03/2024, 09/24/2024, 09/30/2024, 10/07/2024, 10/10/2024, 10/19/2024, 11/19/2024, 11/21/2024, 12/10/2024, 12/18/2024, and 01/03/2025. On 01/21/2025 at 09:59 AM, the surveyor interviewed Licensed Practical Nurse (LPN#2) who stated that all physicians document their notes in the EMR since they have access to it. On 01/21/2025 at 10:03 AM, the surveyor interviewed LPN #3 who stated that all doctors' notes are in the EMR. LPN #3 further stated that if some people could not access it, the handwritten notes are scanned to the EMR, and that the facility did not have paper charts. On 01/21/2025 at 11:47 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/ UM #1) who stated that the doctors' notes were in the EMR under progress notes section. On 01/22/2025 at 12:45 PM, Surveyors #1 and #2 interviewed the Medical Director (MD) who stated that he see's their patients every other month or every third month. MD stated that they usually see their patients in the hospital. The MD confirmed that they do not write physician notes and instead the APNs write the physician notes in the EMR. During an interview with the survey team on 01/22/2025 at 01:55 PM, the Director of Nursing (DON) stated that the APNs visit the residents twice a week and that the medical director could be contacted anytime. The DON further stated that the physician notes were in the EMR which included the History and Physical Examination, diagnosis list, medication review, current complaints, and laboratory findings. A review of a facility provided policy titled Physician Services revised in April 2013 under Policy Interpretation and Implementation included 5. Physician visits, frequency of visit, emergency care of residents, etc. are provided in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy. Consultative services shall be made available from community-based consultants or from a local or medical center. NJAC 8:39-23.2 (b), 23.2 (d)

Based observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently perform quarterly smoking assessments according to facility policy for residents designated as active smokers. This deficient practice occurred for 3 of 3 residents (Resident #30, #58, and #127) reviewed for smoking. This deficient practice was evidenced by the following: 1. On 01/15/2025 at 10:21 AM, Surveyor #1 observed Resident #30 in his/her room getting a haircut. Resident #30 stated that he/she was a smoker, and that the facility staff held their smoking materials. Resident told Surveyor #1 that he/she had designated smoke times, and they could not smoke whenever they wanted to. On 01/16/25 at 12:44 PM, Surveyor #1 reviewed the electronic medical record (EMR) as follows; A review of the Admission Record revealed Resident #30 was admitted to the facility with the following but not limited to diagnoses: Parkinson's disease, dementia, anxiety disorder, and depression. A review of the Minimum Data Set (MDS), an assessment tool, dated October 19, 2024, revealed that Resident #30 had a Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment. According to Section J Resident #30 was an active smoker. A review of Resident #30's comprehensive care plan revealed the following care plan Focus: I [resident name]am a smoker of long duration. The following were listed as Interventions: Smoking supplies are stored in the activity office, instruct resident about smoking risks and hazards and about smoking cessation aids that are available, instruct resident about the facility policy on smoking: locations, times, safety concerns, monitor oral hygiene, notify charge nurse immediately if it is suspected resident has violated facility smoking policy. and observe clothing and skin for signs of cigarette burns, date initiated: 04/22/2024. The care plan did not address quarterly smoking assessments. The EMR revealed that Resident #30's original smoking contract was completed and signed on 10/16/23. Resident #30 had quarterly smoking assessments completed on 01/18/24, 04/22/2024, and 08/22/2024. Review of the Assmt (assessment)tab in the EMR revealed no quarterly smoking assessment had been completed since 08/22/2024 (approximately 5 months) for Resident #30. 2. On 01/16/2025 at 01:22 PM, Resident #127 was observed by Surveyor #1 outside in the designated smoking area without staff supervision. On 01/17/2025 at 08:39 AM, Resident #127 was observed lying in bed and watching television. Resident #127 told Surveyor #1 that he/she does not possess their smoking materials in their room or on their person. Resident #127 explained that they must pay for their own cigarettes and that staff holds them until the designated smoke time which was like 5 times per day. Staff would provide cigarette and lighter to resident at designated smoke times. According to the Admission Record Resident #127 was admitted to the facility with the following but not limited to diagnoses; Traumatic subdural hemorrhage without loss of consciousness (bleeding in the area between the brain and the skull), seizures, type 2 diabetes mellitus, and alcohol abuse. A review of the comprehensive MDS dated [DATE], Resident #127 had a Brief Interview for Mental Status score of 14, which indicated intact cognition. Section J of the MDS revealed that Resident #127 was a current tobacco user. According to Resident #127's comprehensive care plan date initiated: 08/14/2024 revealed the following care plan Focus: I [resident name] am a smoker. Review of the care planned interventions did not address quarterly smoking assessments. A review of the EMR revealed Resident #127 had their initial smoking safety evaluation completed on 08/14/2024. According to the EMR on 01/16/2025 at 01:30 PM under the heading Next Assessment Due Resident #127's Smoking Safety Evaluation V 2.0: was 63 days overdue - with a due date of 11/14/2024. During an interview with Surveyor #1 on 01/17/2025 at 08:44 AM, the corporate activity director (CAD) was asked what the facility process was for residents who were active smokers. The CAD told the surveyor that we purchase the cigarettes for the residents, and we also possess smoking materials which are locked away during non-smoking times. The CAD further stated that we distribute smoking materials to smokers at designated smoke times and the smoke monitor will supervise during the designated times. We have a designated smoke monitor. When asked who was responsible for completing smoking assessments the CAD stated nursing completes the smoking evaluations. During an interview with Surveyor #1 on 01/17/2025 at 08:50 AM, Licensed Practical Nurse/Unit manager (LPN/UM#1) was asked asked who was responsible for the completion of smoking assessments. LPN/UM #1 told the Surveyor #1 that initial and quarterly smoking assessments are completed by activities staff. She further stated that nursing does not complete the smoking evaluations but if I see something wrong, I will give them my input. During an interview with the survey team on 01/17/2025 at 10:41 AM, Surveyor #1 asked the Director of Nursing (DON) who was responsible for the completion of smoking assessments. The DON replied, our activities department completes the smoking evaluations, and the MDS coordinator assists as needed. During an interview with Surveyor #1 on 01/17/25 at 10:45 AM, the Licensed Nursing Home Administrator (LNHA) was made the LNHA aware that resident smoking assessments that were reviewed were noted to not been completed timely. The LNHA told the surveyor that the facility activities director left around a month ago and moved out of state. The LNHA told the surveyor We are actively seeking a new director. 41442 3. On 01/15/2025 at 10:50 AM, during the initial tour, Surveyor #2 observed Resident # 58 in his/her room. Resident #58 stated that he/she smokes during scheduled times and that the activities staff holds his/her cigarettes and lighter. He/she added that staff is always present during smoking times. On 01/15/2025 at 01:51 PM, Surveyor #2 reviewed the Electronic Medical Record (EMR) for Resident #58 as follows; A review of the admission record reflected that Resident #58 was admitted to the facility with a diagnosis that included but not limited to, Metabolic Encephalopathy ( a brain condition that occurs when there is an imbalance of chemicals in the blood), Major Depressive Disorder, Polyneuropathy ( disease that affects peripheral nerves, causing weakness, numbness, and pain), Opioid Induced Disorder, Personality Disorder, and Anxiety. A review of the most recent MDS dated [DATE], indicated that Resident # 58 had a BIMS score of 13/15 indicating Resident #58 was cognitively intact, and under section J indicated that Resident #58 was a current smoker. A review of Resident #58's Comprehensive Care Plan had a focus area indicating, [residents name] am a smoker of long duration . A review of Resident #58's admission Smoking Safety Evaluation, with an effective date of 08/22/24, indicated that Resident # 58 was an unsafe smoker. A further review of the EMR for Resident #58 did not include any further smoking evaluations. A review of the facility policy titled Smoking Policy - Residents, Staff and Visitors, undated. The following was revealed under the Policy Interpretation and Implementation: 5. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: a. Current level of tobacco consumption. b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.). c. Desire to quit smoking if a current smoker; and d. Ability to smoke safely with or without supervision (per a completed Smoking Evaluation). e. All residents that smoke are required to sign a smoking agreement contract. f. All residents that smoke are required to purchase their own smoking materials. 7. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. N.J.A.C. 8:39-31.6 (e)

Based on observation, interview, and document review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. This deficient practice was evidenced by the following: On 01/15/2025 at 09:16 AM, the surveyor, accompanied by the Food Service Director (FSD) observed the following in the kitchen: 1. A meat slicer was observed on a metal table in the cook's area. The meat slicer was not covered and was exposed to the air. The surveyor asked the facility cook if she had used the meat slicer at any point this AM for food production. The cook stated that she had not utilized the meat slicer for food production this AM. The surveyor asked the FSD if the meat slicer was cleaned and sanitized and he said yes that it was cleaned and sanitized. The table behind the blade guard/slicer wheel had unidentified food debris and a white slimy substance present when observed. The meat slicer was not covered while not in use and was exposed to contamination. The cook then further clarified to the surveyor that she had not used the meat slicer today. When interviewed the FSD confirmed that the meat slicer was cleaned and sanitized and stated it was not going to be used any time soon. The FSD then told a kitchen staff to re-clean and sanitize the meat slicer and cover it when not in use. 2. On a lower shelf of what the FSD identified as Drying Rack number 2 a stack of approximately 8 deep 1/4 pans were in the inverted position. The surveyor lifted the top quarter pan and observed a wet water-like substance on the pan directly below in the stack, commonly known in the food service industry as wet nesting (the practice of stacking wet dishes or pots and pans together, which prevents them from drying and creates an environment where bacteria and other microorganisms can grow). The FSD told the surveyor there wet when he observed the stack of deep 1/4 pans. The surveyor and FSD touched with their finger the 1/4 pans and agreed that the pans were not completely air dried prior to stacking. The top 4 pans in the stack were all observed to be wet with a clear, water-like liquid. The deep 1/4 pans were removed from the rack and returned to the dish room to be rewashed and sanitized and completely air dried prior to stacking. On 01/21/2025 from 09:21 to 09:34 AM, the surveyor, accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM #2), observed the following on the North Pantry/Nourishment room: 1. The surveyor observed a thick buildup (about a 1/4 inch) of ice on the bottom of the freezer. Embedded in the ice was a white plastic spoon and what appeared to be several pieces of white napkin, aluminum foil, and what appeared to be Styrofoam pieces. There were also bagged ice packs stored in the freezer with resident food. When interviewed the LPN/UM #2 did not know who was responsible for the maintenance of the pantry/nourishment room freezer. A review of the facility policy titled Foods Brought by Family/Visitors, reviewed 5/2023, failed to identify who was responsible for the maintenance and sanitation of the facility resident nourishment refrigerators. A review of a facility provided policy titled [facility name] Sanitization/Cleanliness, revised November 2024, revealed under Policy Interpretation and Implementation: 7. Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination. 8. When cleaning fixed equipment (e.g., mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are: a. washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air-dried, and sprayed with a sanitizing solution (at the effective concentration); and b. the equipment is reassembled and any food contact surfaces that may have been contaminated during the process are re-sanitized (according to the manufacturer's instructions). N.J.A.C. 8:39-17.2(g)

Based on observation, interview and review of other facility documentation, it was determined that the facility failed to ensure residents were treated with dignity whole being assisted with a meal. This deficient practice was identified for 1 of 3 units, [NAME] wing and was evidenced by the following: On 01/15/2025 at 12:38 PM, the surveyor observed the Infection Preventionist (IP) assisting a resident with their meal who was seated in his/her Geri chair. The IP was standing over the resident while feeding her/him. During an interview at that time, the IP said yes I attempting to feed resident. When asked how should you be positioned when feeding a resident and he replied I would like to be head level with resident but I don't have a chair. On 01/16/2025 at 08:25 AM, Certified Nursing Assistant (CNA #1) was observed to be standing while assisting a resident to eat who was seated in a Geri chair in the west unit dining room. After CNA #1 completed assisting the 1st resident, CNA #1 proceeded to move to a 2nd resident and stood while feeding him/her. There was a chair observed to be available for CNA #1 to sit in while assisting a resident to eat. On 01/16/2025 at 12:16 PM, during a lunch meal observation on the west wing, the surveyor observed CNA #1 to be assisting a resident to eat their entire meal from a standing position. The resident was seated in a Geri chair. During an interview with the surveyor on 01/22/2025 at 01:41 PM, the Licensed Nursing Home Administrator and Director of Nursing were asked is it appropriate for a staff to stand while assisting a resident with their meal. The LNHA responded no, staff is supposed to be sitting while assisting residents with their meals. A review of a facility policy on 01/22/2025 at 12:16 PM, titled [facility name] Feeding Assistance Guidance undated. The list of the guidance indicated that sit facing the resident at eye level. NJAC8:39-4.1(a)(12)

Based on observation, interview and review of other facility documentation, it was determined that the facility failed to ensure residents were treated with dignity while being assisted with a meal and creating a homelike environment during dining by removing the food from the tray. This deficient practice was identified for 2 of 3 units, [NAME] wing and South wing and was evidenced by the following: 1. On 01/15/2025 at 12:38 PM, Surveyor #1 observed the Infection Preventionist (IP) assisting a resident with their meal who was seated in his/her Geri chair. The IP was standing over the resident while feeding her/him. During an interview at that time, the IP said yes I attempting to feed resident. When asked how should you be positioned when feeding a resident and he replied I would like to be head level with resident but I don't have a chair. 2. On 01/16/2025 at 08:25 AM, Certified Nursing Assistant (CNA #1) was observed to be standing while assisting a resident to eat who was seated in a Geri chair in the west unit dining room. After CNA #1 completed assisting the 1st resident, CNA #1 proceeded to move to a 2nd resident and stood while feeding him/her. There was a chair observed to be available for CNA #1 to sit in while assisting a resident to eat. On 01/16/2025 at 12:16 PM, during a lunch meal observation on the west wing, Surveyor #1 observed CNA #1 to be assisting a resident to eat their entire meal from a standing position. The resident was seated in a Geri chair. 40039 3. On 01/15/2025 at 12:16 PM, Surveyor #2 observed the South Unit dining room at the lunch meal. Eight (8) residents were observed to be seated in the South unit dining room across from nurse's station. The second meal cart arrived at 12:19 PM and staff were observed to hold the meal trays to ensure all trays were able to be passed at the same time. Trays were passed to the eight residents at 12:23 PM, by 4 unit staff. 8 of 8 residents present in the dining room were served their lunch meal on the tray. The food was not removed from the tray when placed on the table. 4. On 01/16/2025 at 12:26 PM, Surveyor #2 arrived on the South unit and observed the lunch meal on the South Unit dining room. The meal had already been served prior to the surveyor arriving on the unit and the 4 of 4 residents present in the dining room received their lunch meal on a tray. 5. On 01/21/2025 at 12:12 PM, Surveyor #2 observed the South Unit dining room at the lunch meal. 7 residents were observed in the South unit dining room and were served the lunch meal on the tray. During an interview with the survey team on 01/22/2025 at 01:38 PM, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were notified of the above mentioned meals and the practice of facility staff standing while assisting residents with meals and serving meals on trays. Surveyor #1 asked if it was appropriate for staff to be standing while feeding a resident. The LNHA responded no, staff is supposed to be sitting while assisting resident during meals. Surveyor #2 asked the LNHA if serving meals on trays in the dining room created a home-like environment for the residents. The LNHA responded, To be honest I think that is the way that they have always done it. A review of a facility policy on 01/22/2025 at 12:16 PM, titled [facility name]Feeding Assistance Guidance undated. The list of the guidance indicated that sit facing the resident at eye level. N.J.A.C. 8:39-4.1(a)(12)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to follow hold parameters for the administration of a blood pressure medication in accordance with professional standards of practice. This deficient practice was identified for 1 of 28 residents (Resident #46) reviewed for standards of practice 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 casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 1/15/25 at 11:20 AM, the surveyor observed Resident #46 in their room seated in a high back wheelchair. Resident #46 stated they were a dialysis patient and went to the facility three times a week. The surveyor reviewed the medical record for Resident #46. A review of the Admission Record face sheet reflected the resident was admitted to the facility in July of 2023 with diagnoses which included chronic kidney disease, dependence on renal dialysis, and hypotension (low blood pressure). A review of the most recent comprehensive Minimum Data Set (MDS), and assessment tool dated 11/28/24, reflected a brief interview for mental status (BIMS) score of 9 out 15, which indicated a moderately impaired cognition. A further review reflected the resident received dialysis treatments. A review of the individualized person-centered care plan reflected a focus area initiated 9/6/23, for hemo-dialysis three times a week related to renal failure/disease. Interventions included monitor vital signs. Notify MD (physician) of significant abnormalities. A review of the Order Summary Report (OSR) included a physician's order (PO) dated 10/9/24, Vital signs every shift- if SBP (systolic blood pressure) under 100 [mmHg millimeters of mercury]- See PRN (as needed) order for Midodrine every 8 hours. The corresponding Midodrine order was as follows: Midodrine oral tablet 5 mg (milligram); give one tablet by mouth every 8 hours as needed for b/p (blood pressure); give if SBP less than 100 [mmHg]. A review of the corresponding November 2024 Medication Administration Record (MAR) revealed the resident's blood pressure (SBP) was less than 100 and the resident did not receive Midodrine on the following days: 10:00 PM; 11/19/24, 11/23/24, 11/26/24, 11/20/24. A review of the corresponding December 2024 Medication Administration Record (MAR) revealed the resident's blood pressure (SBP) was less than 100 and the resident did not receive Midodrine on the following days: 2:00 PM; 12/11/24, 12/12/24, 12/16/24 10:00 PM; 12/9/24, 12/10/24, 12/18/24, 12/19/24, 12/24/24 A review of the corresponding January 2025 Medication Administration Record (MAR) revealed the resident's blood pressure (SBP) was less than 100 and the resident did not receive Midodrine on the following days: 2:00 PM; 1/18/25 10:00 PM; 1/9/25, 1/10/25, 1/18/25, 1/19/25 Further review of the December 2024 and January 2025 MAR revealed the resident had received Midodrine when the SBP was above 100 and should not have been given on the following days: 12/11/24 at 8:11 AM 12/28/24 at 12:49 PM 1/12/25 at 10:17 AM, 1/14/25 at 12:27 PM, and 1/17/25 at 11:17 AM During an interview with the surveyor on 01/22/2025 at 11:14 AM, Licensed Practical Nurse # 4 (LPN #4) stated the resident received dialysis three times a week and took Midodrine for their blood pressure. At that time the surveyor and LPN #4 reviewed the resident's MARs. LPN #4 acknowledged the resident had not received Midodrine when their SBP was less than 100 on multiple occasions and had received Midodrine when the dose should have been held based on the physician's hold parameters. During an interview with the surveyor on 01/22/2025 at 11:28 AM, Licensed Practical Nurse/ Unit Manager #2 (LPN/UM #2) and the surveyor reviewed the resident's MARs and confirmed the nurses were not following the physician's hold order parameters for Midodrine on multiple dates. During a meeting with the survey team on 01/22/2025 at 2:21 PM, with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON stated the nurses should follow the parameters of the physician's orders like indicated in the Midodrine order for Resident #46. A review of the facility's Medication Pass policy dated reviewed 2023, included .Hold Parameters: check blood pressure and/or pulse rate immediately prior to pouring . The policy did not include following physician's order regarding medication hold parameters. NJAC 8:39-11.2(b); 27.1(a)

Based on observation, interview, review of the medical record, and other facility documentation, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received services to prevent further decreased Range of Motion (ROM). This deficient practice was identified for 1 of 1 resident reviewed for limited ROM, (Resident #78) and was evidenced by the following: On 01/15/2025 at 10:04 AM during the initial tour of the facility, Resident #78 was observed by the surveyor sleeping with right arm bent at the elbow close to their body. Their right hand was clenched in a fist. There was no observed splint, handroll, rolled towel or napkin on the right hand. During an interview with the surveyor on 01/15/2025 at 12:36 PM, the resident family stated that no splint or hand roll was being applied to resident's right hand. The family said that Resident #78 used to roll a napkin with their left hand to put in their right hand, but someone removed it. The family went on to say they were told that they were going to be replaced with the appropriate device, but no device was provided. On 01/16/2025 at 08:10 AM, the surveyor observed Resident #78 in bed sleeping with right arm bent at the elbow close to their body and their right hand clenched in a fist. There was no splint or handroll noted on their right hand. On 01/16/2025 at 08:11 AM, the surveyor observed resident #78 eating breakfast with their left hand using a fork. Their right arm was bent at the elbow closed to their body. Their right hand had no splint or handroll. A review of Resident #78's Admission Record, in the Electronic Medical Record (EMR) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; Cerebral Infarction (blood vessel blockage in the brain) and Major Depression (a mental health condition that involves a persistent low mood and loss of interest in activities). A review of the most recent Quarterly Minimum Data Set (QMDS), an assessment tool used to manage care, dated 11/01/2024, reflected a Brief Interview of Mental Status (BIMS) score of 6/15 which indicated that the resident's cognition was moderately impaired. Further review of the QMDS under Section O.0500 Restorative Nursing Programs, did not include documentation of wearing splint or brace. A review of the active Physician Orders on 01/16/2025 at 12:21 PM did not reveal order for any care or treatment for the contracture of the right hand. A review of Resident #78's Care Plan initiated on 06/29/2023, with focus for limited physical mobility related to Stroke included the following goal: To remain free of complications related to immobility, including contractures Interventions included: Monitor/document/report as needed any signs and symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury; Provide gentle range of motion as tolerated with daily care; Provide supportive care, assistance with mobility as needed; Document assistance as needed; and PT, OT referrals as ordered as needed. The ongoing care plan did not reveal a specific intervention for the resident's right upper extremity impairment or the contracture of the right hand. A review of the Physician's History and Physical progress notes by Advanced Practice Nurses (APN) dated 01/04/2024, 02/02/2024, 02/27/2024, 03/14/2024, 04/08/2024, 05/15/2024, 06/06/2024, 07/01/2024, 07/22/2024, 08/08/2024, 09/13/2024, 10/07/2024, 11/05/2024, 12/12/2024 and 01/06/2025 revealed assessments of the muscular system to have right-sided weakness with contracture of the right upper extremity (RUE). There was no treatment plan addressing the contracture of the RUE in the notes. During an interview with the surveyor on 01/21/2025 at 10:18 AM, the head therapist stated that the most recent date that the resident was on therapy was on 01/09/2024 to 02/07/2024. A review of the Occupational Therapy (OT) notes revealed the reason for therapy was because the resident was at risk for further contracture. Discharge recommendations included: Patient agreed to don and maintain wearing of right handroll for 4 hours per day with daily caregiver skin checks. During an interview with the surveyor on 01/21/2025 at 10:15 AM, Certified Nursing Assistant (CNA #3) stated that they washed the resident, set up their tray and let them stay in bed per resident's preference. During an interview with the surveyor on 01/21/2025 at 10:23 AM, CNA #4 stated that they took care of the resident in coordination with the hospice aide. They also stated that there were no devices being applied to the resident. During an interview with the surveyor on 01/21/2025 at 11:47 AM, Licensed Practical Nurse/ Unit Manager (LPN/UM #1) stated that they had a handroll and a splint for the resident before, but the resident would not wear them. When asked what the staff were doing at present for the contracture, LPN/UM #1 stated that they would ask the APN to examine the resident for any recommendations. LPN/UM #1 further stated that they did not know what happened with the recommendations as she was not working during that time period. During an interview with the surveyor on 01/22/2025 at 10:20 AM, hospice aide (HA #1) was asked what care she provided to the resident. HA#1 stated that they had to put washcloth in the right hand to clean it because the resident was stiff in the hand. HA#1 further stated that it was difficult to clean under because it was bent at the elbow close to the body. During a telephone interview with the surveyor on 01/22/2025 at 11:03 AM, the APN #1 stated that hospice followed up the resident and that the hospice aide placed rolls of towel in the resident's hand. During an interview with the survey team on 01/22/2025 at 11:32 AM, the Director of Nursing (DON) was asked how the facility addressed residents with contractures. The DON stated that the following interventions were being practiced: Residents were encouraged to reposition, staff anticipated their needs all shifts, the residents were encouraged to get out of bed, follow up with psychiatry if the residents were not compliant, pain will be addressed by the Nurse Practitioners, therapy referral if related to mobility. The DON further stated that these interventions are in the care plans and orders of the EMR. A review of an undated facility policy on 01/21/2025 at 12:42 PM titled [facility name] Assistive Device Policy under Covered Indications revealed on the third paragraph: The clinician, (therapy department or clinician designee) will usually initiate the discussion and consideration of [NAME] (mobility assistive equipment) use. Sequential consideration of the questions below provides clinical guidance for the coverage of equipment of appropriate type and complexity to restore the beneficiary's ability to participate in MRADLs (mobility-related activities of daily living) such as toileting, feeding, dressing, grooming, and bathing. N.J.A.C. 8:39-27.1(a), 27.2(m)

Based on observations, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain an indwelling urinary catheter tubing off the floor to prevent the spread of infection. This deficient practice was identified for 1 of 2 residents (Resident #261) reviewed for catheter care and was evidenced by the following: On 1/15/25 at 11:14 AM, during initial tour the surveyor observed Resident #261 seated in a wheelchair self ambulating using his/her feet down the hallway. The resident was wearing shorts and the tubing of the urinary collection bag was visible hanging out of their shorts and the tubing was dragging on the ground below the chair. The surveyor reviewed the medical record for Resident #261 as follows: A review of the Admission Record face sheet reflected that the resident was admitted to the facility with diagnoses which included urinary tract infection, dementia, and neuromuscular dysfunction of the bladder. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/21/24, reflected that the resident had a brief interview for mental status (BIMS) score of 14/15, which indicated a fully intact cognition. It further included that the resident had an indwelling catheter. A review of the resident's individualized person-centered Care Plan (CP) included a focus area initiated on 12/18/24 for utilizing an indwelling catheter related to a diagnosis of neurogenic bladder (bladder dysfunction caused by the nervous system). Interventions included to: monitor, document, notify medical doctor of signs and symptoms of complication; assess for urine characteristics (volume, color, clarity, odor) and document; keep drainage bag off the floor and cover for dignity; and change bag per facility protocol. During an interview with the surveyor on 01/22/2025 at 2:23 PM, the Infection Preventionist (IP) stated nothing should touch the floor, the tubing and bag should fit in the privacy bag, its important because you don't want cross contamination and germs spread and don't want the resident to get an infection. During an interview with the surveyor on 01/22/2025 at 10:29 AM, Licensed Practical Nurse (LPN #5) stated the urinary collection tubing should never touch the ground. If the tubing did touch the floor the nurse should replace it. During an interview with the surveyor on 01/22/2025 at 10:57 AM, Licensed Practical Nurse/Unit Manager (LPN/UM #2) stated the urinary collection tubing and bag should be placed beneath the resident's bladder and in a privacy bag. The tubing should never touch the ground, its an infection control issue, the catheter bag should then be changed. During an interview with the survey team on 01/22/2025 at 2:23 PM, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were questioned on if it was appropriate for catheter tubing to touch the floor. The DON stated urinary collection tubing should never be on the floor, its an infection control and dignity concern. The nurse should then change the tubing for the resident. A review of the facility's undated Foley Catheter Care policy included . The drainage bag must not touch the floor at any time . The policy did not include that the tubing must also be maintained off the floor. NJAC 8:39- 19.4 (a)5; 27.1 (a)

Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed implement infection control measures for the handling and storage of respiratory equipment for 1 of 3 residents reviewed for respiratory care reviewed (Resident #53). This deficient practice was evidenced by the following: During the initial tour on 01/05/2025 at 09:26 AM, the surveyor interviewed Resident #53 who stated that they had COPD (Chronic Obstructive Pulmonary Disease), (a lung disease causing restricted airflow when breathing). During the interview, the surveyor observed a nebulizer mask ( a machine and tubing used to deliver an inhaled solution into the lungs) was face down inside the bedside on top of the resident's belongings including a book, mirror, napkins, and bracelet. The mask was exposed and was undated. On 01/16/2025 at 08:09 AM, the surveyor observed Resident #53 eating breakfast in bed. A nebulizer mask connected to the machine was observed inside the side table drawer exposed and undated on top of the side table. On 01/17/2025 at 09:40 AM, the surveyor observed that the resident was out of the room and the nebulizer mask laying inside the half-open bedside drawer exposed. A review of the Admission Record revealed Resident #53 was admitted to the facility with diagnoses including but not limited to; Atrial Fibrillation (condition where the heart's upper chamber beats irregularly and rapidly), and COPD. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/19/2024, reflected a Brief Interview for Mental Status (BIMS) score of 13/15, which indicated that the resident was cognitively intact. A further review of Section O reflected the resident had not received any respiratory therapy during a seven day look back period. A review of the Order Summary Report (OSR) dated as of 07/06/2024 included the following: A Physician Order dated 07/05/2024 for Albuterol Sulfate Inhalation Nebulization Solution (a medication used to treats lung conditions like asthma. It works by opening your airways to make breathing easier.) (2.5 milligram/ 3 milliliter) 0.083% (Albuterol Sulfate) 1 dose orally via nebulizer every 6 hours as needed for wheezing. A further review of the OSR showed the order for the nebulizer was discontinued on 08/05/2025. A review of the August 2024 Medication Administration Record (MAR) indicated the last time the resident had received the albuterol solution nebulization was 08/02/2024. A review of the individualized person-centered care plan included a focus for COPD which included an intervention for administration of aerosol or bronchodilators as ordered. On 01/21/2025 at 10:28 AM, the surveyor and the resident's Licensed Practical Nurse (LPN #1) together observed the exposed nebulizer mask in the resident's side table. LPN #1 stated that the mask should have been bagged and labeled. On 01/22/2025 at 01:55 PM, in the presence of the survey team, the Director of Nursing (DON) stated that the nebulizer mask should be put in a bag when not in use. A review of the undated facility's Oxygen Administration policy did not address the care or storage of nebulizers. NJAC 8:39-27.1 (a)

Complaint#: NJ#162903, NJ#173303, NJ#175318, NJ#177086 Based on interviews, Medical Records (MRs) review, and review of other pertinent facility documents on 09/30/24, 10/01/24, 10/02/24, 10/3/24, and 10/04/24, it was determined that the facility failed to protect two residents (Resident #16 and Resident #7) from physical abuse from Resident #14, who was non-compliant with his/her Psychotropic medication, required close supervision and has a known history of aggressive behavior and diagnoses of Dementia with Anxiety Disorder, Schizophrenia and Other Specified Mental Disorders due to known psychological conditions. According to the MRs, on 04/24/24, Resident #14 physically attacked Resident #16 by punching Resident #16 in the face with a closed fist and became verbally aggressive. The residents were separated, the Physician was notified and ordered Resident #14 to be sent to the local hospital for evaluation and treatment. Further review of the MRs revealed on 07/01/24, Resident #14 was observed hitting Resident #7 with a closed fist and pulling the Resident's hair, causing him/ her to fall to the ground screaming. The residents were separated by facility staff, and Resident #14 went into his/her room and slammed the door. Resident #7 sustained a laceration to the forehead and was sent to the emergency room (ER) for evaluation. He/She returned from the ER with a diagnosis of left orbital laceration with hematoma. The police were called, and Resident #14 was taken to the Psychiatric Emergency Screening Services (PESS) unit for evaluation. The facility's failure to protect Resident #7 and Resident #16 from physical abuse and failure to ensure Resident #14 plan of care was revised to address the Resident's needs, implement the recommendation for Supervision placed Resident #7, Resident #16 and all other residents in an Immediate Jeopardy situation. The Immediate Jeopardy began on 04/24/24 through 07/03/24, when Resident #14 was discharged from the facility. The facility also failed to protect Resident #13 and Resident #19 from staff to resident physical and verbal abuse. According to a facility's incident report, which included a witness statement by Certified Nursing Assistant (CNA #12), on 09/16/24 at approximately 8:25 p.m., she saw Resident #19 walk behind the nurse's station and tap the Licensed Practical Nurse (LPN#10) on the shoulder. LPN #10 then pushed Resident #19 and yelled, Get away from here; you are not supposed to be back here. CNA #12 stated she reported the incident to her supervisor. A second incident report, which included a witness statement written by LPN #11 dated 9/17/24, revealed on the following day, Resident #13 grabbed a binder from the nurse's station counter, and LPN #10 tried to pull the binder from Resident #13. LPN #10 yelled at Resident #13, Leave the s--- [expletive] alone, she then swiped the binder away from Resident #13, hitting the Resident's hand, then yelled, Get the f--- [expletive] out of here! LPN #11 tried to separate LPN #10 and Resident #13 and then reported the incident to the Unit Manager (LPN #12). The facility's failure to ensure Resident #19 and Resident #13 was protected from physical and verbal abuse from LPN #10, placed Resident #13, Resident #19 and all other residents at risk for physical and verbal abuse and in an IJ situation. The IJ was determined to exist as of 09/16/24 through 9/17/24. for Freedom from Abuse, Neglect, and Exploitation at a Scope and Severity (S/S) of a J. The Immediate Jeopardies (IJs) was identified and reported to the facility's Director of Nursing (DON) on 10/02/24 at 9:12 p.m. The DON was presented with the IJ templates, which included information about the issues. On 10/11/24, the Surveyor did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating the DON and Assistant Director of Nursing (ADON) on investigating allegations of abuse, reviewing and revising policies, and staff education on abuse. After the removal of the IJ, the noncompliance remained at a scope and severity level of G (Actual harm that is not immediate jeopardy). This deficient practice was identified for 4 of 29 residents, Resident #7, Resident #13, Resident #16, and Resident #19, and was evidenced by the following: 1. According to the Electronic Medical Record (EMR), Resident #14 was admitted with a diagnosis of Schizophrenia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/24, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the Resident was cognitively intact. The assessment indicated the Resident had no hallucinations or delusions and was not a threat to self or others. According to Resident # 14's care plan (CP) dated 1/12/2024, included under Focus,: I (Resident #14) have a long Hx (history) of Mental Illness with behaviors. My behaviors can include: periods of increased agitation, periods of increased anxiety, can be physically/ verbally aggressive, assaultive, throws furniture, bangs/ slams doors, yells/ screams out, responds to internal stimuli, Delusional thinking, refuses Meds (medication) / TX (treatment), conflicts with peers/ roommate, and Low tolerance for cognitive impaired peers. Under Goal, indicated: My mood/ behaviors will remain stable with my baseline . Under Interventions included: alert to impending violence aggressive behaviors, maintain safety for all, remove all objects that can harm (him/ her) or others, keep 4 arm's length apart, decrease his/her stimuli, attempt to verbally de-escalate . Further review of the CP revealed Under Interventions, Resident #14 had an altercation with a peer on 04/24/25. According to the interventions, the Resident assaulted his/her peer and had verbal aggression. The CP interventions indicated that safety maintained for all, the police were called, and the primary care physician (PCP) orders were obtained to send the Resident to the local hospital; the Resident refused to go, pending PESS evaluation, to follow-up with the psychiatric team, and to attempt to identify antecedents to behavior. A review of Resident #14's Progress Note (PN) revealed the following: On 3/12/24, the Psychiatry Progress Note (PPN), written by psychiatric Nurse Practitioner (NP) #1, revealed Resident #14 had fair awareness of events, fair impulse control, and poor judgment. The NP also indicated the Resident had a diagnosis of Schizophrenia with anxiety and was not cooperative during the interview. Medication compliance should be encouraged at this time, and staff should send Resident #14 out to PESS if the Resident becomes a danger to self or others. On 04/24/24 at 10:18 p.m., revealed Resident #14 slapped Resident #16's face with a closed fist and became verbally aggressive. The police were notified. The Physician was notified and ordered Resident #14 to be sent to the local hospital for evaluation and treatment. On 04/25/24 at 7:35 a.m., indicated on 04/24/24 at 11:30 p.m., the emergency medical technicians (EMTS) and the police arrived at the facility to transfer Resident #14 to the hospital, but the Resident refused. The Resident screamed at EMTS, telling them to get out, and slammed the door. The police were unable to take him/ her to the hospital because of his/her refusal unless PESS determined the Resident required hospitalization . At the time of PESS, they determined that the Resident was calm and did not need to go to the hospital. The note indicated the Resident remained calm for the rest of the shift. At 12:59 p.m., the Resident was .being aggressive and combative with behaviors, attempting to hit staff, throwing items unable to redirect .Unable to redirect, 1:1 was placed outside the room for safety. On 04/26/24 at 10:47 a.m., the PPN, written by NP #3, revealed she met with the Resident to assess him/her. The Resident continued to refuse his/her medications and had intermittent outbursts of aggressive behaviors. The NP noted the Resident was evaluated by S-cope on 04/25/24, and due to severe paranoid delusion, it was recommended the Resident be evaluated for a behavioral health nursing home. The Resident is currently on one-to-one. On 4/26/24 at 1:04 p.m., written by the Nurse Manager, the PN revealed, .At times would yell out for no specific reason, throwing food and drinks on the floor. Staff supervised at a distance . On 04/30/24 at 3:46 p.m., the Social Services PN (SSPN) indicated the facility heard back from the Resident's case manager and was informed the Resident did not meet the criteria for behavioral health placement. On 5/2/24 at 1:52 p.m., written by LPN #1, Resident #14 was accosting Resident #7; the police were called, and the police advised that they could do nothing at this time. On 5/09/24 at 7:26 a.m., Resident had an episode of combative, aggressive behavior w/[with] hostile verbal outburst, throwing objects at this writer . On 05/13/24, the PPN written by NP #2 revealed Resident # 14 was seen for follow-up medication management due to refusal of all medications and schizophrenia paranoid type. The note indicated the Resident was agitated, unpredictable, impulsive, and suspicious and slammed the door in front of NP #2. The note continued that the Resident had a history of hitting staff, throwing items, and making multiple calls to the police and PESS. The note revealed the Resident was not taken to the hospital after a PESS evaluation since the Resident refused to go. NP #2 indicated the Resident had poor insight, judgment, and impulse control and directed the facility to call PESS if the Resident became a danger to self or others. On 5/16/24 at 12:44 a.m., Resident #14 got into a verbal altercation with Resident #7. On 5/25/24 at 2:47 p.m., the Resident continued to yell at self-picks up objects and slam them down. On 05/29/24 at 9:50 a.m., the PPN, written by NP #3, revealed the Resident refused his/her physical exam and directed the clinical staff to continue with the Resident's current care plan and encourage medication compliance. 05/29/24 at 2:26 p.m., the PN indicated a housekeeper entered the Resident's room to empty a trashcan. The Resident jumped out of his/her bed, chased the housekeeper, and attempted to throw the trashcan at the staff. The housekeeper twisted her ankle after this encounter. On 06/10/24 at 9:32 a.m., the PPN written by NP #4 revealed the NP attempted to meet with Resident #14. The Resident had his/her head covered with a blanket and refused to answer her questions about the status of his/her health. NP #4 directed the clinical staff to continue medication compliance. On 06/19/24 at 1:36 p.m., Resident #14 was yelling and slamming items in his/her room. After the noise subsided, a nurse entered the Resident's room and found two holes in the wall. Further review of the PN on 06/19/24 revealed that the Resident threw a knife in the hallway and continued to threaten staff and residents verbally and physically. On 06/20/24 at 12:06 p.m., the PNs revealed Resident #14 kicked a garbage can at a CNA, took off his/her belt, swung it at the CNA, and stated he/she was going to beat her with it. According to the note, residents and housekeeping witnessed this incident. PESS was again notified, the Resident was assessed, and the Resident was transported to the hospital. The Resident returned to the facility the same day and showed no behaviors. On 06/29/24 at 10:03 p.m., written by the LPN revealed Resident #14 came out of his/her room and threatened to kill staff if they ever entered his/her room and touched his/her belongings. Further review of the PN showed no evidence that this behavior was addressed. On 07/01/24 at 11:12 p.m., the PNs revealed Resident #14 was seen in the hallway hitting Resident #7 in the face with a closed fist and pulling Resident #7's hair, which caused him/her to fall to the floor. Resident #14 then slammed the door to his/her room. The police were called, and the Resident was taken to the PESS unit for evaluation. Both the Resident's medical provider and responsible parties were notified. On 07/03/24 at 8:00 a.m., the PNs written by LPN #2 indicated Resident #14 was discharged to a behavioral health center. A review of a document provided by the facility titled Statewide Clinical Outreach Program for the Elderly (S-cope), dated 04/25/24, indicated the outreach program screened Resident #14 due to the Resident's continuation of refusals of his/her medications, agitation, and delusional thinking. S-cope made the following recommendations: to continue one-to-one to ensure safety; to follow up with the facility's psychiatrist/physician about lifting the one-on-ones; to utilize ABC tracking (tracking of activity, antecedent, behavior, and consequences related to behaviors) to identify trends and triggers in Resident #14's behaviors; to utilize this method for five days, and then fax the completed forms to S-cope. Review of a second S-cope document dated 06/21/24 indicated the clinician made the following recommendations for the Resident's mental health needs: continue to provide one-on-one to the Resident; utilize the ABC to track and trend the Resident's behaviors, utilize and fax the completed ABC form to S-cope; and to have the facility's psychiatrist follow-up with the Resident and refusals of medications. Review of the EMR revealed no documented evidence that the Physician was notified, and an order was obtained to stop the one-on-one Supervision. In addition, the facility was unable to provide evidence that behavior tracking was forwarded to S-cope as recommended. Review of Resident #14's Medication Administration Record (MAR) dated 3/1/2024 - 3/31/2024 indicated the Resident refused his/her medications as follows: Aricept (used for dementia) Oral Tablet 5 (milligram) mg 1 tablet by mouth at bedtime 9:00 p.m. Refused on 3/2-3/6, 3/9, 3/10, 3/12 - 3/18, 3/20 and 3/22- 3/31/2024. Risperidone (used to treat symptoms of Schizophrenia) Oral Solution 1 mg/ml. Give 1 milliliter (ml) by mouth two times a day at 9:00 a.m. and 9:00 p.m. Refused 9:00 a.m. dose from 3/1- 3/31/2024. Refused 9:00 p.m. dose on 3/2 -3/7, 3/9, 3/10, 3/12-3/18, 3/20 and 3/22-3/31/2024. Review of Resident #14's MAR dated 4/1-4/30/2024 indicated the resident refused the following medications: Aricept Oral Tablet 5 (milligram) mg 1 tablet by mouth at bedtime 9:00 p.m., on 4/1-4/6, 4/8-4/14, 4/16-4/19 and 4/21-4/30/2024. Risperidone Oral Solution 1 mg/ml. Give 1 ml by mouth two times a day at 9:00 a.m. and 9:00 p.m., 9:00 a.m. dose on 4/1-4/5, 4/7, 4/8, 4/10-4/20, 4/22-4/26 and 4/28-4/30/2024, and 9:00 p.m. dose on 4/1-4/6, 4/8-4/14, 4/16-4/19, 4/21-4/25 and 4/27-4/30/2024. Review of Resident #14's MAR dated 5/1-5/31/2024 indicated the resident refused the medications as follows: Aricept Oral Tablet 5 mg 1 tablet by mouth at bedtime 9:00 p.m., on 5/1-5/12, 5/14-5/17, 5/19-5/22, 5/24-5/27 and 5/29 -5/31/2024. Risperidone Oral Solution 1 mg/ml. Give 1 ml by mouth two times a day at 9:00 a.m. and 9:00 p.m. Refused 9:00 a.m. dose from 5/1-5/31/2024, 9:00 p.m. dose on 5/1-5/12, 5/14-5/17, 5/19-5/22, 5/24, 5/25, 5/27, 5/29 and 5/31/2024. Review of Resident #14's MAR dated 6/1-6/30/2024 revealed the resident refused the following medications: Aricept Oral Tablet 5 mg 1 tablet by mouth at bedtime 9:00 p.m., from 6/1-6/30/2024. Risperidone Oral Solution 1 mg/ml. Give 1 ml by mouth two times a day at 9:00 a.m. and 9:00 p.m., at 9:00 a.m. 6/1-6/3, 6/5-6/12, 6/14-6/25 and 6/27-6/30/2024, and 9:00 p.m. dose on 6/1-6/19 and 6/21-6/30/2024. Review of Resident #14's MAR dated 7/1-7/31/2024 indicated the Resident refused the medications as follows: Aricept Oral Tablet 5 mg 1 tablet by mouth at bedtime 9:00 p.m. Risperidone Oral Solution 1 mg/ml. Give 1 ml by mouth two times a day at 9:00 a.m. and 9:00 p.m. on 7/1/2024. There was no evidence that the resident's plan of care was revised or the Physician was notified for all of the aforementioned refusals. 2. Review of the EMR, revealed Resident #16's was admitted with a diagnosis chronic kidney disease, high blood pressure and anxiety disorder. The MDS dated [DATE] showed the Resident had a BIMS score of 15 out of 15, which indicated the Resident was cognitively intact. A review of the CP dated 04/22/24 revealed that Resident #16 was identified as at risk for falls or injury related to decreased mobility, deconditioning and poor safety and at risk for bruising or bleeding and had the potential for alteration in his/her mood due to a diagnosis of anxiety disorder. A review of the PN dated 04/24/24 at 10:27 p.m., revealed that Resident #16 was walking into nourishment room when Resident #14 started yelling at Resident #16 and hit her/his face with a closed fist. The residents were separated and Resident #16 stated [She/he] wanted to press charges. Call to police Ice applied to red area on Resident #16's face. 3. Review of the EMR revealed Resident #7 was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD). The quarterly MDS, with an ARD of 04/19/24, indicated the Resident had a BIMS score of 15 out of 15, which revealed the Resident was cognitively intact. A review of the PNs dated 07/01/24 at 11:00 p.m. revealed that Resident #7 was screaming in the hallway. Facility staff responded and separated Resident #7 and Resident #14. The police were notified, and Resident #14 was removed from the facility. In addition, the RN revealed that Resident #7 sustained a laceration on his/her forehead and was sent to the ER for evaluation and treatment of head injury. Further review of the PN dated 07/02/24, at 4:56 a.m., revealed Resident #7 returned from the hospital with a left orbital laceration with a hematoma. During an interview on 09/30/24 at 6:02 p.m., the ADON stated he expected PESS to be contacted when there was aggressive behavior by a resident to decide if the Resident was a threat. However, there was no evidence provided that PESS was notified every time Resident #14 had changes in his/her behavior. During an interview on 09/30/24 at 6:42 p.m., Resident #7 stated he/she remembered Resident #14. Resident #7 explained that the Resident left his/her room to get a soda, and Resident #14 jumped him/her from behind. Resident #7 explained he/she fell to the floor, was sent to the emergency room , and the staff glued a large gash on his/her forehead. During an interview on 10/01/24 at 10:22 a.m., CNA #3 stated he worked with Resident #14 and stated the Resident would throw things at him and was very violent with both staff and residents. CNA #3 stated that anything would set the Resident off, and he/she would just flip. According to the CNA, Resident #14 would punch holes in the walls of the Resident's room. During an interview on 10/01/24 at 11:10 a.m., Resident #16 confirmed Resident #14 punched him/her in the face. Resident #16 stated it was painful, and the punch took him by surprise. During an interview on 10/01/24 at 11:19 a.m., NP #1 confirmed he remembered Resident #14. According to NP #1, Resident #14 would refuse medications and punch people in the face. NP #1 stated that there were staff who were too scared to enter the Resident's room. He did not make any medication recommendations since it did not matter if he did since Resident #14 did not take his/her psychotropic medications to treat his/her behaviors. During an interview on 10/01/24 at 12:34 p.m., CNA #4 stated she witnessed the assault from Resident #14 to Resident #7. According to the CNA, Resident #14 punched Resident #7, the Resident then fell to the ground, and Resident #14 proceeded to kick the Resident. CNA #4 further stated Resident #7 sustained a cut close to the eye, and the area was bleeding and swollen. The CNA stated the facility was not providing one-on-ones for Resident #14 prior to this incident. During an interview on 10/01/24 at 2:13 p.m., in the presence of the DON and ADON, the Administrator stated that the facility receives recommendations from S-cope for residents and does not keep a resident on one-on-one forever. At the time of the interview, a request was made for evidence of the one-on-one Supervision, why Resident #14 was taken off one-on-one Supervision, and about ABC tracking. The Administrator stated he would have to ask the nursing staff. The Surveyor also requested any psychiatric assessment after the 04/24/24 incident and before the psychiatric NP visit with Resident #14 on 05/13/24 and to provide any information related to safety measures taken with Resident #14 after 04/24/24 when he/she hit Resident #16. However, the facility was unable to provide the requested information. During a second interview on 10/01/24 at 3:34 p.m., the Administrator brought in copies of Resident #14's nursing PNs and stated the Resident had no behaviors after 04/24/24, and the one-on-ones were stopped. He also presented a document from S-cope dated 04/25/24 and stated he believed S-cope came out again prior to 05/13/24. According to the Administrator, Resident #14 refused all of his/her medications. The ABC tracking was used to document all of the resident behaviors. The Administrator stated that S-cope was coming out all the time and providing direction to the facility staff on a regular basis. During an interview on 10/02/24 at 9:59 a.m., the Mental Health Clinician (MHC) with S-cope stated that she assessed Resident #14 on 04/25/24 and again on 06/21/24. The MHC stated she met with the Resident four times between 04/25/24 and 07/01/24 and made the same recommendations on 06/21/24 as on 04/25/24. MHC stated the Resident was determined not to be a danger to others when she met with Resident #14. During an interview on 10/02/24 at 10:14 a.m., Licensed Practical Nurse (LPN) #1 stated he worked the night shift and was not aware Resident #14 was on Supervision. During an interview on 10/02/24 at 10:48 a.m., the Medical Director (MD) stated he was familiar with Resident #14 and was his Primary Care Physician (PCP). According to the MD, he was surprised to hear that the Resident could refuse to go with the EMTs and police, which he had never seen before. The MD stated he remembered getting on the phone with the EMTs, and the EMTs informed him that if Resident #14 refused to be taken to the hospital, they could not force the Resident to do so. The MD stated the only way for the Resident to receive treatment was for the Resident to totally decompensate in his/her condition. Regarding the issue with Resident #14 refusing his/her psychotropic medications, he stated the facility could only monitor his/her condition. During an interview on 10/2/24 at 4:20 p.m., the DON stated that if a resident required one-on-one Supervision, they were not appropriately placed in the facility and needed a higher level of care. She stated the Resident would not be safe, and their needs were too high of an acuity for the facility. According to the DON, If someone needs that one-on-one monitoring, this is not the place for them. Review of the facility's reported incident investigation, provided by the Administrator revealed that two staff to Resident witnessed abuse occurred with Resident #19 and Resident #13 involving the same nurse (LPN #10). According to a witness statement from CNA #12 dated 09/16/24 at approximately 8:25 p.m., Resident #19 walked behind the nurse's station and tapped LPN #10 on the shoulder. LPN #10 then pushed Resident #19 and yelled, Get away from here, you are not supposed to be back here. Review of the second facility's incident investigation dated 09/17/24 revealed a witness statement from LPN #11, which showed on 09/17/24 at 7:00 a.m., she was standing at the medication cart, saw Resident #13 grab a binder from the nurse's station counter, and LPN #10 tried to pull the binder from Resident #13. According to the statement, LPN #10 yelled Leave the s--- [expletive] alone, swiped the binder away from Resident #13, hitting his/her hand, then yelled, Get the f--- [expletive] out of here! LPN #11 also indicated she tried to break them up and then reported the incident to the Unit Manager. 4. Review of Resident #19's EMR showed the Resident was admitted to the facility with diagnoses that included Alzheimer's disease with late onset, anxiety disorder, and major depression. According to the MDS, Resident #19 had a BIMS score of 2 out of 15, which indicated the Resident was severely cognitively impaired. A review of Resident #19's nursing PN dated 09/17/24 at 4:51 p.m. revealed, . Investigating staff reported aggressive behavior from staff to Resident. Witnessed incident with no injuries noted. The assigned nurse was noted to act in a confrontational manner towards [Resident #19]. Other staff members quickly de-escalated the incident. R#19 is unable to verbalize any details r/t [related to] incident but can answer simple yes or no questions. The RN assessed Resident #19, and no injury was noted. NP notified and assessed . Review of R #19's CP dated 09/17/24 revealed a long history of behaviors related to dementia problem area with an intervention of, . victim of incident 09/16/24 follow-up with psych services as needed and provide emotional support to [the] resident . Review of Resident #19's CP date initiated 12/28/23, revealed a long history of behaviors related to dementia. Interventions to include Caregivers to provide opportunity for positive interaction, explain all procedures to the Resident before starting and allow the Resident to adjust to changes. 5. Review of the EMR revealed Resident #13 was admitted with diagnoses that included dementia without behavioral disturbance, anxiety disorder, and depression. The annual MDS, with an ARD of 08/22/24 showed a BIMS score of one out of 15, which indicated Resident #13 was cognitively intact. A review of Resident #13's Physicians Progress Note, dated 09/17/24 at 10:17 a.m., revealed that the . [Resident] was seen ambulating on the unit. Says he/she is feeling well. No c/o [complaints of] pain or discomfort. It was reported to me by the DON [Director of Nursing] that [the] patient [Resident] was pushed by a staff member. The Resident does not remember the incident. No injuries noted . Plan: . Continue current medications .fall precautions. Monitor for bleeding . Review of Resident #13's nursing PNs dated 09/19/24 revealed, .Seen by [Psychiatric Provider]. Xanax [an antianxiety medication] 0.25 mg [milligrams] daily PRN [as needed] anxiety and increase in Buspar [an antianxiety medication] 15 mg BID [twice a day]. Behavior charting for anxiety X [times] 14 days . Review of Resident #13's CP dated 09/17/24 revealed a care area focus of history of behaviors related to dementia with an intervention of, . a victim of incident 9/17/24 follow-up with psych services as needed provide ongoing emotional support to [the] resident, administer medications as ordered, and monitor/document side effects and effectiveness . Review of Resident # 13's CP with a revision date on 11/28/23 revealed, Focus: history of behaviors related to dementia with behaviors that can include periods of increased restlessness, periods of increased anxiety and enters peer's personal spaces. Interventions: Attempt to identify antecedents to my behavior and monitor for wandering into other personal spaces, redirect him/her to his/her own personal space or common area. It was recorded the police were contacted on 09/19/24, and all staff were trained on abuse and neglect on 09/17/24. Both incident investigations revealed the staff to Resident abuse for Resident #19 and Resident #13 was substantiated. LPN #10 was suspended on 09/17/24 while the investigation was in progress. LPN #10 did not work after this date and was terminated on 09/23/24. The documentation further revealed that the DON/ADON was aware of the incidents on 09/17/24. During a combined interview on 09/30/24 at 2:10 p.m., the Administrator and DON revealed that she [DON] was notified of the abuse allegation when she arrived at the facility on 9/17/24 at 8:00 a.m., and the ADON was notified when he arrived at 7:30 a.m. The DON notified the Administrator as soon as it was reported to her. The DON stated LPN #10 was already gone for the day; he was suspended during the investigation and asked to come to the facility to write a statement, and then was terminated on 09/23/24. According to the Administrator, he watched the camera and saw LPN #10 and Resident #13 close to each other at the nurse's station but could not see what occurred. The DON stated the ADON interviewed the residents in the memory care unit, and there was no reported abuse by LPN #10. During an interview on 10/04/24 at 11:30 a.m., CNA #12 stated on 09/16/24 at approximately 8:25 p.m., she saw Resident #19 walk behind the nurse's station, tap LPN #10 on the shoulder, then LPN #10 pushed Resident #19 and yelled, Get away from here, you are not supposed to be back here. CNA #12 stated she did report the allegation to her supervisor. However, LPN #10 continued to provide care for other residents. During a combined interview on 09/30/24 at 2:10 p.m., the DON revealed they were made aware of the abuse allegation when the ADON found a note under his door from Registered Nurse (RN) #3 with a witness statement attached prior to his arrival on 09/17/24. The Administrator confirmed he received LPN #10's statement on 09/17/24. The DON stated she reported the incident to the State Survey Agency (SSA) on 09/17/24. The DON stated she instructed CNA #12 to report allegations of abuse immediately. The DON stated she provided training to all staff members regarding reporting allegations of abuse immediately. A review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with a review date of 05/2023, revealed the following: Under Policy Statement included Residents have the right to be free from abuse, neglect .This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse . Under Policy Interpretation and Implementation included The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect exploitation and mistreatment of property by anyone including but not necessarily limited to: a. facility staff; b. other residents .e. staff from other agencies .j. any other individual .2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents . N.J.A.C.: 8:39-4.1 (a) 5 28604

Complaints #: NJ162903, NJ166982, NJ168479 NJ172819, NJ172820, NJ173142 NJ173303, NJ175318, NJ175692 NJ177086 610 S/S H Based on interviews, review of medical records (MR), and other facility documentation on 9/30/24, 9/30/24, 10/01/24, 10/02/24, 10/03/24, and 10/04/24, it was determined that the facility failed to ensure residents' safety by not initiating a thorough and complete investigation was completed for employee-to-resident and resident-to-resident abuse allegation. Specifically, the facility failed to conduct a thorough investigation when Resident #10 was placed in involuntary seclusion, and Resident #14 threw a knife into the hallway and continued to display verbal and physical threats toward staff and other residents. The facility also failed to implement its policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This deficient practice was identified for 2 of 29 residents (Resident #10 and Resident #14) and was evidenced by the following 1. According to the ADMISSION RECORD (AR), Resident #10 was admitted with diagnoses which included but not limited to Huntington's disease, Muscle Weakness, Gait instability, and Anxiety Disorder. The Minimum Data Set (MDS), an assessment tool dated 4/4/24, revealed that Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating Resident #1's cognition was intact. The Care Plan (CP), dated 4/22/24, indicated that Resident #10 was left in the dayroom against her/his wishes. Review of the REPORTABLE EVENT RECORD (RER), a New Jersey Department of Health (NJDOH) document used by the healthcare facilities to report incidents dated 4/19/2024, revealed that Resident #10 reported around [7:30 a.m. Resident #10] reported that the [CNA #1] assigned last night placed [her/him] in the day room and would not let [her/him] out. A review of the [Long Term Care] Reportable Event Survey (LTCRES), also known as RER, dated 4/19/24, completed by the former Director of Nursing, provided by the facility, revealed Resident #10 reported that around 3:00 a.m., [the] [CNA] c.n.a. on duty put the Resident in the room and blocked the door so [he/she] could not leave. Further review of the LTCRES included an Investigative Summary (IS). According to the IS, on 4/19/24, Resident #10 reported to the nurse that he/she was placed in the day room with the door closed, preventing the Resident from exiting the dayroom. In addition, the IS indicated that during an interview conducted by the former Director of Nursing (DON) and Social Services (SS), Resident #10 reported he/she was in the hallway around 3:00 a.m. and was looking to leave the nursing According to the IS, Resident #10 said the aide took the Resident and placed him/her in the day room. The Resident explained that he/she did not want to be outside the door blocking the Resident's ability to exit. The IS further indicated that Resident #10 stated, After a period of time, the nurse on duty brought the Resident back to [his/her] room. The conclusion indicated, Upon completing this investigation, reading statements that have been provided by staff and Social Service follow-up, it is in my opinion that [Resident #10] was kept in the room against [her/his] wishes . Review of CNA #1's statement, dated 4/19/24, the CNA wrote I .worked on 4/18/24 on the dementia floor of the [NAME] Wing. The patient [Resident #10] tried to go to the west wing at [3:00 a.m.] which was not [her/his first] attempt. The nurse advised me to retrieve [her/him] from south wing [and] direct [her/him] into the dayroom where the other [patients] with behaviors were being monitored [and] so i [I] did. Before [Resident #10] was in the room the nurse instructed us to keep the door closed because they are fall risks to ensure their safety. According to the statement, when [Resident #10] asked to leave the room, the nurse [escorted her/him to her/his] room. No force was used. There was no body-to-body contact. The Resident did say [she/he] was gonna [going to] tell the unit manager I hurt her hand so I could get fired. The CNA further explained that when the door was closed, she was sitting on the other side to ensure the residents' safety and to keep an eye on them. A review of the Disciplinary Action Form, dated 4/19/24, included: Under Nature of Offense, noted Patient Rights and Resident Abuse or Neglect was checked off as the issues. Under: Detailed description of offense . included Resident [#10] stated [CNA #1] put her in the dayroom and would not let her out. Under Action Taken, showed a Suspension start date of 4/19/24. During an interview on 09/30/24 at 5:25 p.m., Resident #10 stated he/she was not permitted to leave the visitation area. Resident #10 further stated that when he/she asked to leave the area, the CNA told her/him to remain in the dayroom area. During a second interview on 10/01/24 at 11:52 a.m., Resident #10 stated that he/she was terrified when [CNA #1] sat in front of the door while she 'begged' the CNA to let him/her out. During an interview on 10/01/24 at 5:30 p.m., the Administrator stated that he reviewed the surveillance camera and saw Resident #10 was locked in the room. The CNA was sitting outside the door, and Resident #10 attempted to open the door. The Administrator further stated that other residents were also in the day room, and a staff member was inside the dayroom with the residents. At the time of the survey, the facility could not provide documented evidence that a complete and thorough investigation was completed for the 4/19/24 incident involving Resident #10 and other residents locked in the day room at 3:00 a.m. and that the facility assessed and ensured the safety of the residents. The facility also could not provide evidence that the nurse and staff in the day room were identified, interviewed, and educated. 2. According to Resident #14's AR indicated the Resident was admitted with diagnoses which included but not limited to Schizophrenia and Anxiety disorder. Review of Resident #14's progress notes (PN), dated 6/19/24 at 2:27 p.m., documented by LPN #5 [Resident #14] was observed throwing a knife into the hallway. [Resident #14] continues to display verbal and physical threats towards staff and other residents records that the Resident threw a knife in the hallway and made verbal and physical threats to staff and to residents. The facility was unable to provide documented evidence that when Resident #14 made verbal and physical threats to staff and to residents was thoroughly investigated to ensure other residents safety. During an interview on 10/01/24 at 5:30 p.m., the Administrator stated that the process for investigating resident/staff allegations is to pull the staff off of the unit and interview the staff and the other residents. The Administrator further stated he would ask staff for written statements and to interview other residents. However, the facility failed to provide documented evidence that the aforementioned incident was thoroughly investigated for safety. During an interview on 10/02/24 at 12:05 p.m., the DON stated she had no control over what happened prior to her hire but stated she would have begun an investigation, which would have included both staff and Resident interviews. A review of a policy provided by the facility titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 05/2023, indicated, .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal management, involuntary seclusion, verbal, mental, sexual or physical abuse .The resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect .by anyone including, but not necessarily limited to: a. facility staff b. other residents .c staff from other agencies .j. any other individual .5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems . NJAC: 8:39-27.1 (a)

Complaint #: NJ#162903, NJ#166982, NJ#168479, NJ#172819, NJ#172820, NJ#173142, NJ#173303, NJ#175318, NJ#175692, NJ#177086 Based on interviews, record review, and review of other pertinent facility documentation, it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure 1) residents' safety and well-being were maintained for physical and verbal abuse. The LNHA also failed to ensure the facility's policies titled Physical Restraints, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, and the Administrator job description were followed. This deficient practice was identified for 5 of 29 residents (Resident #7, Resident #10, Resident #13, Resident 16, and Resident #19) and was evidenced by the following: A review of Resident #14's Progress Note (PN) revealed the following: 1. According to the Electronic Medical Records (EMR), Resident #14 was admitted with a diagnosis of Schizophrenia. The Minimum Data Set (MDS), an assessment tool with an Assessment Reference Date (ARD) of 01/20/24, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the Resident was cognitively intact. The assessment indicated the Resident had no hallucinations or delusions and was not a threat to self or others. According to Resident # 14's care plan (CP) dated 1/12/2024, included under Focus,: I (Resident #14) have a long Hx (history) of Mental Illness with behaviors. My behaviors can include: periods of increased agitation, periods of increased anxiety, Can be physically/ verbally aggressive, assaultive, throws furniture, bangs/ slams doors, yells/ screams out, responds to internal stimuli, Delusional thinking, refuses Meds (medication) / Tx (treatment), conflicts with peers/ roommate, and Low tolerance for cognitive impaired peers. Under Goal, indicated: My mood/ behaviors will remain stable with my baseline . Under Interventions included: alert to impending violence aggressive behaviors, maintain safety for all, remove all objects that can harm (him/ her) or others, keep 4 arm's length apart, decrease his/her stimuli, attempt to verbally de-escalate . Further review of the CP revealed Under Interventions, Resident #14 had an altercation with a peer on 04/24/25. According to the interventions, the Resident assaulted his/her peer and had verbal aggression. The CP interventions indicated that safety maintained for all, the police were called, and the primary care physician (PCP) orders were obtained to send the Resident to the local hospital; the Resident refused to go, pending PESS evaluation, to follow-up with the psychiatric team, and to attempt to identify antecedents to behavior. On 3/12/24, the Psychiatry Progress Note (PPN), written by psychiatric Nurse Practitioner (NP) #1, revealed Resident #14 had fair awareness of events, fair impulse control, and poor judgment. The NP also indicated the Resident had a diagnosis of Schizophrenia with anxiety and was not cooperative during the interview. Medication compliance should be encouraged at this time, and staff should send Resident #14 out to PESS if the Resident becomes a danger to self or others. On 04/24/24 at 10:18 p.m., revealed Resident #14 slapped Resident #16's face with a closed fist and became verbally aggressive. The police were notified. The Physician was notified and ordered Resident #14 to be sent to the local hospital for evaluation and treatment. On 04/25/24 at 7:35 a.m., indicated on 04/24/24 at 11:30 p.m., the emergency medical technicians (EMTS) and the police arrived at the facility to transfer Resident #14 to the hospital, but the Resident refused. The Resident screamed at EMTS, telling them to get out, and slammed the door. The police were unable to take him/ her to the hospital because of his/her refusal unless PESS determined the Resident required hospitalization . At the time of PESS, they determined that the Resident was calm and did not need to go to the hospital. The note indicated the Resident remained calm for the rest of the shift. At 12:59 p.m., the Resident was .being aggressive and combative with behaviors, attempting to hit staff, throwing items unable to redirect .Unable to redirect, 1:1 was placed outside the room for safety. On 04/26/24 at 10:47 a.m., the PPN, written by NP #3, revealed she met with the Resident to assess him/her. The Resident continued to refuse his/her medications and had intermittent outbursts of aggressive behaviors. The NP noted the Resident was evaluated by S-cope on 04/25/24, and due to severe paranoid delusion, it was recommended the Resident be evaluated for a behavioral health nursing home. The Resident is currently on one-to-one. On 4/26/24 at 1:04 p.m., written by the Nurse Manager, the PN revealed, .At times would yell out for no specific reason, throwing food and drinks on the floor. Staff supervised at a distance . On 04/30/24 at 3:46 p.m., the Social Services PN (SSPN) indicated the facility heard back from the Resident's case manager and was informed the Resident did not meet the criteria for behavioral health placement. On 5/2/24 at 1:52 p.m., written by LPN #1, Resident #14 was accosting Resident #7; the police were called, and the police advised that they could do nothing at this time. On 5/09/24 at 7:26 a.m., Resident had an episode of combative, aggressive behavior w/[with] hostile verbal outburst, throwing objects at this writer . On 05/13/24, the PPN written by NP #2 revealed Resident # 14 was seen for follow-up medication management due to refusal of all medications and schizophrenia paranoid type. The note indicated the Resident was agitated, unpredictable, impulsive, and suspicious and slammed the door in front of NP #2. The note continued that the Resident had a history of hitting staff, throwing items, and making multiple calls to the police and PESS. The note revealed the Resident was not taken to the hospital after a PESS evaluation since the Resident refused to go. NP #2 indicated the Resident had poor insight, judgment, and impulse control and directed the facility to call PESS if the Resident became a danger to self or others. On 5/16/24 at 12:44 a.m., Resident #14 got into a verbal altercation with Resident #7. On 5/25/24 at 2:47 p.m., the Resident continued to yell at self-picks up objects and slam them down. On 05/29/24 at 9:50 a.m., the PPN, written by NP #3, revealed the Resident refused his/her physical exam and directed the clinical staff to continue with the Resident's current care plan and encourage medication compliance. 05/29/24 at 2:26 p.m., the PN indicated a housekeeper entered the Resident's room to empty a trashcan. The Resident jumped out of his/her bed, chased the housekeeper, and attempted to throw the trashcan at the staff. The housekeeper twisted her ankle after this encounter. On 06/10/24 at 9:32 a.m., the PPN written by NP #4 revealed the NP attempted to meet with Resident #14. The Resident had his/her head covered with a blanket and refused to answer her questions about the status of his/her health. NP #4 directed the clinical staff to continue medication compliance. On 06/19/24 at 1:36 p.m., Resident #14 was yelling and slamming items in his/her room. After the noise subsided, a nurse entered the Resident's room and found two holes in the wall. Further review of the PN on 06/19/24 revealed that the Resident threw a knife in the hallway and continued to threaten staff and residents verbally and physically. On 06/20/24 at 12:06 p.m., the PNs revealed Resident #14 kicked a garbage can at a CNA, took off his/her belt, swung it at the CNA, and stated he/she was going to beat her with it. According to the note, residents and housekeeping witnessed this incident. PESS was again notified, the Resident was assessed, and the Resident was transported to the hospital. The Resident returned to the facility the same day and showed no behaviors. On 06/29/24 at 10:03 p.m., written by the LPN revealed Resident #14 came out of his/her room and threatened to kill staff if they ever entered his/her room and touched his/her belongings. Further review of the PN showed no evidence that this behavior was addressed. On 07/01/24 at 11:12 p.m., the PNs revealed Resident #14 was seen in the hallway hitting Resident #7 in the face with a closed fist and pulling Resident #7's hair, which caused him/her to fall to the floor. Resident #14 then slammed the door to his/her room. The police were called, and the Resident was taken to the PESS unit for evaluation. Both the Resident's medical provider and responsible parties were notified. On 07/03/24 at 8:00 a.m., the PNs written by LPN #2 indicated Resident #14 was discharged to a behavioral health center. A review of Resident #14's Progress Note (PN) revealed the following: On 3/12/24, the Psychiatry Progress Note (PPN), written by psychiatric Nurse Practitioner (NP) #1, revealed Resident #14 had fair awareness of events, fair impulse control, and poor judgment. The NP also indicated the Resident had a diagnosis of Schizophrenia with anxiety and was not cooperative during the interview. Medication compliance should be encouraged at this time, and staff should send Resident #14 out to PESS if the Resident becomes a danger to self or others. On 04/24/24 at 10:18 p.m., revealed Resident #14 slapped Resident #16's face with a closed fist and became verbally aggressive. The police were notified. The Physician was notified and ordered Resident #14 to be sent to the local hospital for evaluation and treatment. On 04/25/24 at 7:35 a.m., indicated on 04/24/24 at 11:30 p.m., the emergency medical technicians (EMTS) and the police arrived at the facility to transfer Resident #14 to the hospital, but the Resident refused. The Resident screamed at EMTS, telling them to get out, and slammed the door. The police were unable to take him/ her to the hospital because of his/her refusal unless PESS determined the Resident required hospitalization . At the time of PESS, they determined that the Resident was calm and did not need to go to the hospital. The note indicated the Resident remained calm for the rest of the shift. At 12:59 p.m., the Resident was .being aggressive and combative with behaviors, attempting to hit staff, throwing items unable to redirect .Unable to redirect, 1:1 was placed outside the room for safety. On 04/26/24 at 10:47 a.m., the PPN, written by NP #3, revealed she met with the Resident to assess him/her. The Resident continued to refuse his/her medications and had intermittent outbursts of aggressive behaviors. The NP noted the Resident was evaluated by S-cope on 04/25/24, and due to severe paranoid delusion, it was recommended the Resident be evaluated for a behavioral health nursing home. The Resident is currently on one-to-one. On 4/26/24 at 1:04 p.m., written by the Nurse Manager, the PN revealed, .At times would yell out for no specific reason, throwing food and drinks on the floor. Staff supervised at a distance . On 04/30/24 at 3:46 p.m., the Social Services PN (SSPN) indicated the facility heard back from the Resident's case manager and was informed the Resident did not meet the criteria for behavioral health placement. On 5/2/24 at 1:52 p.m., written by LPN #1, Resident #14 was accosting Resident #7; the police were called, and the police advised that they could do nothing at this time. On 5/09/24 at 7:26 a.m., Resident had an episode of combative, aggressive behavior w/[with] hostile verbal outburst, throwing objects at this writer . On 05/13/24, the PPN written by NP #2 revealed Resident # 14 was seen for follow-up medication management due to refusal of all medications and schizophrenia paranoid type. The note indicated the Resident was agitated, unpredictable, impulsive, and suspicious and slammed the door in front of NP #2. The note continued that the Resident had a history of hitting staff, throwing items, and making multiple calls to the police and PESS. The note revealed the Resident was not taken to the hospital after a PESS evaluation since the Resident refused to go. NP #2 indicated the Resident had poor insight, judgment, and impulse control and directed the facility to call PESS if the Resident became a danger to self or others. On 5/16/24 at 12:44 a.m., Resident #14 got into a verbal altercation with Resident #7. On 5/25/24 at 2:47 p.m., the Resident continued to yell at self-picks up objects and slam them down. On 05/29/24 at 9:50 a.m., the PPN, written by NP #3, revealed the Resident refused his/her physical exam and directed the clinical staff to continue with the Resident's current care plan and encourage medication compliance. 05/29/24 at 2:26 p.m., the PN indicated a housekeeper entered the Resident's room to empty a trashcan. The Resident jumped out of his/her bed, chased the housekeeper, and attempted to throw the trashcan at the staff. The housekeeper twisted her ankle after this encounter. On 06/10/24 at 9:32 a.m., the PPN written by NP #4 revealed the NP attempted to meet with Resident #14. The Resident had his/her head covered with a blanket and refused to answer her questions about the status of his/her health. NP #4 directed the clinical staff to continue medication compliance. On 06/19/24 at 1:36 p.m., Resident #14 was yelling and slamming items in his/her room. After the noise subsided, a nurse entered the Resident's room and found two holes in the wall. Further review of the PN on 06/19/24 revealed that the Resident threw a knife in the hallway and continued to threaten staff and residents verbally and physically. On 06/20/24 at 12:06 p.m., the PNs revealed Resident #14 kicked a garbage can at a CNA, took off his/her belt, swung it at the CNA, and stated he/she was going to beat her with it. According to the note, residents and housekeeping witnessed this incident. PESS was again notified, the Resident was assessed, and the Resident was transported to the hospital. The Resident returned to the facility the same day and showed no behaviors. On 06/29/24 at 10:03 p.m., written by the LPN revealed Resident #14 came out of his/her room and threatened to kill staff if they ever entered his/her room and touched his/her belongings. Further review of the PN showed no evidence that this behavior was addressed. On 07/01/24 at 11:12 p.m., the PNs revealed Resident #14 was seen in the hallway hitting Resident #7 in the face with a closed fist and pulling Resident #7's hair, which caused him/her to fall to the floor. Resident #14 then slammed the door to his/her room. The police were called, and the Resident was taken to the PESS unit for evaluation. Both the Resident's medical provider and responsible parties were notified. On 07/03/24 at 8:00 a.m., the PNs written by LPN #2 indicated Resident #14 was discharged to a behavioral health center. A review of a document provided by the facility titled Statewide Clinical Outreach Program for the Elderly (S-cope), dated 04/25/24, indicated the outreach program screened Resident #14 due to the Resident's continuation of refusals of his/her medications, agitation, and delusional thinking. S-cope made the following recommendations: to continue one-to-one to ensure safety; to follow up with the facility's psychiatrist/physician about lifting the one-on-ones; to utilize ABC tracking (tracking of activity, antecedent, behavior, and consequences related to behaviors) to identify trends and triggers in Resident #14's behaviors; to utilize this method for five days, and then fax the completed forms to S-cope. Review of a second S-cope document dated 06/21/24 indicated the clinician made the following recommendations for the Resident's mental health needs: continue to provide one-on-one to the Resident; utilize the ABC to track and trend the Resident's behaviors, utilize and fax the completed ABC form to S-cope; and to have the facility's psychiatrist follow-up with the Resident and refusals of medications. Review of the EMR revealed no documented evidence that the Physician was notified, and an order was obtained to stop the one-on-one Supervision. In addition, the facility was unable to provide evidence that behavior tracking was forwarded to S-cope as recommended. Review of Resident #14's Medication Administration Record (MAR) dated 3/1/2024 - 3/31/2024 indicated the Resident refused his/her medications as follows: Aricept (used for dementia) Oral Tablet 5 (milligram) mg 1 tablet by mouth at bedtime 9:00 p.m. Refused on 3/2-3/6, 3/9, 3/10, 3/12 - 3/18, 3/20 and 3/22- 3/31/2024. Risperidone (used to treat symptoms of Schizophrenia) Oral Solution 1 mg/ml. Give 1 milliliter (ml) by mouth two times a day at 9:00 a.m. and 9:00 p.m. Refused 9:00 a.m. dose from 3/1- 3/31/2024. Refused 9:00 p.m. dose on 3/2 -3/7, 3/9, 3/10, 3/12-3/18, 3/20 and 3/22-3/31/2024. Review of Resident #14's MAR dated 4/1-4/30/2024 indicated the resident refused the following medications: Aricept Oral Tablet 5 (milligram) mg 1 tablet by mouth at bedtime 9:00 p.m., on 4/1-4/6, 4/8-4/14, 4/16-4/19 and 4/21-4/30/2024. Risperidone Oral Solution 1 mg/ml. Give 1 milliliter (ml) by mouth two times a day at 9:00 a.m. and 9:00 p.m., 9:00 a.m. dose on 4/1-4/5, 4/7, 4/8, 4/10-4/20, 4/22-4/26 and 4/28-4/30/2024, and 9:00 p.m. dose on 4/1-4/6, 4/8-4/14, 4/16-4/19, 4/21-4/25 and 4/27-4/30/2024. Review of Resident #14's MAR dated 5/1-5/31/2024 indicated the resident refused the medications as follows: Aricept Oral Tablet 5 (milligram) mg 1 tablet by mouth at bedtime 9:00 p.m., on 5/1-5/12, 5/14-5/17, 5/19-5/22, 5/24-5/27 and 5/29 -5/31/2024. Risperidone Oral Solution 1 mg/ml. Give 1 milliliter (ml) by mouth two times a day at 9:00 a.m. and 9:00 p.m. Refused 9:00 a.m. dose from 5/1-5/31/2024, 9:00 p.m. dose on 5/1-5/12, 5/14-5/17, 5/19-5/22, 5/24, 5/25, 5/27, 5/29 and 5/31/2024. Review of Resident #14's MAR dated 6/1-6/30/2024 revealed the resident refused the following medications: Aricept Oral Tablet 5 (milligram) mg 1 tablet by mouth at bedtime 9:00 p.m., from 6/1-6/30/2024. Risperidone Oral Solution 1 mg/ml. Give 1 milliliter (ml) by mouth two times a day at 9:00 a.m. and 9:00 p.m., at 9:00 a.m. 6/1-6/3, 6/5-6/12, 6/14-6/25 and 6/27-6/30/2024, and 9:00 p.m. dose on 6/1-6/19 and 6/21-6/30/2024. Review of Resident #14's MAR dated 7/1-7/31/2024 indicated the Resident refused the medications as follows: Aricept Oral Tablet 5 (milligram) mg 1 tablet by mouth at bedtime 9:00 p.m. Risperidone Oral Solution 1 mg/ml. Give 1 milliliter (ml) by mouth two times a day at 9:00 a.m. and 9:00 p.m. on 7/1/2024. There was no evidence that the resident's Physician was notified oo the aforementioned medications refusals refusals. 2. Review of the EMR, revealed Resident #16's was admitted with a diagnosis chronic kidney disease, high blood pressure and anxiety disorder. The MDS dated [DATE] showed the Resident had a BIMS score of 15 out of 15, which indicated the Resident was cognitively intact. A review of the CP dated 04/22/24 revealed Resident #16 was identified as at risk for falls or injury related to decreased mobility, deconditioning and poor safety and at risk for bruising or bleeding and had the potential for alteration in his/her mood due to a diagnosis of anxiety disorder. A review of the PN dated 04/24/24 at 10:27 p.m. revealed Resident #16 entered the nourishment room and walked by Resident #14, who then punched Resident #16 in the face. Both residents were separated. Resident #16 sustained no injuries. 3. Review of the EMR revealed Resident #7 was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD). The quarterly MDS, with an ARD of 04/19/24, indicated the Resident had a BIMS score of 15 out of 15, which revealed the Resident was cognitively intact. A review of the PNs dated 07/01/24 at 11:00 p.m. revealed that Resident #7 was screaming in the hallway. Facility staff responded and separated Resident #7 and Resident #14. The police were notified, and Resident #14 was removed from the facility. In addition, the RN revealed that Resident #7 sustained a laceration on his/her forehead and was sent to the ER for evaluation and treatment of head injury. Further review of the PN dated 07/02/24, at 4:56 a.m., revealed Resident #7 returned from the hospital with a left orbital laceration with a hematoma. During an interview on 09/30/24 at 6:02 p.m., the Assistant Director of Nursing (ADON) stated he expected PESS to be contacted when there was aggressive behavior by a resident to decide if the Resident was a threat. However, there was no evidence provided that PESS was notified every time Resident #14 had changes in his/her behavior. During an interview on 09/30/24 at 6:42 p.m., Resident #7 stated he/she remembered Resident #14. Resident #7 explained that the Resident left his/her room to get a soda, and Resident #14 jumped him/her from behind. Resident #7 explained he/she fell to the floor, was sent to the emergency room , and the staff glued a large gash on his/her forehead. During an interview on 10/01/24 at 10:22 a.m., CNA #3 stated he worked with Resident #14 and stated the Resident would throw things at him and was very violent with both staff and residents. CNA #3 stated that anything would set the Resident off, and he/she would just flip. According to the CNA, Resident #14 would punch holes in the walls of the Resident's room. During an interview on 10/01/24 at 11:10 a.m., Resident #16 confirmed Resident #14 punched him/her in the face. Resident #16 stated it was painful, and the punch took him by surprise. During an interview on 10/01/24 at 11:19 a.m., NP #1 confirmed he remembered Resident #14. According to NP #1, Resident #14 would refuse medications and punch people in the face. NP #1 stated that there were staff who were too scared to enter the Resident's room. He did not make any medication recommendations since it did not matter if he did since Resident #14 did not take his/her psychotropic medications to treat his/her behaviors. During an interview on 10/01/24 at 12:34 p.m., CNA #4 stated she witnessed the assault from Resident #14 to Resident #7. According to the CNA, Resident #14 punched Resident #7, the Resident then fell to the ground, and Resident #14 proceeded to kick the Resident. She further stated Resident #7 sustained a cut close to the eye, and the area was bleeding and swollen. The CNA stated the facility was not providing one-on-ones for Resident #14 prior to this incident. During an interview on 10/01/24 at 2:13 p.m., in the presence of the Director of Nursing (DON) and ADON, the LNHA stated that the facility receives recommendations from S-cope for residents and does not keep a resident on one-on-one forever. At the time of the interview, a request was made for evidence of the one-on-one Supervision, why Resident #14 was taken off one-on-one Supervision, and about ABC tracking. The LNHA stated he would have to ask the nursing staff. The Surveyor also requested any psychiatric assessment after the 04/24/24 incident and before the psychiatric NP visit with Resident #14 on 05/13/24 and to provide any information related to safety measures taken with Resident #14 after 04/24/24 when he/she slapped Resident #16. However, the facility was unable to provide the requested information. During a second interview on 10/01/24 at 3:34 p.m., the LNHA brought in copies of Resident #14's nursing PNs and stated the Resident had no behaviors after 04/24/24, and the one-on-ones were stopped. He also presented a document from S-cope dated 04/25/24 and stated he believed S-cope came out again prior to 05/13/24. According to the LNHA, Resident #14 refused all of his/her medications. The ABC tracking was used to document all of the resident behaviors. The LNHA stated that S-cope was coming out all the time and providing direction to the facility staff on a regular basis. During an interview on 10/02/24 at 9:59 a.m., the Mental Health Clinician (MHC) with S-cope stated that she assessed Resident #14 on 04/25/24 and again on 06/21/24. The MHC stated she met with the Resident four times between 04/25/24 and 07/01/24 and made the same recommendations on 06/21/24 as on 04/25/24. MHC stated the Resident was determined not to be a danger to others when she met with him. During an interview on 10/02/24 at 10:14 a.m., LPN #1 stated he worked the night shift and was not aware Resident #14 was on one-on-one Supervision. During an interview on 10/02/24 at 10:48 a.m., the Medical Director (MD) stated he was familiar with Resident #14 and was his Primary Care Physician (PCP). According to the MD, he was surprised to hear that the Resident could refuse to go with the EMTs and police, which he had never seen before. The MD stated he remembered getting on the phone with the EMTs, and the EMTs informed him that if Resident #14 refused to be taken to the hospital, they could not force the Resident to do so. The MD stated the only way for the Resident to receive treatment was for the Resident to totally decompensate in his/her condition. Regarding the issue with Resident #14 refusing his/her psychotropic medications, he stated the facility could only monitor his/her condition. During an interview on 10/2/24 at 4:20 p.m., the DON stated that if a resident required one-on-one Supervision, they were not appropriately placed in the facility and needed a higher level of care. She stated the Resident would not be safe, and their needs were too high of an acuity for the facility. According to the DON, If someone needs that one-on-one monitoring, this is not the place for them. Review of the facility's reported incident investigation, provided by the LNHA revealed that two staff witnessed abuse that occurred with Resident #19 and 13 involving the same nurse (LPN #10). According to a witness statement from CNA #12 dated 09/16/24 at approximately 8:25 p.m., Resident #19 walked behind the nurse's station and tapped LPN #10 on the shoulder. LPN #10 then pushed Resident #19 and yelled, Get away from here, you are not supposed to be back here. Review of the second facility's incident investigation dated 09/17/24 revealed a witness statement from LPN #11, which showed on 09/17/24 at 7:00 a.m., she was standing at the medication cart, saw Resident #13 grab a binder from the nurse's station counter, and LPN #10 tried to pull the binder from Resident #13. According to the statement, LPN #10 yelled Leave the shit alone, swiped the binder away from Resident #13, hitting his/her hand, then yelled, Get the fuck out of here! LPN #11 also indicated she tried to break them up and then reported the incident to the UM. 4. Review of Resident #19's EMR showed the Resident was admitted to the facility with diagnoses that included Alzheimer's disease with late onset, anxiety disorder, and major depression. According to the MDS, Resident #19 had a BIMS score of 2 out of 15, which indicated the Resident was severely cognitively impaired. A review of Resident #19's nursing PN dated 09/17/24 at 4:51 p.m. revealed, .Investigating staff reported aggressive behavior from staff to Resident. Witnessed incident with no injuries noted. The assigned nurse was noted to act in a confrontational manner towards [Resident #19]. Other staff members quickly de-escalated the incident. Resident #19 is unable to verbalize any details r/t [related to] incident but can answer simple yes or no questions. The RN assessed Resident #19, and no injury was noted. NP notified and assessed . Review of Resident #19's CP dated 09/17/24 revealed a long history of behaviors related to dementia problem area with an intervention of, .victim of incident 09/16/24 follow-up with psych services as needed and provide emotional support to [the] resident . Review of Resident #19's CP date initiated 12/28/23, revealed a long history of behaviors related to dementia. Interventions to include Caregivers to provide opportunity for positive interaction, explain all procedures to the Resident before starting and allow the Resident to adjust to changes. 5. Review of the EMR revealed Resident #13 was admitted with diagnoses that included dementia without behavioral disturbance, anxiety disorder, and depression. The annual MDS, with an ARD of 08/22/24 showed a BIMS score of one out of 15, which indicated Resident #13 was cognitively intact. A review of Resident #13's Physicians Progress Note, dated 09/17/24 at 10:17 a.m., revealed that the .[Resident] was seen ambulating on the unit. Says he/she is feeling well. No c/o [complaints of] pain or discomfort. It was reported to me by the DON [Director of Nursing] that [the] patient [Resident] was pushed by a staff member. The Resident does not remember the incident. No injuries noted .Plan .Continue current medications .fall precautions. Monitor for bleeding . Review of Resident #13's nursing PNs dated 09/19/24 revealed, .Seen by [Psychiatric Provider]. Xanax [an antianxiety medication] 0.25 mg [milligrams] daily PRN [as needed] anxiety and increase in Buspar [an antianxiety medication] 15 mg BID [twice a day]. Behavior charting for anxiety X [times] 14 days . Review of Resident #13's CP dated 09/17/24 revealed a care area focus of history of behaviors related to dementia with an intervention of, .a victim of incident 9/17/24 follow-up with psych services as needed provide ongoing emotional support to [the] resident, administer medications as ordered, and monitor/document side effects and effectiveness . Review of Resident # 13's CP with a revision date on 11/28/23 revealed, Focus: history of behaviors related to dementia with behaviors that can include periods of increased restlessness, periods of increased anxiety and enters peers' personal spaces. Interventions: Attempt to identify antecedents to my behavior and monitor for wandering into other personal spaces, redirect him/her to his/her own personal space or common area. It was recorded the police were contacted on 09/19/24, and all staff were trained on abuse and neglect on 09/17/24. Both incident investigations revealed the staff to Resident abuse for Resident #19 and Resident #13 was substantiated. LPN #10 was suspended on 09/17/24 while the investigation was in progress. LPN #10 did not work after this date and was terminated on 09/23/24. The documentation further revealed that the DON/ADON was aware of the incidents on 09/17/24. During a combined interview on 09/30/24 at 2:10 p.m., the LNHA and DON revealed that she [DON] was notified of the abuse allegation when she arrived at the facility on 9/17/24 at 8:00 a.m., and the ADON was notified when he arrived at 7:30 a.m. The DON notified the LNHA as soon as it was reported to her. The DON stated LPN #10 was already gone for the day; he was suspended during the investigation and asked to come to the facility to write a statement, and then was terminated on 09/23/24. According to the LNHA, he watched the camera and saw LPN #10 and Resident #13 close to each other at the nurse's station but could not see what occurred. The DON stated the ADON interviewed the residents in the memory care unit, and there was no reported abuse by LPN #10. During an interview on 10/04/24 at 11:30 a.m., CNA #12 stated on 09/16/24 at approximately 8:25 p.m., she saw Resident #19 walk behind the nurse's station, tap LPN #10 on the shoulder, then LPN #10 pushed Resident #19 and yelled, Get away from here, you are not supposed to be back here. CNA #12 stated she did report the allegation to her supervisor. However, LPN #10 continued to provide care for other residents. During a combined interview on 09/30/24 at 2:10 p.m., the DON revealed they were made aware of the abuse allegation when the ADON found a note under his door from Registered Nurse (RN) #3 with a witness statement attached prior to his arrival on 09/17/24. The LNHA confirmed he received LPN #10's statement on 09/17/24. The DON stated she reported the incident to the State Survey[TRUNCATED]

C#: NJ173888 Based on interviews, record review, and review of other pertinent facility documents on [DATE], [DATE], [DATE], ,d+[DATE], and [DATE], it was determined that the facility failed to provide adequate supervision to prevent falls, determine the root cause of the falls, and implement effective interventions to prevent further falls. The facility also failed to follow its policy titled Falls and Fall Risk, Managing. This deficient practice was identified for 1 of 3 residents (Resident #11) reviewed for falls and was evidenced by the following: Review of the facility's policy titled, Falls and Fall Risk, Managing, dated [DATE] provided by the facility, revealed, . Based on previous evaluations and current data, the staff will identify interventions related to the Resident's specific risks and causes to try to prevent the Resident from falling and to try to minimize complications from falling . Policy Interpretation and Implementation Prioritizing Approaches to Managing falls and Fall Risk . 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . Monitoring Subsequent Falls and Fall Risk. The staff will monitor and document each Resident's response to interventions intended to reduce falling or the risks of falling . 3. If the Resident continues to fall, staff will re-evaluate the situation and determine whether it is appropriate to continue or change current interventions . A review of the electronic medical record (EMR) revealed Resident #11 was admitted with diagnoses that included traumatic brain injury (TBI) and unspecified dementia with other behavior disturbances. Resident# 11 expired on [DATE]. Review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], which indicated Resident #11 could not be interviewed and was assessed to be severely impaired in decision making. This MDS revealed Resident #11 had physical, verbal, and behavioral symptoms directed towards others and was dependent on staff for eating, oral hygiene, toileting, bathing, and dressing. Review of the facility's Fall Investigation (FI), for Resident #11 revealed the following: On [DATE], CNA #11 witnessed Resident #11 stand up from the wheelchair, fall on his/her back, and then bleed from the side of his/her head. On [DATE], Licensed Practical Nurse #7 witnessed Resident #11 get out of the geriatric chair and hit his/her head on the wall. It was recorded that Resident #11 did not suffer any injuries. The root cause of the fall was not documented on the fall investigation. On [DATE], interviews were conducted with six Nurse Aides on the 3:00 p.m. to 11:00 p.m. shift, but they did not witness Resident #11's fall in the day room. The fall investigation stated CNA #10 found Resident #11 on the floor in the day room when she entered at 5:30 p.m. The root cause of the fall was not documented on the fall investigation. Review of Resident #11's progress note (PN) revealed the following: On [DATE] at 12:00 p.m., the Certified Nurse Aide (CNA) #11 alerted Licensed Practical Nurse (LPN) #9 that Resident #11 fell and hit his/her head when he/she got up from the wheelchair in the dayroom. Resident #11 was transported to the emergency room for treatment and returned with one staple to the right side of the head. On [DATE] at 12:30 p.m., Resident #11 had a witnessed fall in the dayroom out of his/her geriatric chair and hit his/her head on the wall. On [DATE] at 5:30 p.m., Resident #11 fell out of the geriatric chair in the day room and sustained a hematoma to his forehead. Review of Resident #11's care plan (CP) dated [DATE], revealed the Resident was care planned for risk for falls with interventions of activities, physical therapy (PT), safe environment, call light within reach, wear proper footwear, and bed in low position. Further review of the CP dated [DATE] revealed no new interventions were added after the fall on [DATE]. Further review of the CP dated [DATE] revealed the fall risk CP was updated with an intervention to monitor frequently for safety in relation to the fall that occurred on [DATE]. At the time of the survey, the facility could not provide evidence that the resident's CP was being implemented for frequent monitoring on [DATE]. During an interview on [DATE] at 12:37 p.m., the Medical Director confirmed falls were discussed in the quality assurance meetings, and interventions were discussed to prevent further falls. The Medical Director stated that if Resident# 11 kept falling out of the geriatric chair, either the Resident needed adequate supervision or the intervention needed to be changed because it was not effective. During an interview on [DATE] at 9:58 a.m., LPN #7 stated she witnessed Resident #11 get out of the geriatric chair and hit his/her head on the wall when she entered the room to administer medications to a resident on [DATE]. LPN #7 stated a nurse aide was in the room, but she was not sitting next to the Resident during the day. LPN #7 stated the nurse aide was responsible for feeding and watching all the residents. LPN #7 indicated there were approximately ten high-fall-risk residents in the day room at the time of Resident #11's fall, and it was difficult to keep the residents safe during mealtimes. During an interview on [DATE] at 4:20 p.m., LPN #6, former Unit Manager on the [NAME] Unit, stated Resident #11 fell out of a geriatric chair twice, was very combative, and was always trying to get out of the bed and wheelchair, and geriatric chair because he wanted to talk. LPN #6 indicated Resident #11 should have been supervised while in the wheelchair and geriatric chair in the dayroom. LPN #6 stated after Resident #11's second fall in the day room, another CNA was added to the day room to provide one-to-one observations of Resident #11 and another resident so that the other CNA could watch the other residents in the day room. According to the LPN, the CNAs were responsible for feeding and watching the residents during meal times. LPN #6 confirmed the former Director of Nursing (DON) completed the fall investigations. Falls were discussed at the morning meetings, but the Interdisciplinary Team (IDT) did not meet on every fall to discuss interventions to prevent falls or re-evaluate interventions to prevent further falls. LPN #6 verified that the interventions were not effective in preventing falls for Resident #11. During a combined interview on [DATE] at 2:10 p.m., the Assistant Director of Nursing (ADON) and DON, both employed for three months, stated the staff held fall huddles after a resident's fall to determine the cause and implement interventions to prevent further falls. The DON stated the IDT meets to discuss the falls, re-evaluate fall interventions and change the interventions if they were not effective in preventing further falls.

Complaints #: NJ173888 Based on interviews, record reviews, and review of other pertinent facility documents on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE], it was determined that the facility failed to assess and monitor for delayed complications after a resident fell from a geriatric chair in the day room and sustained a hematoma. The facility also failed to follow its policy titled Assessing Falls and their Causes. This deficient practice was identified for 1 of 3 residents (Resident #11) reviewed for falls and was evidenced by the following: A review of the facility's undated policy titled Assessing Falls and their Causes revealed, . Steps in the Procedure After a fall . 6. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall and will document findings in the medical record. 7. Document any observed signs of symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings . A review of Resident #11's electronic medical record (EMR) revealed the Resident was admitted with diagnoses that included traumatic brain injury (TBI) and unspecified dementia with other behavior disturbances. Resident #11 expired on [DATE]. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], which indicated the Resident could not be interviewed and was assessed to be severely impaired in decision making. This MDS revealed Resident #11 had physical, verbal, and behavioral symptoms directed towards others and was dependent on staff for eating, oral hygiene, toileting, bathing, and dressing. Review of the Nursing Progress Note (NPN), dated [DATE], revealed, This nurse was made aware by the CNA [Certified Nurse Aide] on duty that [the] patient [Resident #11] fell out of [the] Geri [geriatric] chair in [the] day room. The NPN further showed the Resident was found lying on the left side in the day room. A second CNA reported she did not see when the Resident fell out of the chair but heard it. Resident #11 sustained a hematoma to the forehead. A review of Resident #11's Fall Investigation, dated [DATE] and provided by the facility, revealed no evidence that a neurological assessment was completed after the fall. A review of Resident #11's NPN revealed no documentation status after the fall on [DATE]. Further review of the NPN dated [DATE] revealed Resident #11 was admitted to hospice. Review of Resident #11's Physicians Progress Note, dated [DATE], revealed, . As per nursing staff, patient continues to be aggressive, easily agitated, confused, combative, unable to redirect. fell last night. Has some scattered bruising to [the] forehead. Will make medication adjustments . Past medical history: dementia with behavioral disturbances, aggression, TBI, MVA [motor vehicle accident] . Plan: discontinued Seroquel [an antipsychotic medication used for major depression], start Zyprexa [an antipsychotic medication] . Review of Resident #11's NPN, dated [DATE], revealed, . Resident expired . Review of Resident #11's EMR showed no documented evidence that a neurological assessment was completed or the facility's policy was implemented after the fall on [DATE]. During an interview on [DATE] at 4:14 p.m., Family Member (F) #2 stated Resident #11 could not swallow . food was drooling from his/her mouth, lost weight, had bruises on the forehead, and was not alert when she visited after the fall on [DATE]. During an interview on [DATE] at 12:37 p.m., the Medical Director stated Resident #11 had suffered three falls within a week and could have suffered a subdural hematoma (bleeding in the brain), but the family refused to send him/her to determine that. The Medical Director stated Resident #11 declined after the last fall, and staff should have assessed and monitored for a brain bleed after the fall. During an interview on [DATE] at 1:34 p.m., Registered Nurse (RN) #1 stated she was the Nurse who assessed Resident #11 after his/her fall on [DATE] and that she completed a neurological assessment on the Resident after the fall. She further stated she should have documented the completed assessment in the progress notes, and the assessment should have been added to the fall investigation packet and given to the unit manager. During an interview on [DATE] at 10:12 a.m., F #1 stated she placed Resident #11 on hospice after the last fall on [DATE] because she thought they would be at the facility daily to feed Resident #11. F #1 stated Resident #11 could speak some words when he/she was admitted to the facility, but after the last fall, he/she lay in bed or in the geriatric chair and was not alert. During an interview on [DATE] at 10:15 a.m., CNA #6 stated that Resident #11 chewed and swallowed food and was more alert prior to the last fall on [DATE]. CNA #6 also stated Resident #11 had bruises on his/her forehead, slept more, and could not chew his/her food or swallow it after the last fall on [DATE]. During an interview on [DATE] at 11:06 a.m., CNA #9 stated Resident #11 was on hospice when the CNA was assigned to care for him/her. According to CNA #9, Resident #11 could not swallow his food, was drooling, and was not alert. During an interview on [DATE] at 5:27 p.m., the Director of Nursing (DON) stated she expected the Nurses to complete a neurological assessment after a fall on the paper neurological flow sheet. The DON stated she expected staff to monitor and document the neurological status, vital signs, and any other complications in the NPN so that care interventions could be rendered after Resident #11 experienced falls. NJAC 8:,d+[DATE].1(a)

Complaints #: NJ162903, NJ166982, NJ168479 NJ172819, NJ172820, NJ173142 NJ173303, NJ175318, NJ175692 NJ177086 Based on interviews, review of the Medical Records (MR), and other pertinent facility documentation on 9/30/24, 10/01/24, 10/02/24, 10/03/24, and 10/04/24, it was determined that the facility failed to ensure that Resident #10 was free from involuntary seclusion. On 4/19/24, a Certified Nursing Aide (CNA #1) placed Resident #10 in the dayroom of the [NAME] Unit. CNA #1 shut and blocked the door, sat outside the dayroom to prevent Resident #10 from exiting. According to Resident #10, she/he begged and was terrified when the CNA would not let her/him leave the day room. In addition, the facility failed to follow its policies titled PHYSICAL RESTRAINTS and Abuse, Neglect, Exploitation, and Misappropriation Prevention Program for 1 of 29 residents (Resident #10) reviewed for incident and accident. This deficient practice was evidenced by the following: A review of the REPORTABLE EVENT RECORD (RER), a New Jersey Department of Health (NJDOH) document used by the healthcare facilities to report incidents, dated 4/19/2024, completed by the former DON (FDON), revealed that on 4/19/24 at around 7:30 am, Resident #10 reported that CNA #1, who was assigned to the Resident on 4/19/24 for shift of 11:00 am to 7:00 am, had placed him/her in the day room and would not let the Resident out. The RER further indicated that the CNA was suspended. A review of the [Long Term Care] Reportable Event Survey (LTCRES), also known as RER, dated 4/19/24, completed by the FDON, provided by the facility, revealed Resident #10 reported on 4/19/24 at around 3:00 a.m., CNA #1 put the Resident in the room and blocked the door so he/she could not leave. Further review of the LTCRES included an Investigative Summary (IS), dated 4/19/24, completed by the FDON, indicated that Resident #10 reported to the nurse that he/she was placed in the day room with the door closed, preventing the resident from exiting the dayroom. The IS further indicated during an interview conducted by the FDON and Social Services (SS), Resident #10 reported he/she was in the hallway around 3:00 a.m. and was looking to leave the nursing area. According to the IS, Resident #10 said the aide took the resident and placed him/her in the day room. The Resident explained that he/she did not want CNA #1 to be outside the door blocking the resident's ability to exit. The IS further indicated that Resident #10 stated, After a period of time, the nurse on duty brought the Resident back to [his/her] room. The conclusion indicated, Upon completing this investigation, reading statements that have been provided by staff and Social Service follow-up, it is in my opinion that [Resident #10] was kept in the room against [her/his] wishes . According to the ADMISSION RECORD (AR), Resident #10 was admitted with diagnosis which included but not limited to Huntington's disease and Asthma. The Minimum Data Set (MDS), an assessment tool dated 4/4/24, revealed that Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating Resident #1's cognition was intact. A review of Resident #10's Care Plan (CP) initiated on 4/28/24 revealed under Focus: Resident #10 was left in the dayroom against the Resident's wishes. Under Goal, indicated: [The Resident] will remain free from emotional distress. My safety will be maintained within the facility. Under Interventions, it included: Allow Resident time to answer and verbalize [their] feeling and perception as needed. Analyze key times, places, circumstances, and triggers, de-escalate behavior, and document. Arrange for psychotherapy follow-up as indicated .Monitor and document resident's feelings relative to the event . A review of the Disciplinary Action Form, dated 4/19/24, included: Under Nature of Offense, noted Patient Rights and Resident Abuse or Neglect was checked off as the issues. Under: Detailed description of offense . included Resident [#10] stated [CNA #1] put her in the dayroom and would not let her out. Under Action Taken, the Suspension start date of 4/19/24. Review of CNA #1's statement, dated 4/19/24, the CNA wrote I worked on 4/18/24 on the Dementia floor of the [NAME] Wing. The patient [Resident #10] tried to go to the [NAME] wing at [3:00 a.m.], which was not [her/his first] attempt. The nurse advised me to retrieve [her/him] from South wing [and] direct [her/him] into the dayroom where the other [patients] with behaviors were being monitored [and] so i [I] did. Before [Resident #10] was in the room the nurse instructed us to keep the door closed because they are fall risks to ensure their safety. When the said [Resident #10] asked to leave the room the nurse [escorted her/him to her/his] room. No force was used there was no body to body contact. The resident did say [she/he] was gonna tell the unit manager I hurt her hand so I could get fired. When the door was closed, I was on the other side of [the] door sitting to ensure the safety of the Residents and keep an eye on them as well. A review of Resident #10's Progress Notes revealed the following: On 4/18/24 at 11:50 a.m., the Social Worker wrote, Met with Resident following up on [the] incident that occurred last night. Resident not in any distress. On 4/19/24 at 1:08 p.m., written by the Licensed Practical Nurse (LPN), LPN #14 revealed a Head to toe assessment [was] done, [and there was] no signs of physical harm observed. No further concerns [were] voiced by resident. NP and MD made aware. During an interview on 09/30/24 at 5:25 p.m., Resident #10 stated he/she was not permitted to leave the dayroom. Resident #10 further stated that when he/she asked to leave the area, the CNA told him/her to remain in the day room area. During a second interview on 10/01/24 at 11:52 a.m., Resident #10 stated he/she was terrified when [CNA #1] sat in front of the door while he/she begged CNA #1 to let him/her out. During an interview on 10/01/24 at 5:30 p.m., the LNHA stated that he viewed the surveillance camera. According to the LNHA, he saw that Resident #10 was locked in the dayroom. CNA #1 was sitting outside the door, and Resident #10 attempted to open the door. Review of an undated policy provided by the facility titled PHYSICAL RESTRAINTS undated, indicated, .Devices are considered restraints when they impede the residents' ability to maintain independence and/or mobility . A review of a policy provided by the facility titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 05/2023, indicated, .Residents have the right to be free from Abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal management, involuntary seclusion, verbal, mental, sexual, or physical abuse .The Resident Abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: 1. Protect residents from Abuse, neglect .by anyone including, but not necessarily limited to: a. facility staff .5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems . NJAC 8:39-4.1 (a)

Based on observation, interview, medical record review and review of other pertinent facility documentation, it was determined that the facility failed to implement mitigation strategies to prevent the transmission of COVID-19 by not appropriately identifying residents exposed to COVID-19 as persons under investigation (PUI) for the virus; and failed to implement appropriate Transmission Based Precautions (TBP) according to Centers for Disease (CDC) guidelines and the facility's Outbreak Plan for those residents exposed to Covid-19 positive Health Care Personnel (HCP). This deficient practice was identified for 4 of 4 staff members who provided care to residents on 2 of 2 Long-Term Care (LTC) Units. These units were the West (Dementia unit) and South (Long Term Care). Both units were considered a well, non-ill, non-Covid-19 units. The deficient practice was evidenced by the following: Part 1 On 01/04/2021, the facility became aware that one staff member, a Certified Nursing Assistant (CNA #1) was confirmed positive for Covid-19 with a rapid test and was immediately sent home. According to the facility contact tracing, CNA #1 worked on the Long-Term Care West Unit (well, non Covid unit) on 01/02/21 and provided direct care to 11 residents that resided on that unit. On 01/07/2021, the facility became aware that a second staff member (CNA #2) was confirmed positive for Covid-19 from a Covid-19 test that was collected on 01/04/21. According to the facility contact tracing, CNA #2 last worked on the LTC South Unit (well, non Covid unit) on 01/03/21 and provided direct care to 24 residents that resided on that unit. On 01/12/21 a third staff member (CNA #3) had a test for Covid-19 and was confirmed positive on 01/13/21 by a rapid Covid-19 test. According to the facility contact tracing, CNA #3 worked on the LTC West and South Units (well, non Covid units) on 1/9/21, 1/10/21, 1/11/21 and 1/12/21 and provided direct care to the residents that resided on that unit. According to the employee assignment sheet dated 01/09/21, CNA #3 provided direct care to 9 residents. On 01/10/21, CNA #3 provided direct care to 12 residents. On 01/11/21, CNA #3 provided direct care to 9 residents and on 01/12/21, CNA #3 provided direct care to 9 residents. On 01/19/2021, the facility became aware that a fourth staff member (CNA #4) was confirmed positive for Covid-19. According to the facility contact tracing, CNA #4 last worked on the Long-Term Care (LTC) South Unit (well, non Covid) on 01/17/21 and provided direct care to 11 residents that resided on that unit. On 02/09/2021 at 9:15 AM, Surveyor #1 and Surveyor #2 interviewed the corporate Regional Director of Nursing (RD), the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) who all stated that when CNAs #1, #2, #3 and #4 were identified as being Covid-19 positive they did not consider the residents exposed to the Covid-19 positive healthcare professionals (HCP) as Persons Under Investigation (PUI). The residents that were exposed to the Covid-19 positive HCP on the LTC West and South units were not placed on Transmission-Based Precautions (TBP) and the appropriate PPE for residents exposed to Covid positive persons was not instituted. A review of the guidance issued by the New Jersey Department of Health/Communicable Disease Services (NJDOH/CDS) titled Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated revised 10/22/2020 included that Cohort 2 COVID-19 negative, exposed group consisted of both symptomatic and asymptomatic residents who tested negative for COVID-19 with an identified exposure to someone who was positive. These individuals should be quarantined for fourteen days from their last exposure, regardless of test results. The guideline further included that residents in Cohort Group 2 should be placed on TBP using COVID-19 recommended PPE consisting of an N95 mask, eye protection, gloves, and isolation gowns. A review of the guidance issued by NJDOH/CDS titled Testing in Response to a Newly Identified COVID-19 Case in Long-term Care Facilities dated 1/26/21 included that regardless of attribution of the case, all facilities should take the following steps when a new case of COVID-19 is identified in their facility. The steps included to perform a risk assessment to determine any potential exposures/or infection control breaches at the facility. Determine any possible exposures the new case of COVID-19 (exempli gratia (e.g.) resident, healthcare personnel, essential caregiver) may have had prior to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify close contact including forty-eight hours prior to symptom onset/date of specimen collection of associated case, if applicable. Close contact is identified as being within approximately six feet of a COVID-19 case for a prolonged period of time, a cumulative of fifteen minutes or more over a twenty-four hour period starting from two days before illness onset (or, for asymptomatic residents, two days prior to test specimen collection) until the time the resident is isolated. Quarantine close contacts for fourteen days from last exposure and provide care using all COVID-19 recommended PPE (N95 mask, gown, gloves, eye protection). A review of the NJDOH/CDS Guidance for COVID-19 diagnosed and/or Exposed Healthcare Personnel dated 1/4/21 included healthcare facilities should establish a plan for how exposures in a healthcare facility will be investigated and how contact tracing will be performed. The guidance also included that when a healthcare personnel was positive for COVID-19, facilities should do their due diligence to identify and notify close contacts (fifteen cumulative minutes of exposure at a distance of less than six feet to an infected person during a twenty-four hour period). Prolonged close contact should be determined by taking the cumulative contact the potentially exposed individual had with the infected case over a twenty-four hour period from two days before the symptom onset (or positive collection date in asymptomatic infected individual) until the positive case has been effectively isolated. The guidance also included that patients who are identified as a close contact of a positive healthcare personnel at a healthcare facility should be placed on appropriate transmission-based precautions and monitored for the onset of COVID-19 until fourteen days after their last exposure. According to Centers for Disease Control Responding to Coronavirus (Covid-19) in nursing homes regardless of cohort, all staff should adhere to standard precautions and any necessary Transmission-based Precautions (TBP) according to clinical presentation and diagnoses, when caring for any patient/resident full TBP and all recommended Covid-19 PPE should be used for all patients who are: -Covid-19 positive -Covid-19 PUI -Exposed to Covid-19 Healthcare Professional (HCP) PUI -Exposed to any Covid-19 positive person The facility's failure to identify the Covid-19 exposed cohort resident group, institute necessary TBP and PPE, and appropriately identify the unit as a PUI unit posed a serious and immediate threat to the safety and wellbeing of all non-ill residents residing in the facility. After consultation with the office it was determined that an Immediate Jeopardy (IJ) situation was identified on 02/10/2020 at 04:32 PM. The facility provided an acceptable IJ Removal Plan on 02/11/2021 at 12:02 PM. The IJ removal plan was verified on-site on 2/12/21. This deficient practice was evidenced by the following: On 02/09/2021 at 9:15 AM, Surveyor #1 and Surveyor #2 interviewed the Administrator, the Director of Nursing and the corporate Regional Director of Nursing who revealed that the facility followed the CDC guidelines for cohorting which was included on the facility policy implemented 03/06/2020 and updated 12/18/2020, titled, Policy for Emergent Infectious Diseases (Covid-19) Outbreak Plan and indicated that: Cohorting means any group of individuals affected by common diseases, environmental or temporal influences, treatments, or other traits whose progress is assessed in a research study should be house together. This cohorting guideline was as follows: a) Cohort 1 - COVID-19 Positive: This cohort consists of both symptomatic and asymptomatic patients/residents who test positive for COVID-19, including any new or re-admissions known to be positive, who have not met the discontinuation of Transmission-Based Precautions criteria. If feasible, care for COVID-19 positive patients/residents on a separate closed unit. Patients/residents who test positive for COVID-19 are known to shed virus, regardless of symptoms; therefore, all positive patients/residents would be placed in this positive cohort. b) Cohort 2 - COVID-19 Negative, Exposed: This cohort consists of symptomatic and asymptomatic patients/residents who test negative for COVID-19 with an identified exposure to someone who was positive. Exposed individuals should be quarantined for 14 days from last exposure, regardless of test results. All symptomatic patients/residents in this cohort should be evaluated for causes of their symptoms. Patients/residents who test negative for COVID-19 could be incubating and later test positive. To the best of their ability, long-term care facilities (LTCFs) should separate symptomatic and asymptomatic patients/residents, ideally having one group housed in private rooms. Even though symptomatic COVID-19 negative patients/residents might not be a threat to transmit COVID-19, they still may have another illness, such as influenza. Asymptomatic patients/residents should be closely monitored for symptom development. c) Cohort 3 - COVID-19 Negative, Not Exposed: This cohort consists of patients/residents who test negative for COVID-19 with no COVID-19 like symptoms and are thought to have no known exposures. The index of suspicion for an exposure should be low, as COVID-19 has been seen to rapidly spread throughout the post-acute care setting. In situations of widespread COVID-19, all negative persons in a facility would be considered exposed. Cohort 3 should only be created when the facility is relatively certain that patients/residents have been properly isolated from all COVID-19 positive and incubating patients/residents and HCP. Facilities may not be able to create this cohort. d) Cohort 4 - New or Re-admissions: This cohort consists of all persons from the community or other healthcare facilities who are newly or readmitted . This cohort serves as an observation area where persons remain for 14 days to monitor for symptoms that may be compatible with COVID-19. Testing at the end of this period could be considered to increase certainty that the person is not infected. COVID-19 positive persons who have not met the discontinuation of Transmission-Based Precautions should be placed in Cohort 1 - COVID-19 Positive. Individuals who have cleared Transmission-Based Precautions and it has been <3 months after the date of symptom onset or positive [CONDITION(S)] test (for asymptomatic) of prior infection can go to cohort 3. On 2/10/2021 at 10:14 AM, Surveyor #1 interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #1) on the South Unit (LTC) who stated that if a HCP tested positive for the Covid-19 virus on the South unit then the DON would perform contact tracing to see what residents the infected HCP exposed or had direct contact with. She revealed that there were also CNA's who became infected with Covid-19 on the South Unit and that the facility did not make any changes in what PPE was required on the unit. She confirmed that the residents that were exposed to the infected HCP were not put on TBP or identified as PUI. LPN/UM #1 told the surveyors that HCP continued to wear the facility's requirement of a surgical mask and a face shield. The unit staff were observed by Surveyor #1 to be wearing a surgical mask and face shield or eye protection. On 02/10/2021 at 10:30 AM, Surveyor #1 interviewed the LPN/UM #2 of the LTC West unit who told Surveyor #1 that this unit was a well, non-ill unit. She added that if a staff member on the West Unit was infected with the Covid-19 virus that the facility would immediately perform Covid-19 tests on the residents that had been exposed to the Covid positive employee and that the facility would monitor the exposed residents every shift for signs and symptoms of Covid-19. She confirmed that the facility did not implement TBP for the exposed residents but wore the facility requirements of a surgical mask and a face shield because the residents were not identified by the facility as Persons Under Investigation (PUI) for Covid-19. The unit staff were observed by Surveyor #1 to be wearing a surgical mask and face shield or other eye protection. On 02/10/2021 at 10:40 AM, Surveyor #1 interviewed the Registered Nurse/UM for the North Unit concerning facility practice for residents who had been exposed to positive HCP. She told the surveyor that the exposed residents were not considered PUI by the facility and no TBP were implemented. She stated that the residents that had been exposed to the Covid-19 infected HCP were not considered PUI by the facility so TBP were not implemented. She added that if an employee who tests positive for Covid-19 the exposed residents would be monitored every shift for signs and symptoms of Covid-19 and vital signs were taken. There was no change to the PPE of a surgical mask and a face shield. On 02/10/2021 at 11:30 AM, Surveyor #1 interviewed the facility Infection Preventionist (IP) who stated that residents considered PUI were new admissions, re-admissions and residents that were exposed to someone who was positive for Covid-19. She added that residents who were considered PUI were on TBP (droplet precautions) and that staff were required to wear full PPE which consist of N95 or KN95 (covered with a surgical mask), isolation gown, gloves, face shields or goggles. The IP revealed that if an employee test positive for Covid-19 and had contact with residents, those exposed residents would be considered PUI and transmission-based precautions would be implemented. She added that the staff should be wearing full PPE when caring for the exposed residents because the residents would be on droplet precautions. The IP did not have any comments on why appropriate TBP were not implemented in the facility after residents were exposed to HCP who were tested positive for Covid-19. On 02/10/2021 at 12:30 PM, the surveyors interviewed the LNHA and RD and were told that the facility followed the recommendations of the Local Health Department (LHD) who handled pandemics and that the LHD recommendations superseded what the state, CDC or what the facility Outbreak plan indicated. On 02/10/2021 at 4:10 PM, the surveyors interviewed the LNHA and the Regional Director of Nursing who both agreed that the facility usually followed the facility cohorting policy and Disease Outbreak Plan however were given direction from the Local Health Department that residents exposed to infected Health Care Personal just needed to be monitored for signs and symptoms of Covid-19 and were not considered PUI and did not need to be put on TBP. The surveyors received the Removal Plan on 2/11/12 at 9:56 AM via email and it was accepted. The implementation of the removal plan was verified with an on-site visit on 2/12/21. On 2/12/21 at 10:40 AM, the surveyors toured the North and South, and West units of the facility and verified through observations, interviews with facility staff, and review of in-service education, facility documentation that the Removal Plan had been implemented. Part B: F880 remains a deficiency, at a scope and severity level of a E based on the following: On 02/10/21, it was determined that F 880 deficiency continued at an E level, for failure to ensure staff followed appropriate infection control protocols related to donning (applying) and doffing (removing) appropriate PPE on a unit identified as Persons under Investigation (PUI) in accordance to facility protocols. This deficient practice was identified for 2 of 2 nursing staff observed on 1 of 2 PUI units during a focused infection control survey conducted on 02/10/21 and was evidenced by the following: On 02/09/21 at 9:11 AM, during an entrance conference with the DON, LNHA, and Regional Director of Nursing the surveyors were told that the PUI Unit consisted of new admission/readmission residents and any residents that were exposed to Covid-19. The staff were to wear a N95 or KN95 mask covered with a surgical mask, face shield or goggles, a washable isolation gown and gloves prior to entering a PUI resident's room. Upon exiting a PUI room, the staff was to remove the gloves and discard the gloves in the room's trash can, remove the washable gown and dispose of the gown in the bins located in the hallway. The staff could hang the contaminated gown on the hooks on the doorway of each resident's room if the gown was to be used again on their shift. On 02/09/2021 at 12:06 PM, the two surveyors toured the North PUI Unit. The PUI Unit was located on the North Unit and had a plastic zippered barrier doorway with signage attached to the plastic which indicated that Standard Precautions and Droplet Precautions were to be used and the appropriate PPE was to be worn on the unit. Upon entering the PUI unit, the surveyors observed 3 tier bins containing clean PPE in the hallways outside the residents' rooms and bins in the hallway to dispose of trash and washable isolation gowns. The surveyors observed white lab coats and washable isolation gowns hung on hooks of resident's doors facing the hallway and on a set of hooks located in the hallway by the zippered doorway. The washable isolation gowns and lab coats were layered on top of one another on the hooks near the zippered plastic barrier doorway. On 02/09/2021 at 12:08 PM, the surveyors observed a staff member in room [ROOM NUMBER] on the PUI Unit performing care for a resident with the curtains closed. The surveyors observed the staff member exit the room without removing the contaminated washable gown she was wearing. The staff member proceeded to walk down the hallway and place a trash bag in the trash can located at the end of the hallway near the plastic barrier door. She then performed hand hygiene with hand gel and continued to walk through the hallway wearing the contaminated gown. The staff member identified herself as a Registered Nurse (RN#1) and was interviewed at that time. RN #1 admitted to the surveyors that she should not be wearing the contaminated gown in the hallway and that she should have removed the gown before exiting the resident's room. RN #1 then removed the gown, rolled the gown in a ball and carried the contaminated gown down the hallway and disposed of the gown in the bin located in the hallway. RN#1 stated that staff was to use one isolation gown for each resident and were to hang the contaminated gown on the hooks of each resident's room to reuse again. The surveyors observed that the 2 hooks on the resident doors were not labeled and were located on the door side facing the hallway. RN #1 then stated that even though the hooks were not labeled to identify who the gown belonged to; she would know which gown belonged to her. RN #1 further stated that a contaminated gown was to be removed prior to exiting a PUI room, roll it with the dirty side in and the clean side outside, then dispose of the contaminated washable gown in the bin located in the hallway or the bin located by the zippered plastic doorway. When asked if the PUI Unit hallway was considered contaminated, RN #1 stated that she thought it was about 50% contaminated. RN #1 stated that the white lab coats and gowns that were layered together on the hooks located in the hallway of the PUI unit were used by doctors who came to see the residents in the PUI Unit. She explained that the doctors came and applied the gowns to examine residents and then after they were done would hang the gowns back up on the hooks. She said that they could be contaminated because they had been used in residents' rooms. On 02/09/2021 at 12:15 PM, Surveyor #1 observed a staff member enter the PUI unit through the zippered barrier and take a washable isolation gown off the hook that was located just beyond the zippered barrier. The gown that the staff member took off the hook was mixed with other gowns. She applied the gown and entered a residents room. The staff member was identified as a CNA (CNA #5) On 02/09/2021 at 12:50 PM, the surveyor interviewed CNA #5 who stated that she was assigned to the PUI Unit. She stated that she took the gown from the stack of gowns hanging on the hooks because it was her gown. She added that she knew it was her gown because it was green. She stated that she did not know that the gown was contaminated even though she wore the gown earlier in a resident's room to provide care and then hung the same gown up on a hook with other gowns to be used again. On 02/20/21 at 10:36 AM, the surveyors interviewed the RN/UM #1 for the North Unit which contained the PUI Unit. RN/UM#1 stated that the staff were to change isolation gowns between residents. When exiting a PUI room, the contaminated gowns were to be removed prior to exiting a resident's room then placed in a plastic bag to be disposed of in the designated bins in the hallway. She further stated that she would consider the gowns /lab coats hanging on the hooks located in the hallway to be contaminated therefore the hallway would be considered contaminated. On 02/10/21 at 11:29 AM, the surveyors interviewed the IP who stated that on the PUI Unit the staff were to wear a N-95 mask (covered with a surgical mask), a face shield or goggles, then don (apply) an isolation gown and gloves prior to entering a PUI resident's room. Upon exiting the PUI room, staff were to remove gloves and gown prior to exiting the room and dispose of the isolation gowns in bins located inside each PUI resident's room then perform hand hygiene. On 02/10/21 at 03:04 PM, during an interview with the RD and IP, both stated they were unaware that the staff were disposing of the contaminated gowns in disposal bins located in the hallways of the PUI Unit. Both the RD and IP stated that bins for gown disposal should have been in each PUI room in order for staff to dispose of contaminated gowns prior to exiting the room. The RD, LNHA, DON and IP were also unaware that staff were hanging contaminated gowns on top of one another on the hooks located in the hallway near the zippered barrier and admitted that this was not the facility process. The surveyor reviewed the education provided by the facility for RN #1 which included but not limited to the following: -COVID-19: PPE Guidance for Use dated January 20, 2020. -Infection Control (F880, F881, F882, F883) dated January 20,2020. -2020 Annual education records which included hand hygiene and infection control precautions. -Symptoms of Covid-19 vs the Flu/cold dated 11/16/20. -Keeping Covid Out- infection prevention Overview dated 12/18/20 (which included proper use of PPE). The surveyor reviewed the education provided by the facility for CNA #5 which included but not limited to the following: -COVID-19-PPE Guidance for Use dated January 20, 2021. -2020 Annual Education record which included Infection prevention, Hand Hygiene, Covid Vs other Illnesses, PPE and Extended Use. -Keeping Covid Out- infection prevention Overview dated 12/18/20 (which included proper use of PPE). The facility policy implemented 03/06/2020 and updated 12/18/2020, titled, Policy for Emergent Infectious Diseases (Covid-19) Outbreak Plan and indicated that: -Facility would implement the isolation protocol in the care center (isolation rooms, cohorting, cancellation of group activities and social dining) as described in the center's infection prevention and control plan and/or recommended by the local, state or federal public health authorities. -Activate quarantine interventions for residents and staff with suspected exposure as directed by local and state public health authorities and in keeping with guidance from the CDC. -When cohorting residents the facility shall identify a minimum of three cohort groups: a.) Individuals who are showing symptoms of Covid-19 or who have tested positive for Covid-19. b.) Individuals who have been exposed to someone who has tested positive for Covid-19 or has shown symptoms of Covid-19 (i.e., individuals who are not themselves symptomatic, but may potentially be incubating the virus); and c.) Individuals who are not ill and not been exposed. d.) Facility shall assign dedicated staff to each cohort and allow for necessary space to do so at the onset of and outbreak. The facility policy dated 11/10/2020 and titled, Use of Personal Protective Equipment Utilized by Cohort indicated that the policy serves for use of Standard, Droplet, and Contact Precautions for residents with symptoms of respiratory infection unless the suspected diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] ., [CONDITION(S)]). The policy indicated that for suspect or confirmed Covid-19 case (s) Standard and Transmission-based Precautions including use of N95 respirator or higher (or facemask, if available), gowns gloves, and eye protection is recommended. Use of PPE by Cohort: -Positive: N95/KN95, Protective Eye Equipment such as goggles/face shield, Gown and Gloves. -Persons under Investigation (PUI): N95/KN95, Protective Eye Equipment such as goggles/face shield, Gown and Gloves. -New admissions/Readmissions: N95/KN95, Protective Eye Equipment such as goggles/face shield, Gown and Gloves. -Negative: Surgical Mask, Eye Protection The facility policy updated 03/06/2020 and titled, Quarantine indicated that the facility will protect the health and wellbeing or residents and staff during infectious disease outbreaks. Quarantine is generally enacted by governmental authorities. The facility policy updated 03/06/2020 and titled, Respiratory Infection, Prevention and Control of indicated that that facility follows current guidelines and recommendations for the prevention and control of respiratory infections. The policy indicated that: Standard Precautions: during care of any resident, all staff should adhere to standard precautions, which are the foundation for preventing transmission of infectious agents in all healthcare settings. (Hand hygiene, gloves, and gowns) According to this policy gowns will be worn for any resident care activity when contact with blood, body fluids, secretions (including respiratory) or excretions is anticipated. Gowns will be removed, and hand hygiene will be performed before leaving the residents room and the same gown will not be worn for care of more than one resident. - Droplet precautions will be implemented for residents with suspected or confirmed respiratory infection for seven days after illness or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. -In some cases, droplet precautions may be applied longer periods based on clinical judgement. -Residents with suspected or confirmed respiratory infection would be placed in a private room and when single room is not available, the IP will assess the risk associated with other resident placement options (e.g., cohorting or keeping the resident with an existing resident.) -Alternative PPE would be provided such as face shields and N95 respirators. The facility policy updated 03/06/2020 and titled, Isolation-Categories of Transmission-Based Precautions indicated that Droplet Precautions may be implemented for and individual documented or suspected to be infected with microorganisms transmitted by droplets. Residents on droplet precautions will be placed in private room if possible, masks will be worn, gloves, gowns and goggles should be worn if there is a risk of spaying respiratory secretions. The facility policy also indicated that Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status and droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particles larger than 5 microns in size) that can be generated by the individual coughing, sneezing, talking, or performance procedures such as suctioning. NJAC 8:39-19.4 (a)(b)(c)(d)

Complaint : NJ Based on interview and record review, it was determined that the facility failed to provide a safe environment for all residents. This deficient practice was identified for 1 of 3 residents (Resident #1) who was assessed as a risk for wandering and demonstrated exit seeking behavior, was able to elope through a window which opened 12 inches. The failure of the facility staff to ensure that all residents' room windows were restricted from opening to the extent that allowed for possible elopement. This was determined by the following: The Immediate Jeopardy (IJ), which began on 1/30/16 and was corrected on 1/31/16 by securing all windows was identified as an IJ situation on 2/8/16 at 3:30 p.m. This deficient practice was evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The day 5 admission Minimum Data Set (MDS), an assessment tool dated 1/30/16 for Resident #1 showed no available data. The facility electronic record titled Neurological Assessment dated 1/29/16 indicated that Resident #1 was alert with confusion. On 2/4/16, the Department of Health (DOH) received a Reportable Event Form (FRE) from the facility. This report revealed the following: On 1/30/16 at 10:15 a.m., Resident #1 was reported as exit seeking, not accepting redirection. Non-pharmacological interventions ineffective. Refusal of Intravenous Antibiotic. Offered Anxiolytic successfully at 11 a.m. Anxiolytic reduced behaviors for approximately 3 hours. Behaviors began escalating at approximately 3 p.m. Again, non-pharmacological interventions ineffective. Remained in visual sight of the Administrator while pacing in hallway. Nurse placed call to Medical Doctor (MD) for added intervention. Nurse administered Nicoderm Patch and increased dose of Anxiolytic as per MD at 5 p.m. Last witnessed by Administrator at approximately 5:25 p.m. in hall. Lost sight moments later. Team immediately responded with room to room search. Identified window in room 422 opened 12 inches high. At 5:30 p.m., Nurse Supervisor retrieved Resident #1 knocking at door before Code Gray could be called. Immediately assessed by RN Supervisor. Complained of chest pain. MD approved to be sent to hospital. In contact with hospital to identify alternate placement. A post survey review of the Acute Care hospital on [DATE], of a record dated 1/30/16, showed that Patient admitted to in-patient bed. A review of the form attached to the FRE titled Wander Risk Evaluation dated 1/29/16 showed that Resident #1 scored 7, which indicated moderate (5-10) for wander risk. A review of the form attached to the FRE under Post Occurrence Response dated 1/30/16 showed All Center Windows were audited and height of opening was reduced to 6 inches. All resident rooms and common areas were completed by 8:00 p.m. on Sunday 1/31/16. All offices and business areas were completed by 12 p.m. 2/1/16. An independent audit was conducted by Medical Records technician to confirm that all windows had been adjusted to a 6 inch opening by 2:30 p.m. on 2/1/16. On 2/8/15 at 9:20 a.m., a room to room window check was conducted by the Maintenance Director in the presence of surveyor. The finding was: On the West Unit also called Secured Unit had 26 residents' room. All 26 residents' room windows had an opening of 6 inches high (including window in room 422). During an interview with the surveyor on 2/8/16, the Maintenance Director was asked about the 12 inch high opening in room 422, prior to the incident on 1/30/16. The Maintenance Director stated All the residents' room windows were maintained on 6 inches high opening except the window in room 422 which was 12 inches. I do not know the reason but I told the previous Maintenance Director, to keep it at 6 inches high. Obviously he never did. During a follow up interview with the Maintenance Director on 2/8/16, the surveyor asked the Maintenance Director about the window check audit log prior to the incident on 1/30/16. The MD stated We never did a windows check prior to the incident on 1/30/16. The MD further stated I started window checks weekly after the incident on 1/30/16. The surveyor asked the Maintenance Director about the exact date, start and completion time when the residents' room window height was adjusted to 6 inches. The Maintenance Director stated We started on 1/31/16 at 6 a.m. and completed before 8 a.m. During an interview with the the surveyor on 2/8/16 at 1:15 p.m., the Administrator confirmed that all the windows in the facility were audited and the openings were adjusted to 6 inches high. The Administrator further stated We identified the 3 windows on the West unit (rooms 422, 418 and 420) that had 12 inches opening and those windows were used by the construction workers as a way out to remove the debri from the West unit last year. The surveyor reviewed the facility Electronic Record for Resident #1 titled Progress Notes (PN) written by the Administrator dated 1/30/16 timed at 18:00. The PN revealed At approximately 5:25 p.m., Resident #1 was no longer in the hall .At 5:30 p.m., Certified Nurse Assistant (CNA) identified a window open approximately 12 inches. Simultaneously door alarm was announced via overheard speaker. Nurse Supervisor had opened the door where the Resident was standing in front of. Resident brought back inside immediately. Resident complained of chest pains . Resident #1 was sent to Hospital. In an interview with the Director of Nursing (DON) on 2/8/16, the DON indicated that the ambulance personnel had taken Resident #1 to the hospital on [DATE] at 6:03 p.m. The surveyor asked the DON What was done to the window in room 422 after Resident #1 left to the hospital? The DON stated I cannot give specific details because I was not here at that time. During a subsequent interview with the surveyor, the Administrator was asked about the measures taken on residents' room windows from the time Resident #1 left the facility at 6:03 p.m. to ensure the other residents' safety. The Administrator stated We kept room 422 door and window closed, and the room was kept empty. The Administrator further stated All windows in the Center were audited and the height of the windows opening were adjusted the following day 1/31/16. We ensure that all residents with Wander Risk Assessment older than 30 days were reassessed and Elopement Photo book was updated. At 3:30 p.m., the Administrator and the DON were notified that an Immediate Jeopardy past noncompliance which began on 1/30/16 for failure to ensure that the resident environment remains safe. The IJ was corrected when the facility implemented an acceptable Plan of Correction (POC) that included staff education on Elopement dated 1/31/16. The acceptable POC was documented as follows: 1). Resident #1 was immediately affected. Resident was recovered within 5 minutes. Resident placed on 1:1 until medics arrived. Door to room closed and window latched. Identified open window. Called physician for additional interventions. All windows audited and adjusted to ensure opening does not exceed 6 inches before 8 a.m. 2) All other residents had the potential to be affected by the deficient practice as identified by the Wander Risk Evaluation. 3) All residents were re-evaluated to ensure that each person resides on a nursing unit that best accommodate their needs by 2/2/16. Elopement photo book at reception was confirmed to be updated. Staff in-serviced on Identification of Residents at risk for Wandering. Staff in-serviced on Wander Risk and Elopement. 4) Maintenance Director or Designee to continue Door Alarm audits weekly to include 100% of the exterior doors. Maintenance Director or Designee to audit window openings weekly to include 100% (percent) of windows on West unit and 20% of windows throughout the remainder of the center. Elopement and Wander risk assessments will be completed by nursing, at a minimum, quarterly and on as needed basis. Elopement drills will be conducted monthly. 5) Compliance date: 1/31/16. NJAC 8:39-31.2 (e)

Based on observation, interview and record review, it was determined that the facility failed to off-load a resident's heels from the bed, floor or geri recliner to prevent pressure sores. The resident had a known behavior of sliding his/her feet back and forth on any surface which placed the resident at high risk for pressure sores. Interventions were not started until after the resident presented with 2 facility-acquired pressure sores on both heels. This deficient practice was identified for Resident #18, 1 of 2 residents reviewed for wounds/pressure sore treatment and was evidenced as follows: During the initial tour on 7/30/2014 at 10:30 a.m., the surveyor observed Resident #18 who was seated in a geri-recliner with heel booties on both feet. According to the Unit Manager (UM), the resident had two facility-acquired pressure sores on both heels as the resident constantly moved his/her feet back and forth. Record review revealed Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), an assessment form dated 9/15/2013, indicated the resident was cognitively impaired, non ambulatory, incontinent, required an extensive assist of two staff for transfers, skin was noted to be intact, and the resident was at risk for pressure sores. The resident was out of bed daily to a wheelchair. On 5/7/2014 at 10:56 a.m. an Interdisciplinary note stated, "Resident c/o (complained) feet hurt points to left heel is slightly pink is boggy and right heel is red MD made aware new order for [MEDICATION NAME] no sting barrier film to left and right heel qd (daily) times 14 then reevaluate." The [MEDICATION NAME] barrier film was continued to the heels. On 5/16/2014 there was an order for [REDACTED]. According to the 6/8/2014 Quarterly MDS, the resident still required an extensive assist of two for transfers, was non- ambulatory, incontinent, and had no skin breakdown. The surveyor reviewed the Interdisciplinary Note of 6/23/14 that stated Resident #18's right heel "with approximately 4 x 3 cm boggy/red area with very faint 0.8 x0.8 cm purple area." A new order to offload both feet was started. On 7/14/2014, the Wound Team recommended a plan for the heels which included to off load bilateral heels with heel lift boots. Use of either boots or a pillow when in the geri-recliner and having Sensilase testing (measures blood flow and circulatory health) was recommended. On 7/14/2014 the Physicians Order Sheet included an order to off-load heels with heel lifts while in bed and use either boots or a pillow when in the recliner. On 7/18/2014 a Sensilase study was done to the feet. The test results indicated moderate bilateral Peripheral Artery Disease, and that wound healing potential appeared reasonable. On 8/4/2014, the right foot wound was documented by the Wound Team as a full thickness wound of the right medial heel, 1.3 x 1.3 cm. and the wound base was a reabsorbed blood blister. The left foot full thickness wound of the left medial heel- 3.5 x4.0 cm. wound was a blood blister reabsorbing, both unstageable. On 8/5/2014 at 11:38 a.m. the UM said the resident's heel blisters were from pressure secondary to Resident #18's behavior of moving and pushing their feet back and forth. The UM also stated that Resident #18 "has always pushed (his/her) feet up and down since admission." On 8/6/2014 at 9:15 a.m., the surveyor observed Resident #18 in the unit dayroom seated in the geri-recliner. The resident's feet were elevated and resting between the two foot rests. The physician-ordered heel boots were not observed. The UM was notified and the resident was returned to his/her room and the assigned Certified Nursing Assistant (CNA) came into the room as well. The surveyor questioned the CNA as to why the booties to protect the resident's feet were not applied. The CNA said she was not aware of that order. The surveyor asked if there was a CNA care card available. The UM opened the resident's closet door where the instructions for the residents care was located. The only item checked for use was the geri-recliner with a note to "see photo below." The black and white photo was of the resident seated in the geri-recliner, but there was no pillow or booties applied to the feet in the photo. At that time the UM removed the resident's socks and the pressure sores were observed by the surveyor. The UM then got the booties from the resident's closet and applied them to both feet. NJAC-8:39-27.1(a)