COMPLAINT #NJ162233 Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This deficient practice was identified for 1 of 1 resident reviewed, Resident #70. This deficient practice was evidenced by the following: On 7/22/24 at 11:02 AM, during initial tour, the surveyor observed Resident #70 resting in their bed with their eyes closed. The surveyor also observed the Registered Nurse (RN) in the room who stated that she assessed the resident's vital signs. On 7/22/24 at 11:32 AM, the surveyor reviewed the form that was provided by the facility titled, Reportable Event Record/Report for a Facility Reported Event (FRE) dated 3/9/23 which included the following: Today's date: 3/9/23 Date of Event: 3/7/23 Was This a Significant Event: Yes Was Significant Event Called in? Yes Date: 3/8/23 Time: 2:30 PM Type of Incident: Other, specify: Resident had a tuft fracture (a break at the tip of the fingers or toes) of the left thumb. The surveyor reviewed the medical record for Resident #70. A review of Resident #70's admission Record (an admission summary) indicated that the resident was admitted to the facility with diagnoses which included but not limited to Hypertension (elevated blood pressure), Metabolic Encephalopathy (a brain dysfunction [problem or fault] caused by problems with your metabolism, such as low glucose or high toxins), Cerebral Infarct (when an area of brain tissue dies due to inadequate blood supply and oxygen), and Age-related Osteoporosis (a condition that weakens bones and makes them more likely to break) without current pathological fracture (a broken bone that is caused by an underlying disease, rather than an injury). A review of Resident #70's Quarterly Minimum Data set (Q/MDS), an assessment tool used to facilitate the management of care, dated 1/10/23, reflected that Resident #70 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated that the interview with Resident #70 was not successful. Resident #70 had problems with short term and long-term memory. A review of Resident #70's progress notes (PN) dated 3/6/2023 at 08:42 AM, revealed that the resident was observed with bruising and some swelling to the left great thumb in the morning of 3/6/2024. The PN further documented that the Nurse Practitioner was notified who ordered to perform a left finger x-ray (painless test that captures images of the structures inside the body - particularly the bones). The x-ray was completed at on same day at 3:30 PM. A review of Resident #70's X-ray report dated 3/6/23 at 18:50 (6:50 PM) which revealed a result finding, minimally displaced tuft fracture of the distal (Situated away from the center of the body, or from the point of origin) thumb. A review of the resident's PN dated 3/7/2023 at 08:31 AM documented that x-ray result was faxed (a form of communication that involves scanning and transmitting printed documents from one machine to another) to MD (medical doctor). On 7/23/24 at 10:05 AM, the surveyor reviewed a form titled, Incident Investigation Sheet for Statements and Statement for investigation that was provided by Director of Nursing (DON). The form was utilized as an incident investigative form to document the statement of all the staff assigned to the resident in the last 72 hours prior to the incident. The Incident Investigation Sheet for Statements (IISS) form listed the names of the staff including nurses and Certified Nurse Assistants (CNAs), who provided the care to the resident prior to the incident beginning on 3/3/23 through 3/6/23 when the injury was identified. During the review of the IISS form, the surveyor noted that there were missing statements to complete the investigations for the incident on the following shifts: The surveyor did not see a CNA Statement for Investigation for 3/3/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/3/23 shift 11-7. The surveyor did not see a Nurse Statement for Investigation for 3/4/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/4/23 shift 11-7. The surveyor did not see a Nurse Statement for Investigation for 3/5/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/5/23 shift 11-7. On 7/23/24 at 12:53 PM, the surveyor interviewed the DON and the Licensed Practical Nurse / Regional Clinical Coordinator (LPN/ RCC) who stated that the facility usually goes back 2-3 days prior to the incident to gather the statements of the staff assigned to the resident. The surveyor notified the concern regarding the missing staff statements as part of the investigation process for the above-mentioned dates and shifts. The DON and LPN/RCC acknowledged that they could not find the missing statements mentioned above. The DON and LPN/RCC further stated that they were not employed by the facility at the time of the incident. On 7/25/24 at 11:14 AM, in the presence of second surveyor, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Business Office Manager (BOA) who stated, 7 staff members were a substantial number of staff who did not provide an explanation or statements. The LNHA further stated, providing statements were not an option. The LNHA acknowledged that the investigation of Resident #70's injury of the unknown origin was incomplete and should have included the complete staff interviews on all staff involved. No further information was provided. On 07/29/24 at 12:12 PM, the survey team met with the DON, LNHA and RCC. The LNHA could not provide any further information. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating was revised on 3/12/24, under Policy Statement included: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under Section Reporting Allegations to the Administrator and Authorities of Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating included: 7h.) interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. NJAC 8:39-4.1(a)(5)

COMPLAINT #NJ162233 Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This deficient practice was identified for 1 of 1 resident reviewed, Resident #70. This deficient practice was evidenced by the following: On 7/22/24 at 11:02 AM, during initial tour, the surveyor observed Resident #70 resting in their bed with their eyes closed. The surveyor also observed the Registered Nurse (RN) in the room who stated that she assessed the resident's vital signs. On 7/22/24 at 11:32 AM, the surveyor reviewed the form that was provided by the facility titled, Reportable Event Record/Report for a Facility Reported Event (FRE) dated 3/9/23 which included the following: Today's date: 3/9/23 Date of Event: 3/7/23 Was This a Significant Event: Yes Was Significant Event Called in? Yes Date: 3/8/23 Time: 2:30 PM Type of Incident: Other, specify: Resident had a tuft fracture (a break at the tip of the fingers or toes) of the left thumb. The surveyor reviewed the medical record for Resident #70. A review of Resident #70's admission Record (an admission summary) indicated that the resident was admitted to the facility with diagnoses which included but not limited to Hypertension (elevated blood pressure), Metabolic Encephalopathy (a brain dysfunction [problem or fault] caused by problems with your metabolism, such as low glucose or high toxins), Cerebral Infarct (when an area of brain tissue dies due to inadequate blood supply and oxygen), and Age-related Osteoporosis (a condition that weakens bones and makes them more likely to break) without current pathological fracture (a broken bone that is caused by an underlying disease, rather than an injury). A review of Resident #70's Quarterly Minimum Data set (Q/MDS), an assessment tool used to facilitate the management of care, dated 1/10/23, reflected that Resident #70 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated that the interview with Resident #70 was not successful. Resident #70 had problems with short term and long-term memory. A review of Resident #70's progress notes (PN) dated 3/6/2023 at 08:42 AM, revealed that the resident was observed with bruising and some swelling to the left great thumb in the morning of 3/6/2024. The PN further documented that the Nurse Practitioner was notified who ordered to perform a left finger x-ray (painless test that captures images of the structures inside the body - particularly the bones). The x-ray was completed at on same day at 3:30 PM. A review of Resident #70's X-ray report dated 3/6/23 at 18:50 (6:50 PM) which revealed a result finding, minimally displaced tuft fracture of the distal (Situated away from the center of the body, or from the point of origin) thumb. A review of the resident's PN dated 3/7/2023 at 08:31 AM documented that x-ray result was faxed (a form of communication that involves scanning and transmitting printed documents from one machine to another) to MD (medical doctor). On 7/23/24 at 10:05 AM, the surveyor reviewed a form titled, Incident Investigation Sheet for Statements and Statement for investigation that was provided by Director of Nursing (DON). The form was utilized as an incident investigative form to document the statement of all the staff assigned to the resident in the last 72 hours prior to the incident. The Incident Investigation Sheet for Statements (IISS) form listed the names of the staff including nurses and Certified Nurse Assistants (CNAs), who provided the care to the resident prior to the incident beginning on 3/3/23 through 3/6/23 when the injury was identified. During the review of the IISS form, the surveyor noted that there were missing statements to complete the investigations for the incident on the following shifts: The surveyor did not see a CNA Statement for Investigation for 3/3/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/3/23 shift 11-7. The surveyor did not see a Nurse Statement for Investigation for 3/4/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/4/23 shift 11-7. The surveyor did not see a Nurse Statement for Investigation for 3/5/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/5/23 shift 11-7. On 7/23/24 at 12:53 PM, the surveyor interviewed the DON and the Licensed Practical Nurse / Regional Clinical Coordinator (LPN/ RCC) who stated that the facility usually goes back 2-3 days prior to the incident to gather the statements of the staff assigned to the resident. The surveyor notified the concern regarding the missing staff statements as part of the investigation process for the above-mentioned dates and shifts. The DON and LPN/RCC acknowledged that they could not find the missing statements mentioned above. The DON and LPN/RCC further stated that they were not employed by the facility at the time of the incident. On 7/25/24 at 11:14 AM, in the presence of second surveyor, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Business Office Manager (BOA) who stated, 7 staff members were a substantial number of staff who did not provide an explanation or statements. The LNHA further stated, providing statements were not an option. The LNHA acknowledged that the investigation of Resident #70's injury of the unknown origin was incomplete and should have included the complete staff interviews on all staff involved. No further information was provided. On 07/29/24 at 12:12 PM, the survey team met with the DON, LNHA and RCC. The LNHA could not provide any further information. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating was revised on 3/12/24, under Policy Statement included: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under Section Reporting Allegations to the Administrator and Authorities of Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating included: 7h.) interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. NJAC 8:39-4.1(a)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00165369 Based on interviews, and record review, as well as review of pertinent facility documents on 9/13/23, 9/14/23, and 9/19/23, it was determined that the facility failed to report an allegation of a resident-to-resident physical and verbal abuse to the New Jersey Department of Health (NJDOH) and to follow the facility policy Abuse Neglect Exploitation Mistreatment and missappropriatin of Property Prevention for 1 of 3 residents (Resident #7) reviewed for grievance. This deficient practice is evidenced by the following: According to the admission Record (AR), Resident #7 was admitted to the facility on [DATE] with diagnoses which included but were not limited to; Dementia, Post Traumatic Stress Disorder, and Obsessive Compulsive Disorder. A Minimum Data Set (MDS), an assessment tool, dated 9/7/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated his/her cognition was intact and the resident needed assistance with activities of daily living (ADLs). Review of the Concerns/Grievance Form (CGF), dated 12/12/22 for Resident #7. The CGF indicated see the attached written compliant from resident. The CGF also indicated that the letter was forwarder to Administrator and Director of Nursing (DON). Furthermore, the CGF, under ACTION TAKEN indicated that the Social Worker (SW) had asked resident on numerous occasions if [she/he] would like a room change which [she/he] declined. The CFG indicated that the situation had been resolved. Included in the CFG was a written letter from Resident #7, dated 12/12/22. Resident #7 indicated on the letter that she/he felt that she/he was being physically and verbally abused by her/his roommate (Resident #9). The letter further indicated Resident #9 would call Resident #7 an animal, live like an animal, and ugly. Resident #7 also indicated on the letter that these words were acts of verbal and emotional abuse. The letter revealed that Resident #9 physically abused Resident #7, Resident #9 would use her/his walker and used as a weapon. Resident #7 explained that Resident #9 takes [her/his] walker and rams it into the chair. [Resident #9] repeats this action 4 or 5 times in a row, several times a day - EVERYDAY. This has been going on for at least two months .[she/he] doing so violently .I'm emotionally drained by the verbal and non-verbal abuse . During an interview with the surveyor on 9/19/23, 1:36 p.m., the Social Worker (SW) confirmed receiving the letter from Resident #7 on 12/12/22. The SW stated the letter was not thoroughly read; however, she asked the Resident to summarize the letter. The SW added the letter was forwarded to the Administrator and Director of Nursing (DON). She further stated that she did not report the allegation of abuse to the NJDOH. During an interview with the DON and Administrator on 9/19/23 at 12:15 p.m. and 2:30 p.m., the Administrator stated that he received and discussed the letter with Resident #7's after 12/12/22 (unable to recall exact date and time). He further stated that the letter was unreadable and discussed the content of the letter directly to the Resident. The Administrator explained that during the interview with the Resident, she/he did not verbalize of the abovementioned allegation of physical and emotional abuse and was not reported to the NJDOH. Review of a facility policy titled Abuse Neglect Exploitation Mistreatment and misappropriation of Property Prevention, dated 8/2023, indicated .The purpose is to assure that the facility is doing all that is within its control to prevent occurrences .Reporting/Response .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will 1. Ensure that all alleged violations involving abuse, neglect .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .to other officials (including the State Survey Agency .in accordance with State law through established procedures. 2. Have evidence that all alleged violations are thoroughly investigated . NJAC 8:39-9.4 (f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00165369 Based on interviews and review of medical records (MRs) and other facility documentation on 9/13/23, 9/14/23, and 9/19/23, it was determined that facility failed to thoroughly investigate an alleged staff-to-resident verbal abuse allegation and to follow facility policy titled Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention for 1 of 3 residents (Resident #2). This deficient practice is evidenced by the following: A review of the statement written by the Certified Nursing Assistant (CNA #1) to the Facility's Regional Human Resources (RHR) via email, dated 9/11/23 at 12:51 a.m., revealed that CNA #1 heard and seen [CNA #2] abuse, scream, and disrespect patients and their Families on XX unit. The statement further revealed that CNA #1 reported the aforementioned incident to the Licensed Practical Nurse (LPN #1). According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to; Alzheimer's Disease, Hemiplegia and Hemiparesis. A Minimum Data Set (MDS), an assessment tool, dated 9/7/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated his/her cognition was severely impaired and the resident needed assistance with activities of daily living (ADLs). A Care Plan (CP), initiated on 12/15/21, included that the resident had an increased in forgetfulness as well as difficulty with problem solving and trouble sequencing, had diagnosis of Alzheimer's Dementia. During an interview with the surveyor on 9/13/23 at 7:18 a.m. and 9/14/23 at 8:30 a.m., CNA #1 confirmed what was written on the statement. CNA #1 stated that she verbally reported an allegation of verbal abuse to RHR and LPN #1 (unable to recall date and time). According to CNA #1 she witnessed CNA #2 being rude, screamed at [Resident #2] and family members, when [CNA #2] talks to residents, she snapped and would say, 'you have to wait, stop, I'm coming to you when I come.' During an interview with the RHR on 9/13/23 at 9:43 a.m. and 1:38 p.m., the RHR confirmed receiving the 2 statements (statement #1 and statement #2) via email from CNA #1 (unable to recall time and date) involving CNA #1 and CNA #2. RHR admitted that she read the statements, however, she did not report the allegation of abuse (Statement #2) to the Administrator and the Director of Nursing (DON). The RHR stated that when she received the email and read it, the RHR didn't follow-up the allegation of abuse because it was a personality conflict among staff. The RHR further added that the letter that she received was attention seeking, clearly its personality conflict among staff and not an abuse . During an interview with the Assistance DON (ADON), DON, and Administrator on 9/13/23 at 11:36 a.m. and 2:30 p.m., the Administrator stated that he received the email on 9/11/23, however, he only read statement #1 not realizing there was statement #2 until 9/12/23. The Administrator stated that the incident was not investigated and reported to the New Jersey Department of Health (NJDOH) because he was not aware of statement #2. The Administrator added if there was an allegation of abuse, the facility would immediately investigate and reported to NJDOH within 2 hours. The administrator also stated that the statement #1 and statement #2 involving CNA #1, CNA #2, and CNA #3 was not considered an allegation of abuse. During the survey on 9/13/23, 9/14/23, 9/19/23, CNA #2 was not available for interview. CNA #2 last worked on 9/9/23 and will not be returning to work until 1/2024. Review of a facility policy titled Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention, dated 8/2023, indicated .The purpose is to assure that the facility is doing all that is within its control to prevent occurrences .Prevention .Reporting/Response .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will .2. Have evidence that all alleged violations are thoroughly investigated . NJAC 8:39-9.4 (f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C #: NJ00160399 and NJ00167145 Based on interviews, medical record review, and review of other pertinent facility documents on 9/13/23, 9/14/23, and 9/19/23, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to the facility protocol for 3 of 4 residents (Resident #2, Resident #3, and Resident #4) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the facility admission Record (AR), Resident #2 was admitted on [DATE], with diagnosis that included but were not limited to: Hemiplegia and Hemiparesis, and Alzheimer's Disease. The Minimum Data Set (MDS), an assessment tool, dated 9/7/23, revealed a Brief Interview of Mental Status (BIMS) of 3 which indicated the resident's cognition was severely impaired and the resident needed assistance with activities of daily living (ADLs). Review of Resident #2's DSR (ADL Record) and the progress notes (PN) for the month of 8/2023 and 9/2023, lack any documentation to indicate that the care for dressing, personal hygiene, toileting, transfer, and eating was provided and/or the resident refused care on the following dates and shifts. 7:00 a.m.-3:00 p.m. shift on 8/1/23, 8/10/23, 8/11/23, 8/18/23, 8/17/23, 8/25/23, 8/28/23, and 8/31/23. 3:00 p.m.-11:00 p.m. shift on 8/1/23, 8/4/23, 8/7/23, 8/10/23 to 8/12/23, 8/15/23, 8/18/23, and 8/21/23. Toileting: 11:00 p.m.-7:00 a.m. shift on 8/1/23 to 8/423, 8/11/23 to 8/13/23, 8/18/23 to 8/21/23, 8/23/23 to 8/25/23. 2. According to the facility AR, Resident #3 was admitted on [DATE], with diagnosis that included but were not limited to: Need for Assistance with Persona Care. The MDS, dated [DATE], revealed a BIMS of 15 which indicated the resident's cognition was intact and the resident needed assistance with ADLs. Review of Resident #3's DSR and the PN for the month of 8/2023 and 9/2023, lack any documentation to indicate that the care for dressing, personal hygiene, toileting, transfer, and eating was provided and/or the resident refused care on the following dates and shifts. 7:00 a.m.-3:00 p.m. shift on 8/19/23, 9/2/23, and 9/7/23. 3:00 p.m.-11:00 p.m. shift on 8/26/23, 8/28/23, 9/6/23, and 9/7/23. 5/7/23. 11:00 p.m.-7:00 a.m shift (exclude eating and toileting) on 8/1/23 to 8/31/23, 9/1/23 to 9/12/23. Toileting: 11:00 p.m.-7:00 a.m. shift on 8/20/23, 8/21/23, and 9/3/23. 3. According to the facility AR, Resident #4 was admitted on [DATE], with diagnoses that included but was not limited to: Muscle Weakness, repeated Falls, and Cataract. The MDS, dated [DATE], revealed a BIMS of 3 which indicated the resident's cognition was severely impaired and the resident needed extensive assistance with ADLs. Review of Resident #4's DSR and the PN for the month of 8/2023 and 9/2023, lack any documentation to indicate that the care for dressing, personal hygiene, toileting, transfer, and eating was provided and/or the resident refused care on the following dates and shifts. 7:00 a.m.-3:00 p.m. shift on 8/2/23, 8/4/23 to 8/10/23, 8/13/23, 8/14/23, 8/16/23 to 8/18/23, 8/20/23, 8/21/23, 8/25/23. 3:00 p.m.-11:00 p.m. shift on 8/1/23, 8/7/23, 8/8/23, 8/11/23, 8/14/23, 8/25/23, 8/28/23. 11:00 p.m.-7:00 a.m. shift (exclude eating and toileting) on 8/1/23 to 8/31/23, 9/1/23 to 9/12/23. Toileting: 11:00 p.m.-7:00 a.m. shift on 8/2/23, 8/9/23, 8/13/23, 8/16/23, 8/18/23, 8/23/23, 8/29/23, 9/3/23, and 9/7/23. During an interview with the surveyor on 9/12/23 at 11:54 a.m., CNA #3 stated that CNAs are responsible for documenting the ADL care provided into the Point of Care (POC), is a mobile-enabled app that runs on wall-mounted kiosks or mobile devices that enables care staff to document activities of daily living at or near the point of care to help improve accuracy and timeliness of documentation. CNA #1 further stated that they would document even if the care was not provided due to refusal. She explained that the documentation must be completed in the resident's DSR by the end of each shift to show that the care was provided to the residents. During an interview with the surveyor on 9/13/23 at 8:14 a.m., Licensed Practical Nurse (LPN #1) stated that the Certified Nursing Assistants (CNAs) were expected to document ADL care provided to the resident by the end of the shift in the DSR. He explained that the care were provided. During an interview with the surveyor on 9/14/23, the residents confirmed that the CNAs were providing care and had no care issues. During an interview with the surveyor on 9/13/23 at 1:02 p.m., the Director of Nursing (DON) and ADON stated that the CNAs were expected to document the care provided to the residents in the DSR at the end of the shift. NJAC 8:39-35.2(d)(9)

Based on observations, record review, interviews, and review of facility policy, the facility failed to ensure one of one resident's (Resident (R) 101) right to make choices about his life that were important to him, were encouraged. Specifically, the facility failed to ensure R101 could go out for walks into the community, interact with members of the community, and encouraged to promote the self determination of needs for resident. The facility also failed to ensure R101 was being included and updated in any discussions about his choice to go for walks in the community. By not promoting resident choices this resident was left feeling as though his needs were not being met to address his right to go into the community for walks. Findings include: 1. During observation and interview on 08/28/22 at 11:22 AM, R101 was observed walking independently from his room to look out a window on the first floor. R101 was well groomed, wearing shorts, t-shirt, and tennis shoes. During interview R101 stated, I want to go walking. I love going outside and getting fresh air. I used to go outside all the time and walk the neighborhood, talk to people, go down to the police station, the stop shop car dealer place, and just walk the neighborhood. R101 stated, I'm able to walk independently. I feel alive when I'm able to go for walks. Now, I feel depressed because the new administrator says I can't go outside. I get excited when I used to go for walks to get fresh air and just say hi to everyone in the neighborhood. I used to work for a printing company, my son is a police officer, and when able, he will come and get me and sign me out and we spend the day together. At this time, R101 stated, There has been a new administrator that says I can't go for my walks anymore. When asked why, R101 stated, They were saying one time I was trying to bring alcohol in the building for someone, but I was not. This was about a year ago. Now, I'm not able to go outside to walk. I used to sign myself in/out when I came and when I left. They tell me now if I want to go outside, I have to have someone with me, but I used to take my walks everywhere by myself. We've had meetings about this, but I feel they don't want to help me. R101 stated, I even worked with therapy, and they had even asked me why I wasn't going on my walks outside anymore. I just love going outside and talking to people and getting fresh air. Since the COVID pandemic, I make sure I have my mask on, I get my tests and they are negative. During observation on 08/29/22 at 9:00 AM, R101 was observed to be well dressed in shorts, shirt, socks, and tennis shoes. R101 was observed walking from his room (located across the hall from the facility elevator) to the dining room, saying good morning to the staff and other residents, getting a cup of coffee, then returning to his room. During this time, R101 was observed not attempting to elope, wander or take the elevator downstairs to the ground floor, or make any attempts to leave the building. During observation on 08/31/22 at 8:36 AM, R101 was observed to be lying in bed and talking with housekeeping staff in his room. During an observation and interview on 08/31/22 at 10:57 AM, R101 was observed coming out his room, well dressed in shorts, slippers, and t-shirt. R101 stated, I washed my clothes today. Have a good morning. Review of an undated Profile located in R101's electronic medical record (EMR) under the Profile tab revealed R101 was his own responsible party. Review of an undated Admitting Face Sheet located in R101's paper chart also indicated R101 was his own responsible party. Review of R101's medical diagnoses located in R101's EMR under the Med (medical) Diag (diagnosis) tab indicated R101 was admitted to the facility 03/20/17. Diagnoses included essential hypertension; major depressive disorder; and epilepsy, unspecified, not intractable without status epilepticus. Review of an Elopement Risk Guide located in R101's paper chart under the Assessment tab and dated 03/20/17 indicated a score of 2 of 5 indicating low risk for elopement. It further indicated, R101 was independently mobile, had no history of elopement/elopement from prior settings, no verbalized plans to leave the facility whether or not authorized, no expressed desire to leave the facility Against medical Advice (AMA), no disregard for facility policies and procedures related to leaves of absences, and no history of wandering behaviors. Review of Social Progress Notes located in R101's paper chart Social Services tab and dated 01/09/18 indicated, Resident is alert/oriented x3, able to make his needs known. Scored 15/15 [15 out of 15] on BIMS [Brief Interview of Mental Status]. Is OOB [out of bed] daily and ambulates. He enjoys walking out and going for walks. Review of Social Progress Notes dated 07/13/18 indicated, He enjoys being outdoors. Review of Social Progress Notes dated 02/18/19 indicated, He ambulates around facility . He enjoys going for walks. Review of R101's annual Minimum Data Set (MDS) found in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/13/22 indicated, it is Very Important for R101 to choose what clothes to wear, very important to do things with groups of people, and very important to go outside to get fresh air when the weather is good. Review of R101's quarterly MDS found in the EMR under the MDS tab with an ARD date of 05/15/22 revealed the resident had a BIMS score of 12/15, which indicated the resident was cognitively intact. The MDS further indicated R101 was independent for transfers, independent for dressing, and was steady at all times for moving from a seated to standing position, steady at all times when walking, turning around and face the opposite direction while walking, and moving on and off the toilet. The MDS further revealed no behaviors of wandering, or elopement. The MDS indicated R101 was not at risk for falls and has had no falls. Review of a Recreation Department Assessment found in the EMR under the Misc (Miscellaneous) tab dated 08/19/21 and 05/16/22 indicated, Current Hobbies and Interest: like to take walks outside and in building and Outdoors . Cognitive: Alert. Attention Span: normal. Vision: intact. Physical: Ambulatory. Mobility: Independent. Behaviors: None. Review of an Interdisciplinary Team Meeting Form, located in R101's paper chart under the Notes tab and dated 02/24/21 indicated, Likes to ambulate around the building, socializing . keeps busy on his own throughout the day by talking to peers, visiting with rehab, ambulating in the facility. Review of a Meeting Note located in R101's paper chart dated 07/28/21 indicated, We discussed the IC [Infection Control] aspect of going out on pass in the community and return to the NH [Nursing Home]). He was reminded of . signing the OOP [out on pass] book when he leaves and comes back, wearing a mask while in the community, stay at least 6 feet apart from others because don't know who is vaccinated or not, no close contacts such as hugging, shaking hands, not accepting any food items from people from the street. Upon return must do proper handwashing, days/times prefers to leave the building and return, and local health dept. [Department] suggest do a rapid test every 2-5 days although he is vaccinated. He acknowledged understanding. Review of R101's quarterly MDS found in the EMR under the MDS tab with an ARD date of 08/09/22, indicated a BIMS score of 15/15 indicating the resident was cognitively intact. The MDS further indicated no behaviors or wandering or elopement. The MDS indicated, No history of falls within last six months. Vision- adequate. No behaviors of wandering. The MDS indicated R101 was independent for bed mobility, transfers, walking in room, walking in corridor, locomotion on and off the unit, dressing, toilet use and personal hygiene. Review of a Fall Risk Evaluation found in the EMR under the Assessment tab, dated 08/09/22 and 02/13/22 indicated R101 was Low Risk for falls. Review of Progress Notes located in R101's EMR under the Prog (progress) Note tab revealed many different dates from 2018-2021 in which R101 has gone out on pass with family, has signed in/out and has returned within 1-2 hours for various activities. Review of Social Services Progress Notes located in R101's EMR under the Prog Note tab indicated dates in 2022 in which Interdisciplinary Team Meetings (IDT) were held to discuss R101's care. However, there was no documentation of R101's wishes to go outside for walks in the community. Notes indicated, BIMS of 15/15, can make needs known, attends group activities, spending time in courtyard, remains independent with ADLS [activities of daily living], no falls, family is passively involved. Review of an additional Wandering/Elopement Risk Assessment located under the Assessment tab dated 08/31/22, indicated his desire to walk in the community as part of his exercise program . Low risk for elopement. Review of a Release of Responsibility for Leave of Absence located in R101's paper chart revealed multiple dates/times in which R101 has signed himself in/out of the facility. During interview on 08/30/22 at 1:23 PM, the Administrator stated, he had only been the administrator since June 2022 and This is just all hearsay, but before I got here, I had heard from the previous administrator and our DON [Director of Nursing] that said there was a history of him [referring to R101] going out into the community and panhandling, knocking on doors, and buying alcohol in the nearby stores. [R101] would be walking down to the nearby turnpike areas to where we have no way to find out where he is. I told [R101] if he is looking into another facility who could accommodate this, we would assist him in trying to accommodate his needs, but because it is a liability and due to his history of panhandling (again hearsay), that was a concern. The Administrator stated, He [R101] would say that he always went on walks with no problems, but because of his safety, I can't allow him to go on walks by himself. For one, he is not stable on his feet, and he gets tired a lot, and with this area we have a concern of him falling. There was also a history of him going to a liquor store, again this is what I was told, so we came up with a plan. I told him I would start taking him on walks. He was in agreement with this. The Administrator stated, Our plan we came up with was that I would take him for a walk. We set up a schedule, then that was always changing. We did speak to his family. We expressed we had some safety concerns with him just going out for long walks. The Administrator stated, We had a meeting with the team, and we were in agreement that it's not safe for him to go on these long walks. He is able to go out to the courtyard anytime. When the Administrator was asked if there was a written agreement or anything in writing set up with the facility and R101, he stated, No. The Administrator stated, He [R101] can sign himself in/out, but again its what he may do when out in the community when by himself that would be a potential harm. He may bring something to the facility, i.e., alcohol, money, panhandling, but now its frowned upon. From what I'm told, this is all based on his previous history. The Administrator stated, No staff have ever come to me with concerns like he has been trying to get out of the building or targeting any certain staff to let him out to go for a walk. No. Whenever he asks, we can try to schedule to go for a walk with him. He doesn't come to me repeatedly and ask can I go out; can I go out. No, not at all. The Administrator stated, He may have a day where he asks 'can I go out by myself?', and my response is its for your safety you don't. We could work on your gait, balance before you go. Generally, he has pretty good mobility, and has pretty good gait, but due to those safety concerns he can't just go out for walks by himself. During interview, on 08/31/22 at 8:45 AM, Licensed Practical Nurse (LPN) 4 stated, He [referring to R101] will go outside to the back enclosed patio, he is able to do that on his own. He can get in the elevator by himself and go downstairs to the first floor without any problems and out into the courtyard. He likes to go to activities as well on the second floor to keep busy. LPN4 stated, I've never known him [R101] to just go for walks into the community and I've never seen him wanting or trying to leave the facility out into the community. He . is very independent for his ADLs. During interview on 08/31/22 at 9:09 AM, LPN2 stated, I used to do recreational activities and from what I remember, he [R101] liked playing dominoes, he likes to dance, likes karaoke, and singing. LPN2 stated, He used to go for walks in the community before COVID by himself, but I think they stopped it since COVID. I'm not sure if he is doing it now or not. I do remember he would sign himself in/out whenever he would go on his walks. Now, he walks in the outside courtyard. I haven't seen him wanting to leave the building or trying to go into the community now. He is pretty involved in activities. During interview on 08/31/22 at 9:27 AM, Registered Nurse (RN) 1 stated, He [R101] is very independent with is ADLs. I usually see him walking out in the courtyard, but not into the community. I've never known him to just wander off. He likes activities, bingo, movies, entertainment that comes from the community to sing, play music. RN1 stated, He can take his own showers, takes meds [medications] well, and is pretty independent. During interview on 08/31/22 at 9:51 AM, Recreational Assistant (RA) 1 stated, He [R101] comes upstairs on his own for activities, likes to make his own signs, figures, baseball, likes group activities, dominoes, and Spanish music. He also loves to walk around the building. RA1 stated, From what I heard, he is unable to go out into the community. Someone has to be with him. I have not seen him leave for walks into the community by himself . He likes to get exercise and will walk on each floor. He doesn't have to ask to go outside into the courtyard. That is also where the smokers go. He has never tried to leave the building. He stays busy. He can come upstairs whenever he wants to. He sticks with his routine. RA1 then stated, He used to go out into the community years ago and wave to people, then he would come back without any problems, but I'm not sure what happened. During an interview on 08/31/22 at 1:26 PM, the Social Services Director (SSD) stated, she had only heard of R101 wanting to go out for walks in the community as hearsay, and From what I was told, he was waiting for the DON or Administrator to give the approval for him to go on walks on his own. The SSD stated, I do know he was walked with our Administrator at times, and he likes to go on longer walks around the neighborhood. The SSD stated, We have meetings quarterly every three months but, in those meetings, we just talk about things his medications, diet, weight, ADLs, and advanced directives. As far as any specific meetings about going for walks into the community, no. Not that I'm aware of. Since this new administrator started, there hasn't been much talk about him [R101] going out for walks. He [R101] is considered his own responsible person and is pretty independent. During an interview on 08/31/22 at 1:36 PM, the DON stated, Prior to COVID-19, it was ok'd by PT [Physical Therapy] for him [R101] to take walks around the blocks. We gave him that opportunity until things started to change. The DON stated, We were told he started knocking on doors of people who live in the community and asking for money and was also seen by a [convenience] store with a cup begging for money. When the DON was asked when this occurred, she stated, I would say this was in late 2019 and at that time, he was free to go for walks. He would tell us what time he was leaving and would sign himself in/out and he would come back. Then after COVID we started to open things back up again. He wanted to start going out again. So, in late 2021 we had heard that he started going to a liquor store, but we were not sure. The owner of the liquor store had him [R101] on camera as buying some alcohol and paying for it at the register. When the previous administrator asked him about it, at first, he lied to us and said it never happened. Then in this year 2022, he [R101] finally decided to apologize to us and confessed to buying alcohol and was sorry about it. The DON stated, Now this administrator says it's a safety issue. Not only are you going door to door and trying to get money from people but are standing up by the wayside [of a convenience store] begging for money. The DON stated, He [R101] agreed he could walk around the circumference of the facility. He has done well. The DON stated, We are planning on having a discussion to see if we could put a plan into place, but that has not taken place with him yet. We could put a contract in place but that hasn't been put in place yet. We would have to get something set up and discuss with him that he cannot buy anything illegal and is not supposed to go to anybody's houses. His thing is, he just wants to exercise and walk around the block. He likes to wave at the neighbors. We will have to start a new discussion, but I don't have anything in place. He does ask me, 'Are we still discussing when I can go out again.' I tell him, we are working on it. The DON started, This has all been just verbal discussions, we were not documenting anything in his chart that we have a current plan in place . The only thing that we could actually prove that was he was at the alcohol store in 2019. He has been our only patient that has gone out for walks. In early 2022, we started having some talks again with the previous administrator, then he left, but nothing has been in writing. When the DON was asked if there would be any reason R101 could not go out into the community for walks, the DON stated, Well, no. PT gave us the green light that he can walk by himself. Make sure he watches for uneven surfaces. We think it is more of a behavior issue to make sure he is not knocking on doors. I will have to have another discussion with our administrator to see if he will give the green light. The DON stated, His BIMS is 15/15, he is not an elopement risk. He has never been an elopement risk. He is also a low risk for falls. The DON stated, He [R101] approached me again today to ask, 'Are you working on me going out in the community?' I said, we are working on it. We don't have any concerns about him trying to elope or escape. No. He is alert, walks around independently. PT made sure he was safe to walk on sidewalks, cross the street, and make sure he uses the stop light. During an interview on 08/31/22 at 2:16 PM, the Receptionist stated, Everybody coming into the building I make sure they sign in/out into the Kiosk and get screened. Before COVID, she stated, He [R101] has had privileges of going out into the community. He would come and go. He would sign himself in/out and tell me he was going for walks in the community. The receptionist stated, He would sign out on the 'Resident Sign out Form' where we put a time in and time out. I would see him personally sign himself in/out and I would always check with the nurses as well who would verify he was going out. The receptionist stated, After COVID, I've seen him with his son who has signed him out to go grocery shopping then comes right back. During an observation and interview on 09/01/22 at 7:50 AM, R101 was observed coming out of his room and walking independently to the dining room. During interview R101 stated, I asked the Administrator for an update on me being able to go outside for my walks. He used to take me out, just to go around the building, but that is not really walking to me. They don't feel comfortable with me walking out there I guess. R101 then stated, I said I just want to walk outside by myself. I say hi to people. Every time before, I had to sign in/out which I did, but there is nothing set up like a contract. Too many people smoke in the courtyard. I don't smoke. The last time I walked with the Administrator was a couple of months ago. Like only two times that we went out. The previous guy gave me the okay and just to be careful. R101 stated, As soon as I eat my breakfast, I would like to go out for just an hour and go outside. I like to come back about 10:30 AM or so. I like to take my time and say good morning, say hi to people. This stopped with the pandemic and nothing now. The previous guy in charge use to see me go for my walks. When I asked the director lady [referring to the Director of Nursing] yesterday about it, she just said, 'We are working on it. We are waiting for the state to give the okay'. R101 stated, I feel happy, excited, healthier to get some fresh air. I always make sure I have my mask on due to the pandemic. I'm not a troublemaker. I just love saying hello to everyone. When R101 was asked if there were any rules that were discussed with him about going outside by himself for walks, R101 stated, Just to make sure I keep social distance, keep aware of driveways. Wash my hands. R101 stated, Even my family knows how I am. My son comes to get me every three months. He is a police officer. I don't drink and I don't smoke. I just do my walking. Sometimes people will give me a couple of bucks or give me a cup of water in the summertime. At one time I had my own water bottle. R101 stated, The new Administrator says he is just not comfortable with me walking out by myself because he is new here. I respect the rules, I take my cane with me. During interview on 09/01/22 at 7:58 AM, LPN6 stated, Before COVID-19 he [R101] would walk back and forth into the community. After COVID, it was rumors that people had seen him begging for money. One person who worked here who no longer works here had said he was knocking on doors, but I don't know if that was true or not. We just told him because of COVID, to be careful. LPN6 stated, He just stays around here now. He is a very social person. I think they started letting him walk around the building and he does okay with that. For some reason, someone said something then it stopped. LPN6 stated, He is good about wearing his mask when he goes outside. When asked if there was something like a written contract in place for R101 to continue to go outside for walks into the community, LPN6 stated, No, there is nothing like that in place at this time. No. He can walk around the building, but not all the way into the community. No. During interview on 09/01/22 at 12:15 PM, the Director of Rehabilitation stated, Back in 2019 he [R101] used to be on rehab and we started doing training on walking in the community. He was very independent. Then there was a different Administrator that at one time showed him how far he could go. He would come back. Just would make big circles in the community, then would come back. Then, I'm not sure, but something happened so that stopped. We tried sending out a recreation aide in the past. I've seen him walking and up until I left in 2019, he was taking all the appropriate precautions to cross the road. We have not seen him since the COVID pandemic and since 2019. During interview on 09/01/22 at 2:30 PM, the DON stated, We are going to start to put a plan in place for him, but we have not actually sat down and talked to him as of yet. We don't have a plan in place as of yet and have not set up an actual meeting with him and everyone. From 07/28/21 until now I guess we were just trying to see how he would do with the walks he was taking. Review of the facility's undated policy titled, Resident Self Determination and Participation, indicated, Our facility respects the right of each resident to exercise his or her autonomy regarding with the resident considers to be important facets if his or her life. 1. Each resident is allowed to choose activities . that are consistent with his or her interests, values, assessments, and plans of care including: a. daily routine. 3. Residents are encouraged to make choices about aspects of their lives including . interacting with . members of the community; and participating in community activities inside and outside the facility. Review of the facility's 02/01/22 policy titled, Resident Right-Self Determination, indicated, The resident has the right to, and the facility will promote and facilitate resident self-determination through support of resident choice, including but not limited to the following: b. The resident has a right to make choices about aspects of his or her life that are significant to the resident . The resident has a right to interact with members of the community. Review of the facility's 02/01/22 policy titled, Resident Right-Respect, Dignity/Right to have Personal Property, indicated, Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care. Review of an undated admission Agreement- Appendix: Resident Rights, indicated, As a nursing home resident, you have certain rights . Certain rights are . Leave the Nursing Home: Leaving for visits: If your health allows . you can spend time away from the nursing home visiting family or friends during the day or overnight. NJAC 8:39-4.1(a)25 NJAC 8:39-7.3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to ensure advance directives and Practitioner Orders for Life-Sustaining Treatment (POLST) information was completed and obtained for three of 25 sampled residents (Resident (R) 68, R62, and R105). The failure created the potential for residents to not have their wishes known should they suffer a health emergency. Findings include: 1. Review of R78's Census tab of R78's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Review of R78's diagnoses, located under the Diagnosis tab of her EMR, revealed diagnoses which included chronic atrial fibrillation and atherosclerotic heart disease. Review of R78's Physician's Orders, located in R78's EMR under the Orders tab, revealed the resident had a code status of ''DNR'' (do not resuscitate) resuscitation status. Review of R78's Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/11/22 revealed the facility assessed R78 to have a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated R78 was cognitively impaired. Review of the medical record for R78 under the ''Advance Directives'' tab revealed document titled ''New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST)''. The POLST document was signed by a Physician but undated. Further review of R78's medical record revealed an undated 'Living Will'. During an interview on 08/31/22 at 10:23 AM, the Social Services Director (SSD) confirmed the above findings and stated that an undated POLST was not a completed POLST. 2. Review of the admission Record located in the Profile tab of the EMR revealed, R62 was admitted to the facility on [DATE] with diagnoses that included dementia and Rhabdomyolysis (A breakdown of muscle tissue that releases a damaging protein into the blood.) Review of the quarterly MDS assessment with an ARD of 07/10/22 revealed R62 had a BIMS of 99 which indicated he was impaired in cognition for daily decision-making and unable to complete the assessment. Review of the undated New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) revealed that R62 had signed the POLST indicating that he requested. Limited treatment. Transferred to the hospital . No artificial nutrition . Do Not Resuscitate . Do Not Intubate [DNI]. In addition, a physician signed the POLST however, the form was not dated and timed, as required, on the POLST form. During an interview on 08/31/22 at 8:52 AM, Licensed Practical Nurse (LPN) 3 was asked to review R62's POLST form, located in the EMR. LPN3 confirmed that there was no date/time, either for the resident or the physician, indicated on the form and was incomplete. During an interview on 08/31/22 at 9:30 AM, the SSD was asked if R62 was cognitively intact to make end-of-life decisions. The SSD stated she had just started working at the facility in January 2022 and was not aware of his cognitive status before she started. The SSD was asked to review R62's POLST form. The SSD confirmed and verified that the POLST form was incomplete as it was not dated, as required on the form. 3. Review of R105's Census tab of R105's EMR revealed he was admitted to the facility on [DATE]. Review of R105's diagnoses, located under the Diagnosis tab of her EMR, revealed diagnoses which included Huntington's disease, gastrostomy status, dysphagia, oropharyngeal phase, and mild protein-calorie malnutrition. Review of R105's Physician's Orders, located in R105's EMR under the Orders tab, revealed the resident had a code status of ''full code'' resuscitation status. Review of R105's admission MDS with an ARD of 08/06/22 revealed the facility assessed R105 to have a BIMS score of 99 which indicated R105 was cognitively impaired and unable to complete the assessment. Review of the medical record for R105 revealed a blank POLST form under the 'Advance Directives' tab. Review of a Social Services progress notes dated 08/05/22 at 11:22 AM in the Progress Notes tab in the EMR revealed ''Advance Directives: [Social Worker] discussed various possibilities/options with Advanced Directives: i.e, DNR, DNI and tube feedings with resident's wife with resident present. Facility protocol re: same discussed. Resident wife verbalized and demonstrated understanding of all discussed. Wife verbalized she has advanced directives at home and will bring facility a copy.'' During an interview on 08/31/22 at 10:23 AM, the SSD stated that Advance Directives information had been provided to R105's spouse on admission and that DSS had made several attempts to discuss Advance Directives with R105's spouse, but the spouse was unwilling to discuss. SSD stated she had no documentation of follow-up discussions with R105's spouse. During a follow-up interview on 08/31/22 at 3:14 PM, SSD stated she spoke with R105's son who stated that the POLST form the family had, was never completed, and requested a fresh form. Review of facility's Policy titled ''Resident Right - Advanced Directive Tracking Program, dated 02/01/22 revealed as follows: ''It is the policy of the facility to honor the advance directives of all residents and to make information available to the resident on how to prepare such directives, should the resident not have them in place or to change existing directives. PROCEDURE: 1. During the admission process the Social Services Director or designee will discuss with each resident and/or the person accompanying the resident the following: a. Whether they have an advance directive such as a health care surrogate designation, living will or durable power of attorney? b. Whether they have a POLST? c. If they have those forms with them? If so, secure copies. If not, inquire as to where the documents can be found. 2. The resident and or the person accompanying them will be given a copy of the advance directives information, including the forms used by the facility, whether they have completed advance directives or not. The resident or the person accompanying them should sign that they have received this information. 4. Social Services or the appropriate designee will carefully review any and all advanced directive related documents to ensure that the information is complete and that the requirements of the law are met. If there is a question it is the responsibility of the reviewer to seek clarification.'' NJAC 8:39-4.1(a)2 NJAC 8:39-9.6(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of the facility policies, the facility failed to report to administration when one of two residents (Resident (R) 68) in a total sample of 25 experienced a resident-to-resident altercation. This failure placed the residents at risk for further altercations and a diminished quality of life. Findings included: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R68 was admitted to the facility on [DATE] with diagnoses that included fragile X chromosome abnormality (an inherited condition characterized by an X chromosome abnormality which tends to have limited intellectual disabilities.) Review of the 05/13/20 Behavior Care Plan located in the Care Plan tab of the EMR revealed, .Behaviors: laughing/talking to self loudly, yelling out, vocal outbursts, kicking/hitting staff, scratching self, wandering into others' rooms and touching others belongings, looking for snacks, attempting to use bathroom several times, constantly wanting fluids, patient tries to hit other patients if she thinks the patient is looking at her, throwing coffee cup, going through dirty dishes on the tray, pulling her own hair, attempting to put toilet papers in her mouth (after soaking it in toilet.) Aggression towards others [sic] hit/kicks . Review of the quarterly Minimum Data Set (MDS) assessment with and Assessment Reference Date (ARD) of 07/15/22 revealed, R68 had a Brief Interview of Mental Status (BIMS) of 03 out of 15 which indicated she was severely impaired in cognition for daily decision-making and had no behaviors. Review of the admission Record located in the Profile tab of the EMR revealed, R22 was admitted to the facility on [DATE] with diagnoses which included Rheumatoid arthritis and heart disease. Review of the quarterly MDS assessment with ARD of 06/13/22 revealed, R22 had a BIMS of 13 out of 15 which indicated she was cognitively intact for daily decision-making. During a random observation on 08/29/22 at 10:37 AM, R68 was observed walking into R22's room (which was the room next door.) R22 was observed seated in her wheelchair at the foot of her bed. R68 began to yell at R22 to give her food and R68 became upset verbally when R22 told her no, and to leave her room. R68 started to leave R22's room and saw the surveyor in the hall outside the room. R68 showed the surveyor that she had obtained a package of cookies and then put them into her pocket. R68 was very unsteady while holding onto the handrail and stopped just outside her room door. This surveyor noted that no staff, licensed or certified, was in the hallways. On 08/29/22 at 10:40 AM, Registered Nurse (RN) 2 was observed at the far end of the hall at the medication cart. RN2 was told about the altercation and was asked about R68's behaviors. RN2 stated that R68 was not combative but had wandered into other residents' rooms in the past but had not done this for long-time. RN2 stated that R68 was not to be up walking independently and that most of her behaviors centered around asking for food and drinks. During an interview on 08/30/22 at 3:29 PM, Licensed Practical Nurse (LPN) 2 was asked if she had been made aware of the verbal altercation between R68 and R22 on 08/29/22. LPN2 stated, No, I did not know. LPN2 was asked what she would do if she witnessed or had become aware of a resident-to-resident altercation. LPN2 stated she would separate the residents to make sure they were safe and to monitor them for any affects. LPN2 was asked who would be notified of the altercation to ensure there was no potential abuse. LPN2 stated, The DON [Director of Nursing]. During an interview on 08/30/22 at 1:33 PM, LPN3 was asked if she had been made aware of the altercation between R68 and R22. LPN3 stated, No, I had not heard that she had gone into R22's room and yelled at her. LPN3 further stated that at one time, R68's behaviors were very bad, and we had to one-to-one her, but since then she has calmed down. During an interview on 08/31/22 at 10:23 AM, the Social Services Director (SSD) was asked if she had been made aware of the altercation between R68 and R22. SSD stated, No, I wasn't aware of it, and no one informed me. During an interview on 08/31/22 at 10:27 AM, the Director of Nursing (DON) was asked if she was made aware of the altercation between R68 and R22 on 08/29/22. She stated no. The DON was told about the altercation that was witnessed and was reported to RN2. The DON stated, Then it should have been reported to me. The DON further stated that an incident report should have been done to rule out potential abuse, statements should have been collected and interview with R22. The DON stated that RN2 was the night supervisor however, she should have told me, that is our policy. During an interview on 08/31/22 at 3:51 PM, R22 was asked about the altercation with R68 on 8/29/22. R22 stated, Yes, she comes in my room all the time. She will take food off my table, drink my drinks, it's very upsetting to me. She will get very loud sometimes, and I tell her to leave. What bothers me is that when I'm asleep and I wake up, there she is, and it scares me. She has never hit me, but she talks loud to me. Review of the facility policy titled, Resident to Resident Altercations, dated July 2021 revealed, .All altercations, including those that may represent resident-to-resident abuse, shall be investigated, and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator . Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents must be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator . If two residents are involved in an altercation, staff will . Complete an incident/accident report and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify the need for a new Preadmission Screening and Resident Review (PASARR-a screening which looks for indicators that a person may have intellectual disability, related disability, or serious mental illness) when a resident had a new diagnosis of mental illness for one of three residents (Resident (R) 17) reviewed for PASARR. This failure placed R17 at risk for not receiving necessary services for her mental health. Findings included: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R17 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder. Review of the 06/18/18 Level I PASARR located in the Miscellaneous tab of the EMR revealed, R17 had a diagnosis of major depressive disorder and did not require a Level II evaluation (an evaluation to identify specialized services required by the resident for conditions identified in a Level I). Review of the Medical Diagnosis List located in the Medical Diagnosis tab of the EMR revealed on 05/16/21, R17 had a new diagnosis of bipolar disorder (a mental illness characterized by both manic and depressive episodes.) Review of the EMR did not show that a new Level I screening had been obtained to determine if R17 required a Level II evaluation for the new diagnosis of a serious mental illness. Review of the annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/06/22 revealed, R17 had a Brief Interview of Mental Status (BIMS) of 15 out of 15 which indicated she was cognitively intact for daily decision-making, had verbal behaviors for four to six days and other behaviors for one to three days during the seven-day observation period. In addition, the assessment indicated that these behaviors were worse since her previous assessment. During an interview on 08/31/22 at 9:17 AM, Social Services Director (SSD) was asked if a new Level I PASARR was done in May 2021. The SSD stated, No, it appears that one should have been done especially with the diagnosis change. Review of the facility policy titled, Coordination - Pre-admission Screening and Resident Review (PASRR) program, dated 02/01/22 revealed, .A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. NJAC 8:39-5.1(a) NJAC 8:39-11.2(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the state mental health authority after a significant change in condition for one (Resident (R) 68) of three sample residents who were reviewed for Preadmission Screening and Resident Review (PASARR- a screening which looks for indicators that a person may have intellectual disability, related disability, or serious mental illness). This has the potential for failure for the facility to identify the resident's needs and provided services appropriate for the residents mental health. Finding included: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R68 was admitted to the facility on [DATE] with a diagnosis of fragile X chromosome abnormality (an inherited condition characterized by an X chromosome abnormality which tends to have limited intellectual disabilities.) Review of the 05/05/20 Level I PASARR located in the Miscellaneous tab of the EMR revealed, R68 was marked positive for intellectual disabilities/developmental disabilities (ID/DD) and a Level II PASARR (a more in-depth evaluation) would need to be completed. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/09/20 revealed, R68 had a Brief Interview of Mental Status (BIMS) of 03 out of 15 which indicated R68 was severely impaired in cognition; and had physical, verbal, and other type behavior for one to three days during the seven-day observation period. In addition, the assessment showed R68 required extensive assistance of one staff for activities of daily living (ADLs), was totally incontinent of bowel and bladder, and was administered an antianxiety medication daily. Review of the 08/11/20 Level II PASARR located in the Miscellaneous tab of the EMR revealed she was not referred for services related to her Severe physical illness-CVA [stroke]. Review of the 05/13/20 Care Plan located in the Care Plan tab of the EMR revealed an update on 08/13/20 which showed, R68 is noted with cognitive impairment secondary to dx [diagnosis]: Fragile X Syndrome, DD, history of CVA with aphasia [a language disorder that affects a person's ability to communicate]. She is able to make needs known using gestures, facial expressions or one-word answers. She understands simple, direct communication from staff. [R68] is exempt from the PASSR [sic] process due to severely impaired cognition. Review of the current quarterly MDS assessment with an ARD of 07/15/22 revealed, R68 had a BIMS of 03 out of 15, required limited assistance with ADL's, had no behaviors, was rarely incontinent of bladder, continent of bowel and was on an antipsychotic medication and antianxiety medication daily during the observation period. During an interview on 08/31/22 at 2:52 PM, the Social Services Director (SSD) was asked if R68 had improved since the previous assessment due to her ambulating on her own, had improved in her ability to perform ADLs, behaviors had improved, and she had started on an antipsychotic medication, would the expectation be that a change in her condition and behavior management warrant a new Level II PASARR. The SSD confirmed and verified that a new Level II PASARR should have been done as she, might have missed out on something that she may have benefited from. Review of the facility policy titled, Coordination - Pre-admission Screening and Resident Review (PASRR) program, dated 02/01/22 revealed, .A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. NJAC 8:39-5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure that the resident and/or the resident's responsible party (RP) for two of two residents (Residents (R) 61 and R103) reviewed for baseline care plans, had baseline care plans developed and implemented to address the resident's immediate needs within 48 hours of admission to the facility. The facility failed to ensure the residents and/or representatives were in attendance of a baseline care plan and provided with a written summary of the baseline care plan that included, at a minimum, the initial goals of the resident; medications, nursing, and dietary instructions; and services and treatments to be administered by the facility and personnel. Findings include: Review of the facility's 02/02/22 policy titled, Baseline Care Plan, indicated, Intent: Every resident will have an Interdisciplinary Care Plan, with the Baseline Care Plan completed within 48 hours of admission. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident . The interdisciplinary plan of care will be developed through collaborative efforts of the Interdisciplinary Team and other health care professionals . The resident and/or family member will be involved in the care planning . The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational, and environmental needs as appropriate. Procedure: The baseline care plan will: 1. Be developed within 48 hours of a resident's admission. 2. Include the minimum healthcare information necessary to properly care for a resident including but not limited to: a. initial goals based on admission orders. B. physician orders. C. dietary orders. D. Therapy services. E. Social services . 4. The facility will provide the resident and their representative with a summary of the baseline care plan prior to completion of the comprehensive care plan, that includes but is not limited to: a. the initial goals of the resident, b. a summary of the resident's medications and dietary instructions, c. any services and treatments to be administered by the facility personnel acting on behalf of the facility . 5. The facility will provide the resident and their representative with a summary of the baseline care plan prior to completion of the comprehensive care plan. 1. During an observation on 08/29/22 at 10:25 AM, R61 was observed laying on his side and sleeping in bed. When attempting to interview the resident, he stated, Sleeping and was not able to further communicate his needs at this time. During an interview on 08/29/22 at 4:13 PM, regarding base line care plans for the care R61 was going to receive, family member (F) 61 (R61's Responsible Party) stated, When he first came to the facility in April, I vaguely recall a discussion that took place, but I never received anything in writing regarding a discussion about the care he was going to receive, or anything called a baseline care plan. No. I never received anything in writing that I recall. During a second interview on 08/31/22 at 12:05 PM, R61 was observed finishing his lunch tray. At this time, the resident was not wanting to be interviewed. Review of a Face Sheet located in R61's electronic medical record (EMR) under the Med (medical) Diag (diagnosis) tab revealed R61 was admitted to the facility on [DATE] with diagnoses to include osteoarthritis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, and type 1 diabetes mellitus. Review of R61's EMR under the Assessment tab indicated no documentation for a baseline care plan. Further review of the medical record revealed no documentation that a baseline care plan was completed after admission to the facility on [DATE], or that R61 and F61 received any written documentation of a baseline care plan. Review of a Social Service Admission/readmission Note located in R61's EMR under the Progress Notes tab dated 04/06/22 (5 days after admission) by the social worker, indicated R61 was admitted to the facility on [DATE] .requires assistance with all ADLs [Activities of Daily Living] . was noted to be declining functionally and medically and was admitted to rehab to regain strength and endurance. Further review of the Social Service notes revealed no documentation that a written summary of a baseline care plan was completed, or discussion with R61 or F61 took place upon admission or written documentation was given to F61. Review of Nursing Notes located in R61's EMR under the Progress Notes tab indicated R61 went out to the hospital and returned to the facility on [DATE]. Review of an admission Baseline Care Plan, located in R61's EMR under the Assessment tab dated 05/20/22 indicated an admission baseline care plan was initiated on 05/20/22, but no evidence of any written summary of initial goals, treatments, or various disciplines involved was given to R61 or F61 when R61 was re-admitted to the facility on [DATE]. The portion of the baseline care plan labeled, Signature of Resident and Representative was blank. During an interview on 09/01/22 at 8:42 AM, regarding baseline care plans, the Social Services Director (SSD) stated, The process for the baseline care plans is I do that within 48 hours of admission, or the next business day. I go up and interview the patient and set up a family meeting with the families. Upon admission, I will set up a meeting with the family or resident and I do my section for social services. Most prefer to do them over the phone, and I do document that I attempted to call the family. When the SSD was asked if she had any documentation to provide that a written summary of the baseline care plan was provided to R61 or F61 and any information discussed from the first admission on [DATE], or the re-admission on [DATE], to include at a minimum, the initial goals of the resident, medications, nursing, dietary instructions, and any services to be administered by the facility, the SSD stated, No, but going forward, I will ensure that I'm doing that. 2. Review of the undated admission Record in the EMR under the Profile tab, revealed R103 was admitted to the facility on [DATE] with diagnoses including sepsis, hypoglycemia (low blood sugar), acute kidney failure, heart failure, acute respiratory failure, leukemia, protein calorie malnutrition, and type two diabetes mellitus. Review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/22 revealed the resident was unimpaired in cognition with a Brief Interview for Mental Status score (BIMS) of 15 (score of 13 - 15 indicates cognition is intact). Review of the Baseline Care Plan dated 07/08/22 and provided by the facility revealed the care plan was completed by a Registered Nurse (RN) on 07/08/22 following R103's admission to the facility. R103 required one-person physical assistance with most activities of daily living (ADLs). The resident was cognitively intact, alert, frequently incontinent of bladder and incontinent of bowel, received insulin, and had current skin integrity issues. The section for signature of the resident and representative was blank (not filled out). There was no evidence the summary of the baseline care plan including the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services, and treatments to be administered was provided to the resident or family. Review of the Baseline Care Plan dated 08/01/22 and provided by the facility revealed the care plan was completed by the SSD and a Registered Nurse (RN) on 08/01/21 following R103's readmission to the facility on 7/30/22 after a period of hospitalization. R103 required two-person physical assistance with most ADLs. R103 was alert, had an indwelling catheter, was incontinent of bowel, was a diabetic, had pain, and had current skin integrity issues. The resident was prescribed both a pureed diet and received nutrition via a feeding tube. The resident received physical, occupational and speech therapy. The section for signature of the resident and representative was blank (not filled out). There was no evidence the summary of the baseline care plan was provided to the resident or family. During an interview on 09/01/22 at 10:34 AM, R103 and his family member (F) 103 were interviewed together. F103 stated she had not been to a care plan meeting and had not been provided with a baseline care plan summary initially or following R103's readmission from the hospital on [DATE]. F103 stated she came to visit R103 daily from around 10:00 AM - 6:00 PM. R103 also denied being given a care plan summary or attending a baseline care plan meeting. During an interview on 09/01/22 at 1:00 PM, the SSD stated she, the nurse, and representatives from other disciplines met usually the day after a resident's admission to discuss the baseline care plan. The SSD stated family members and the residents could attend. The SSD stated if families could not attend, the facility could call them and conduct the meeting over the phone. The SSD stated the facility typically set up a family meeting and reviewed the baseline care plan at the meeting. The SSD stated she documented if a family meeting occurred; however, had not provided a written baseline care plan summary to the resident or family. The SSD stated she would check her records to determine whether R103 or F103 had attended a baseline care plan meeting in person or via the phone. During a follow up interview on 09/01/22 at 1:49 PM, the SSD stated she did not have documentation of giving the base line care plan summary to R103 or F103 within 48 hours of admission or upon readmission. The SSD further stated she had no record of having a baseline care plan meeting with R103 or F103. Review of the facility's 02/02/22 policy titled, Baseline Care Plan, indicated, Intent: Every resident will have an Interdisciplinary Care Plan, with the Baseline Care Plan completed within 48 hours of admission. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident . The interdisciplinary plan of care will be developed through collaborative efforts of the Interdisciplinary Team and other health care professionals . The resident and/or family member will be involved in the care planning . The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational, and environmental needs as appropriate. Procedure: The baseline care plan will: 1. Be developed within 48 hours of a resident's admission. 2. Include the minimum healthcare information necessary to properly care for a resident including but not limited to: a. initial goals based on admission orders. B. physician orders. C. dietary orders. D. Therapy services. E. Social services . 4. The facility will provide the resident and their representative with a summary of the baseline care plan prior to completion of the comprehensive care plan, that includes but is not limited to: a. the initial goals of the resident, b. a summary of the resident's medications and dietary instructions, c. any services and treatments to be administered by the facility personnel acting on behalf of the facility . 5. The facility will provide the resident and their representative with a summary of the baseline care plan prior to completion of the comprehensive care plan. NJAC 8:39-11.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plan was updated for one of 29 residents (Resident (R) 96) reviewed. The failure to keep a care plan current could affect the appropriateness of care provided to any of the 127 current residents receiving care in the facility. Findings include: 1. Observation of R96 on 08/29/22 at 12:45 PM showed a tube feeding running at 65 milliliters per hour that was dated as hung on 08/29/22 at 11:00 PM. Review of R96's admission Record printed from the electronic medical record (EMR) Profile tab showed an admission date of 10/14/20, and a readmission date of 08/09/22, with medical diagnoses that included pneumonia, hypertension, dysphagia, moderate protein calorie malnutrition, dementia with behavioral disturbance, major depressive disorder, generalized anxiety disorder, and gastrostomy. Review of R96's Progress Notes, from the EMR Prog Notes tab showed: 8/26/2022 12:09 [12:09 PM] General Nurses Note Note Text: .Resident is presently NPO [nothing by mouth] receiving jevity [sic] 1.2 at 65cc [cubic centimeters or milliliters]/hr [hour] for 20hrs totaling 1300ml [milliliters]. Dietician notified and will make adjustments to Jevity order. MD [name] and [Resident Representative name] notified. Review of a discharge Minimum Data Set [MDS], assessment reference date (ARD) 07/22/22 showed R96 was not coded for receiving enteral [tube] feeding. The significant change of status MDS ARD 08/02/22 showed R96 was coded for receiving enteral feeding. Review of R96's care plan from the EMR Care Plan tab showed: Focus: [R96 name] has a nutritional problem or potential nutritional problem r/t [related to] therapeutic diet, altered consistency, . asp [aspiration] PNA [pneumonia], malnutrition, PEG [percutaneous endoscopic gastrostomy tube] placed 7/29. Date Initiated: 10/18/2020 Revision on: 08/03/2022 Goal: [R96 name] will maintain adequate nutritional status as evidenced by maintaining weight within 5% of CBW [current body weight], no s/sx [signs/symptoms] of malnutrition, and consuming at least 75% of at least 3 meals daily through review date. Date Initiated: 10/18/2020 Revision on: 07/04/2022 Target Date: 11/03/2022 . -Monitor/document/report to MD PRN for s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Date Initiated: 10/18/2020 . During an interview on 08/31/22 at 4:54 PM regarding the references to three meals a day and issues with food in the mouth, the Director of Nursing (DON) stated, Yes, his care plan should have been updated by now. Review of the 02/01/22 facility policy titled Comprehensive Resident Centered Care Plans showed: Intent . Every resident will have an Interdisciplinary Care Plan. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. Procedure:. 2. The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; . Developing the Care Plan: 1. A comprehensive care plan will be: . c. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. . Updating Care Plans: 1. Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals. 2. Meetings of the Director of Nursing, Social Services Coordinator (if appropriate), MDS Coordinator, Registered Dietitian, Activities Director and Therapy Professional are held to review the current status of skilled residents and determine needed interventions to meet resident goals. The Care Plan will be updated and/or revised for the following reasons: a. Significant change in the resident's condition. b. A change in planned interventions. NJAC 8:39-11.2(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, and policy review, the facility failed to ensure one of seven residents (Resident (R) 66) reviewed for falls received appropriate care and services following an unwitnessed fall in which she sustained a bruise below her eye. Neurological (neuro) checks were not completed to rule out a head injury after the fall. Findings include: 1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R66 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, history of cerebral infarction (stroke), osteoarthritis, type two diabetes mellitus, and abnormalities of gait and mobility. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/13/22 in the EMR under the MDS tab revealed R66 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 10 (score of 8 - 12 indicates moderate cognitive impairment) out of 15. R66 required limited assistance from one person for transfers and walking in her room and in the corridor. R66 had not experienced any falls in the preceding six-month period. Review of the Care Plan dated 07/14/22 in the EMR under the Care Plan tab revealed the problem of, [R66] is at risk for falls r/t [related to] impaired mobility, narcotic for pain, poor safety awareness. The goal was for R66 to be free of falls with injury. The care plan revealed, The resident has had an actual fall on 07/25/22 with no apparent injuries due to poor balance. Patient said her knee gave out . The resident will resume usual activities without further incident through the review date. Review of a General Nurses Note dated 07/24/22 at 11:30 PM in the EMR under the Progress Notes tab documented in full, Found sitted [sic] on the floor. Denies pain. Able to stand with assistance and walk. Review of the #791 Fall investigation dated 07/25/22 at 5:44 AM and provided by the facility revealed R66 was found sitting on the floor in her room and had experienced an unwitnessed fall. The investigation noted R66 was assessed and was not in pain, her range of motion (ROM) was good, and she was able to stand and walk. The investigation documented vital signs were taken, and R66 was confused and unable to give a description of the incident. The investigation noted a two-by-two bruise to the left corner of her eye, R66 denied pain or discomfort. Per the investigation, R66's family and physician were notified. R66 was noted to have a gait imbalance, impaired memory, and her walker was not next to her. Review of the Neuro Checks form dated 07/25/22 at 5:44 AM and provided by the facility revealed staff completed neuro checks for R66 on 07/24/22 at 11:25 PM which included taking vital signs, determining orientation, level of consciousness, observed pupils, general response, and evaluation of pain. No additional Neuro Checks forms were completed for 72 hours after the fall in accordance with facility policy. During an observation on 08/30/22 at 10:17 AM, R66 was sitting in a chair in her spouse's room visiting him (he was also a resident), with a walker located next to the chair. R66 stated she walked with a walker and visited her husband who lived at the other end of the hallway. R66 stated she was mostly independent with activities of daily living. R66 verified she had fallen shortly after she was admitted to the facility; however, did not have any additional falls after that time. R66 was unable to provide specific information about the fall that occurred in July 2022. During an interview on 09/01/22 at 3:15 PM, Licensed Practical Nurse (LPN)5 and (LPN)1 stated if a resident fell, the Registered Nurse (RN) on duty completed an assessment. LPN1 stated when a resident hit their head or if it was unwitnessed, the nurses completed neuro checks in the computer, if directed to do so by the physician, to rule out a head injury. LPN1 showed the surveyor a document posted at the nursing station with the parameters for neuro checks. The undated Neuro Checks as Follows document indicated neuro checks should be completed every 15 minutes for the first hour, every hour for four hours, every two hours for four hours, and every eight hours for three days. LPN1 reviewed the EMR and stated there was one set of neuro checks completed on 07/25/22 following R66's fall. LPN1 stated she could not tell if the physician ordered neuro checks to be completed or not because this information went away, and she could not retrieve it. LPN1 verified there were no other neuro checks completed. During an interview on 09/01/22 at 3:57 PM, Registered Nurse (RN) 2 stated there had been a recent change in policy to complete neuro checks in the computer versus on paper. RN2 stated the facility protocol called for neuro checks to be completed every 15 minutes for the first hour, every hour for the next four hours, every two hours for the next four hours, then every eight hours for three days. RN2 stated, at times it was difficult to get all the neuro checks completed due to high use of agency nursing staff. During an interview on 09/01/22 at 4:35 PM , the DON stated R66's fall occurred early in the morning on 07/25/22 and not on 07/24/22. The DON stated, if a resident experienced a fall and hit their head, neuro checks had to be completed or the resident had to go to the hospital for a CT scan. The DON verified one neuro check was completed for resident R66 and if the physician wanted more neuro checks, such as if there was a change in mental status, the physician would have ordered additional checks. The DON verified R66 was noted with a bruise below her eye after the fall. The DON further stated R66 did not experience a change in mental status so additional neuro checks were not warranted. The DON stated the facility did not have a specific neuro check policy. The DON verified the facility's Fall Reduction Program policy directed documentation of neuro checks for 72 hours and the policy did not specify a physician's order was necessary to proceed. Review of the Fall Reduction Program policy dated 02/01/22 and provided by the facility revealed, All residents will receive adequate supervision, assistance and assistive devices to aid in the prevention of falls. Investigative guidelines A. Check resident for injuries . ii. Neuro-checks, for head injuries or unwitnessed fall and resident unable to communicate if he hit his/her head . Document in the Nurse's Notes: i. Observed circumstances; resident fell, slid from chair, found on floor, etc . Neuro-checks . Each nurse, each shift will observe resident and document for 72 hours in the resident's medical record. i. Vital Signs ii. Neuro-checks iii. Neurological changes . Nursing staff is to document Q [every] shift for 72 hours. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer two of five residents (Resident (R) 31 and R103) reviewed for pneumonia vaccinations and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer R31 the opportunity to be vaccinated with Pneumococcal polysaccharide vaccine (PPSV23) and if this vaccination was not available to offer one dose of Prevnar 20 (PCV20). The facility failed to offer R103 the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) in accordance with nationally recognized standards. Findings include: 1. Review of R31's admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R31 was admitted to the facility on [DATE] and was older than [AGE] years of age at the time of admission. Review of the Immunizations located in the Immunization tab of the EMR revealed R31 had historical documentation that he had received the PCV-13 on 02/20/20 however, when he admitted to the facility, he was not offered the PPSV-23 or PCV-20, as recommended. There was no documentation to show that he had refused the second vaccine. During an interview on 08/31/22 at 9:35 AM, the Infection Control Preventionist (ICP) stated that she had been employed at the facility for the last six months and was not aware that R31 was not offered or refused the PCV-20 or PPSV-23. 2. Review of the admission Record located in the Profile tab of the EMR revealed, R103 was admitted to the facility on [DATE] and was older than [AGE] years of age at the time of admission. Review of the Immunizations located in the Immunization tab of the EMR revealed R103 had a documented pneumonia however, there was no indication of the type of pneumonia vaccine R103 had or documentation to show if R103 would potentially require an additional dose. During an interview on 08/31/22 at 9:35 AM, the ICP stated that she had reached out to the R103's physician to determine which vaccine he had but had not heard back since he admitted in July. Review of Center of Disease Control (CDC) website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults 65 years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended. For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete . The CDC guidelines went into effect on 10/21/21 per recommendations from the Advisory Committee on Immunization Practices (ACIP). Review of the facility policy titled, Pneumococcal Vaccine, dated 2021, revealed, .All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal Infections . Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of pneumococcal vaccination status will be conducted with five (5) working days of the resident's admission if not conducted prior to admission. NJAC 8:39-19.4(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interviews, the facility failed to develop a comprehensive plan of care directing measurable goals and interventions for five residents in a total sample of 25 (Resident (R) 3, R32, R43, R101, and R103). The facility failed to develop a care plan for pain for R3, resident choices for R101, side rails for R32, behaviors for R43, and nutrition for R103. These failures placed the residents at risk for unmet care needs and a diminished quality of life. Findings included: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] with diagnoses that included dementia, stroke, and heart failure. Review of the current Order Summary located in the Orders tab of the EMR revealed R3 was prescribed Tramadol [a pain medication] 50 mg [milligram] every six hours for moderate-severe pain on 07/26/22. Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/24/22 revealed, R3 had a Brief Interview of Mental Status (BIMS) of 03 out of 15 which indicated she was severely impaired in cognition for daily decision-making, had no pain indicators and received an opioid medication daily during the assessment period. Review of the EMR showed a care plan for pain had not been developed with measurable goals or resident-specific interventions. During an initial interview on 08/29/22 at 11:37 AM, R3 was lying in bed, softly crying. She stated that her left leg hurt. Licensed Practical Nurse (LPN) 2 was informed of the resident's pain and stated, She is scheduled to receive Tramadol at 12:00 but I will give it to her now. During an interview on 09/01/22 at 8:30 AM, LPN3 was asked about R3's pain and how it was managed. LPN3 stated the Tramadol used to be as needed, however we now have a standing order for the Tramadol. The pain is located in her left leg and foot and at times both legs. LPN3 stated R3 had peripheral vascular disease and venous insufficiency. LPN 3 was asked if there was a care plan for R3's pain and current interventions. LPN3 confirmed that a Care Plan for pain was not developed for R3's pain. 2. Review of R32's printed admission Record from the EMR Profile tab showed an admission date of 12/28/09, and a readmission date of 09/20/21, with medical diagnoses that included cerebral palsy, obesity, chronic osteomyelitis, sacral pressure ulcer, difficulty in walking, and fall history. Observation on 08/29/22 at 2:26 PM showed R32's bed had bilateral upper side rails, and R32 was sitting up at the bedside using the side rails for mobility. On 08/30/22 at 3:03 PM, R32's bed had bilateral upper side rails. Review of R32's hard (paper) chart showed an .Assist Bar/Side Rail assessment completed on 09/20/21 with a signed informed consent (the risks and benefits of side rails) dated 03/30/22. The consent form stated: POTENTIAL NEGATIVE OUTCOMES: I understand that the use of side rail(s) may involve risks such as: getting caught in the rails, getting caught between the rail and the mattress, strangulation, hitting against the rail(s) causing skin tears and/or bruising and crawling over the top of a rail risking a fall from a higher level with a risk for greater injury or death. Review of R32's care plan, from the EMR Care Plan tab, showed, in pertinent parts: Focus: [R32's name] has an ADL [activities of daily living] Self Care Performance Deficit secondary to pain, impaired mobility Date Initiated: 05/18/2016 Revision on: 12/22/2021. Focus: [R32's name] is at risk for falls r/t [related to] history of multiple falls, impaired balance, use of psychotropic medications & pain medications, poor safety awareness, . Date Initiated: 10/03/2014 Revision on: 09/27/2021. Interventions: Assist with bed mobility, transfers, toileting, dressing, hygiene, bathing Date Initiated: 09/27/2021. Further review of R32's care plan did not address the use of side rails with inherent risks. During an interview on 08/31/22 at 4:48 PM, the Director of Nursing (DON) stated an expectation that side rails would be care planned under ADLs. 3. Review of R43's printed admission Record from the EMR Profile tab showed a facility admission date of 03/18/22 with medical diagnoses that included frontotemporal dementia, adjustment disorder, and bipolar disorder. Review of R43's care plan from the EMR Care Plan tab showed: Focus: [R43's name] is currently on Antipsychotic & Antidepressant medication, as well as Depakote for mood/behavior S/S [signs/symptoms] of depression noted- states he wants to be home in his environment DX[diagnosis]: Frontotemporal Dementia, Depression, Bipolar D/O, inappropriate mood/behaviors [R43's name] makes sexual innuendos towards nursing staff Continues accusatory & sexually inappropriate behavior towards staff, grabbing staff breast and private areas, touching himself inappropriately. Date Initiated: 03/25/2022 Revision on: 08/29/2022 Goal: [R43's name] will have fewer behaviors weekly x 90 days Date Initiated: 03/25/2022 Revision on: 07/05/2022 Target Date: 10/01/2022 -[R43's name] will fewer s/s of depression x 90 days Date Initiated: 03/25/2022 Revision on: 07/05/2022 Target Date: 10/01/2022 . Further review of the care plan did not address how many behaviors and/or signs and symptoms of depression R43 experienced in the 90 days prior to the revision on 07/05/22 to have a baseline to measure if the goal had been attained. During an interview on 09/01/22 at 4:10 PM the DON confirmed the care plan goals were not measurable and [the facility] could tighten up on the behavior and side effect monitoring. 4. During observation and interview on 08/28/22 at 11:22 AM, R101 was observed walking independently from his room to look out a window on the first floor. During interview, R101 stated, I want to go walking. I love going outside and getting fresh air. I used to go outside all the time and walk the neighborhood, talk to people, go down to the police station, the stop shop car dealer place, and just walk the neighborhood. R101 stated, I'm able to walk independently. I feel alive when I'm able to go for walks. Now, I feel depressed because the new administrator says I can't go outside. At this time, R101 stated, There has been a new administrator that says I can't go for my walks anymore. R101 stated, I used to sign myself in/out when I came and when I left. They tell me now if I want to go outside, I have to have someone with me. R101 stated, We've had meetings about this in the past, but I feel they don't want to help me. During an observation and interview on 09/01/22 at 7:50 AM, R101 was observed walking around independently. He was observed well dressed in tennis shoes, socks, shorts, and a t-shirt. During interview R101 stated, I asked the Administrator on an update about being able to go for my walks outside. I guess they don't feel comfortable with me walking out there. I would like to go for my walks on my own. I say hi to people. I would sign myself in/out. As soon as I eat my breakfast, I would like to take an hour, take my time, say hi to people and go for a walk. It makes feel excited, happier, and I feel better just to get fresh air. Review of an undated Profile located in R101's electronic medical record (EMR) under the Profile tab revealed R101 was his own responsible party. Review of R101's medical diagnosis located in R101's EMR under the Med (medical) Diag (diagnosis) tab indicated R101 was admitted to the facility on [DATE]. Diagnoses includes essential hypertension, major depressive disorder, and epilepsy, unspecified, not intractable without status epilepticus. Review of an Elopement Risk Guide located in R101's paper chart under the Assessments tab and dated 03/20/17 indicated a score of 2 of 5 indicating low risk for elopement. It further indicated, R101 was independently mobile, has no history of elopement/elopement from prior settings, no verbalized plans to leave the facility whether or not authorized, no expressed desire to leave the facility Against Medical Advice (AMA), no disregard for facility policies and procedures related to leaves of absences, and no history of wandering behaviors. Review of an Interdisciplinary Team Meeting Form, located in R101's paper chart under the Notes tab and dated 02/24/21 indicated, Likes to ambulate around the building, socializing . keeps busy on his own throughout the day by talking to peers, visiting with rehab, ambulating in the facility. Review of a Meeting Note located in R101's paper chart dated 07/28/21 indicated, We discussed the IC [Infection Control] aspect of going out on pass in the community and return to the NH [Nursing Home]. He was reminded of . signing the OOP [out on pass] book when he leaves and comes back, wearing a mask while in the community, stay at least 6 feet apart from others because don't know who is vaccinated or not, no close contacts such as hugging, shaking hands, not accepting any food items from people from the street. Upon return must do proper handwashing, days/times prefers to leave the building and return, and local health dept. [Department] suggest do a rapid test every 2-5 days although he is vaccinated. He acknowledged understanding. Further review of the note revealed no documentation that a care plan would be developed with measurable goals, interventions regarding the possibility of R101 to go for walks into the community. Review of R101's Annual MDS found in the EMR under the MDS tab with an ARD of 02/13/22 indicated, it is Very Important for R101 go outside to get fresh air when the weather is good. Review of R101's Quarterly MDS found in the EMR under the MDS tab with an ARD date of 08/09/22, indicated a BIMS score of 15/15 indicating the resident was cognitively intact. The MDS further indicated no behaviors or wandering or elopement. The MDS indicated, no history of falls within last six months, adequate vision, and No behaviors of wandering. The MDS indicated R101 was independent for bed mobility, transfers, walking in room, walking in corridor, locomotion on and off the unit, dressing, toilet use and personal hygiene. Review of a Care Plan initiated and revised on 08/31/20, found in R101's EMR under the Care Plan tab indicated, [name of R101] is independent with pursuits & socializes with his peers. Interventions listed were: Enjoys being outside in courtyard and dancing to music when weather is warmer, enjoys walking around the building & socializing with his peers. Further review of the care plan located in the EMR revealed no resident person centered care plan specifically developed regarding R101's choice to go for walks in the community, being able to sign himself in/out, where to go, education, meetings held with the resident, or any specific goals, interventions put into place regarding his desire to go for walks into the community. Review of a General Nurses Note located in R101's EMR under the Prog Notes tab dated 08/20/21, indicated, IDCP (Interdisciplinary Team) met . [name of R101] has independent pursuits which include walking around the building and socializing . Was permitted to go for a walk outside the facility this past quarter. He failed to comply with the policy on OOP [Out on Pass] and currently OOP is on hold for [name of R101] to go out himself . The following is addressed in the CP (care plan) . Further review of the note revealed no specific resident centered care plan was developed or implemented specifically with R101 wanting to go outside, specific measurable goals, or any interventions put into place to address wanting to go outside for walks. Review of Social Services Progress Notes located in R101's EMR under the Prog Note tab indicated dates in 2022 in which Interdisciplinary Team (IDT) Meetings were held on 08/19/22, 08/09/22, 07/29/22, 05/20/22, 05/16/22, and 02/14/22 to discuss R101's care. However, there was no discussion or documentation of a person-centered care plan that was developed or implemented to discuss measurable goals and specific interventions put into place to address R101's wishes to go for walks by himself into the community. Review of a Plan of Care Note located in R101's EMR under the Prog Note tab dated 05/20/22, 08/09/22 and 08/19/22, indicated, Meeting took place in resident room with nurse and SWer (social worker) present . awake alert . remains verbally responsive and cam make his needs known to staff . He continues to enjoy spending time in the courtyard . Further review of the Progress Notes revealed no discussion or documentation that took place regarding R101's wishes to go for walks into the community, and no documentation of a person-centered care plan being developed with measurable goals and interventions regarding R101's wishes to go out for walks into the community. During an interview on 08/30/22 at 1:23 PM, the Administrator stated, When I got here as the Administrator in June 2022, I was told just from hearsay that there was a history of him [R101] going out and panhandling in the nearby stores . It is a liability due to a history of panhandling back in the day that was a concern. He would say that he always went on walks, but because of his safety, I can't allow him to go on walks by himself. When the Administrator was asked if there was a plan put into place, or a person-centered care plan that shows discussions took place about putting specific measurable goals into place with interventions regarding R101 wanting to go for walks into the community. The Administrator stated, We came up with a plan. I told him I would start taking him on walks. Sometimes we did, and other days he hasn't wanted to go out for a walk. We came up with a schedule but that kept moving. We were all in agreement that is is not safe for him to go on these long walks. This was just all verbal, there is no written plan in place. During an interview on 08/31/22 at 1:26 PM, the Social Services Director (SSD) stated, We have had care plan meetings every quarter but mostly we cover his weight, ADLs, advanced directives, and meds [medications]. He [R101] is considered his own responsible party. We have not discussed anything in his care plans regarding him wanting to go for walks into the community. During an interview on 08/31/22 at 1:36 PM, the DON stated, We started having some discussions about him going for walks back into the community, I want to say in early 2022 but then that administrator left, and we got a new one. Now, we will be starting some more discussions, but we were not officially documenting that in our computer charting. When the DON was asked if she could show documentation of a resident specific person centered care plan that has been developed specifically with measurable goals and interventions, meetings that took place, education, and a plan about R101 going on walks into the community, the DON stated, We have a care plan that was initiated on 02/22/21 but there was nothing specific about this issue. I don't see our discussions on it, or when we have spoken to him about this. The DON stated, He [R101] approached me again this morning about where we were at with him wanting to go for walks into the community. I said to him that I'm working on it. Over the past couple of months, he has proven himself somewhat, but we don't have anything in writing like a care plan of our discussions. 5. Review of the undated admission Record in the EMR under the Profile tab, revealed Resident (R103) was admitted to the facility on [DATE] with diagnoses including sepsis, hypoglycemia (low blood sugar), acute kidney failure, heart failure, acute respiratory failure, leukemia, protein calorie malnutrition, and type two diabetes mellitus [DM]. Review of the Significant Change MDS with an ARD of 08/12/22 revealed the resident was unimpaired in cognition with a BIMS score of 15 (score of 13 - 15 indicates cognition is intact). During an interview on 08/29/22 at 10:58 AM, R103 and his family member (F)103 were interviewed together. F103 stated R103's blood sugars (BS) had been, terrible recently, with levels between 400 - 500. Review of the Nurses' Notes revealed R103 had low blood sugar (hypoglycemia) on 07/13/22 as follows resulting in hospitalization: Review of a Nurse's Note dated 07/13/22 at 6:51 AM, in the EMR under the Progress Notes tab revealed, BS: 38 mg [milligrams]/dL [deciliter] [65 - 109 normal range per lab] . 2 injections of glucogen [hormone that increase blood sugar level and prevents it from dropping too low] given. Supervisor made aware. Long-acting insulin placed on hold. MD [medical doctor] called awaiting call back for possible d/c [discharge]. BS at 6:45 AM 53 mg/dl. Will keep monitoring. Review of a Nurse's Note dated 07/13/22 at 7:07 AM in the EMR under the Progress Notes tab revealed, Patient remains unresponsive. Patient in high fowlers [seated upright]. Patient given addition glucogen injection. increased to 91 mg/dl and then dropped back to 59 mg/dl. supervisor made aware. Review of a Nurse's Note dated 07/13/22 at 7:15 AM in the EMR under the Progress Notes tab revealed, Patient remains unresponsive. 4th glycogen IM [intramuscular] given. BS: 77mg/dL. MD called awaiting call back. supervisor aware. Review of a Nurse's Note dated 07/13/22 at 07:35 AM in the EMR under the Progress Notes tab revealed, Transfer to ER [Emergency Room] due to hypoglycemia. BS: 86 mg/dL. In and out of consciousness. Review of the Insulin Report dated August 2022 in the EMR and under the Orders tab, revealed R103's recent BS levels had been elevated (hyperglycemia) with levels exceeding 500 mg/dL, noted on the following dates: 08/18/22 BS 526; 08/20/22 BS 530; and 08/26/22 BS 512. Review of the Order Summary Report dated August 2022 in the EMR and under the Orders tab, revealed R103's current insulin orders were as follows: -Novolog, inject as per sliding scale: If 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 - 400 = 6 units; 401 - 450 = 8 units; 451 - 500 = 10 units; 501 - 550 = 12 units, Call physician if BS is less than 60 or more than 550, administer subcutaneously two times a day for DM, accucheck at 8:00 AM & 4:00 PM with sliding scale, initiated on 08/27/2022. -Insulin Glargine-yfgn Subcutaneous Solution 100 unit/ML, inject 26 unit subcutaneously at bedtime for DM initiated on 08/26/22. During an interview on 08/30/22 at 01:23 PM, LPN5 and LPN1 stated there had also been multiple insulin adjustments made to R103's regimen due to recent incidents of hyperglycemia. R103 received nutrition via a feeding tube and the formula had been changed due to high blood sugars. R103 was served a pureed diet; however, he did not eat it. R103's Care Plan dated 07/11/22 in the EMR under the Care Plan tab was reviewed. There was no care plan specific for the problem of diabetes mellitus, to address hypoglycemia or hyperglycemia. Review of the Care Plan dated 07/30/22 in the EMR under the Care Plan tab revealed the only reference to DM was as follows: [R103] is at risk for skin impairment r/t impaired mobility, incontinence, DX: DM, CA [cancer], at risk for malnutrition . The goal was [R103] will have no further skin breakdown x 90 days. Interventions included, B/L [bilateral] heel floats for protection offload heels when in bed; DM management as ordered, podiatry consults as needed; Monitor peg [percutaneous endoscopic gastrostomy] site for s/s [signs and symptoms] of infection. Treatment as ordered; Reposition every 2 hours as needed; Toileting hygiene/incontinence care in a timely manner; Weekly skin assessments. Pressure reducing mattress to bed. Dietitian to follow with recommendations. Roho cushion for chair. During an interview on 09/01/22 at 4:12 PM, the DON stated the MDS nurse was currently out of the facility and not available for interview. The DON verified R103 had a diagnosis of diabetes mellitus and stated R103's blood sugars had been significantly elevated recently. The DON also verified previous incidents of hypoglycemia due to the resident failing to eat. The DON stated the physician changed the resident's insulin dose several times and his tube feeding formula in response to the elevated BS. The DON stated she was not aware that the resident's diagnosis of diabetes mellitus and incidents of hypoglycemia and hyperglycemia had not been care planned and she verified diabetes mellitus should be care planned. The DON stated she would review the care plan and if she found any pertinent information, she would provide it. No additional information was provided to illustrate DM was care planned for R103. Review of the 02/01/22 facility policy titled Comprehensive Resident Centered Care Plans showed: Intent . Every resident will have an Interdisciplinary Care Plan. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. There will be ongoing documentation of the nursing process related to resident needs from admission to discharge. The interdisciplinary plan of care will be developed through collaborative efforts of the Interdisciplinary Team and other health care professionals. It will be consistent with the medical plan of care and those disciplines that have direct involvement with the resident's care It is our purpose to ensure that each resident is provided with individualized, goal directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care. Review of the Resident Assessment Instrument [RAI] Manual, dated October 2019, page 4-8, showed: .4.7 The RAI and Care Planning As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. NJAC 8:39-11.2(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to: a.) perform an assessment of a resident's condition, b.) maintain documentation of monitoring for complications related to hemodialysis and c.) communicate with the hemodialysis center. This deficient practice was identified for 1 of 4 residents (Resident #69) reviewed for dialysis. The deficient practice was evidenced by the following: On 03/08/19 at 9:21 AM, the surveyor observed Resident #69 in the doorway of the room seated in the wheelchair. The surveyor reviewed Resident #69's medical records. A review of the Admitting Face Sheet, revealed that Resident #69 was admitted to the facility on [DATE] and with diagnoses that included End Stage Renal Disease (ESRD). The surveyor reviewed Resident #69's March 2018 Physician's Orders Form. The resident had orders dated 09/01/18 for the following: Hemodialysis (a therapy that filters waste and removes extra fluid from the body) three times weekly on Monday, Wednesday, Friday and Monitor catheter to left arm for positive bruit and thrill (The bruit and thrill are terms used when assessing the health of a fistula site, which is a connection or passageway between an artery and a vein surgically created for hemodialysis treatments. The bruit is the sound of the blood flow through the fistula heard with a stethoscope, and the thrill is this blood flow felt on examination by touch) every shift. A review of the Dialysis Communication Forms (DCF) revealed: 1. No DCF completed for the following dialysis days: 01/02/19, 01/04/19, 01/09/19, 01/14/19, 01/18/19, 02/01/19, 02/04/19, and 02/15/19; 2. Incomplete facility portions of the DCF for the following dialysis days: 01/23/19, 02/06/19, 02/20/19, and 03/01/19. A review of Resident #69's Nurse's Notes (NN) from January 2019 to present, revealed no additional documentation related to communication to and/or from the dialysis center, nor was there any documentation of the nurses performing a post dialysis assessment on the resident or the access site. Based on inquiry on 3/11/19 at 10:59 AM, with the Registered Nurse (RN) and the Licensed Practical Nurse Unit Manager (LPN UM), were not aware that the catheter to the right chest was the primary access site for the resident's Hemodialysis treatments. They were not aware that the fistula to the resident's left arm was no longer functioning properly and was not being used for Hemodialysis. At the time of the interview, the LPN UM asked Resident #69 if the fistula in the left arm was the site for dialysis and the resident stated the fistula doesn't work anymore. The resident further stated the dialysis center uses the catheter for dialysis access. On 03/12/19 at 01:49 PM, the surveyor discussed these concerns with the Director of Nursing (DON) and Administrator. The DON stated that the dialysis communication form should be completely filled out and if it isn't the nurse was to call the dialysis center. A review of the facility's policy for Dialysis Care, under the procedure for the Documentation, number one listed the following: Initiate a communication book with the dialysis unit. The documentation book will contain routine communication between the facility and dialysis unit. If the book returns and is blank for that day, nursing staff will call the dialysis unit and will request the information. This will be documented in the dialysis book. There was no documented evidence this policy was consistently followed. NJAC 8:39-11.2 (b), 27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to implement a gradual dose reduction (GDR) of an anti-psychotic medication for 1 of 4 residents (Resident #35) reviewed. The deficient practice was evidenced by the following: On 03/07/19 at 10:50 AM, the surveyor observed Resident #35 during a morning activity in the day room. The resident was seated in a recliner chair with eyes closed. The surveyor reviewed Resident #35's medical record. The resident was admitted to the facility on [DATE] and according to the March 2019 Physician's Order Form (POF) Resident #35 had diagnoses that included Dementia with Behavioral Disturbances, Psychosis, Anxiety and Alcohol Abuse. A review of Resident #35's March 2019 POF indicated that Resident #35 had a physician's order (PO) dated 01/15/18 for Seroquel 100 mg at bedtime, Seroquel 50 mg at bedtime and Seroquel 50 mg at 4:00 PM for Psychosis (Seroquel is an antipsychotic medication). The resident also had a PO dated 03/17/15 for Lorazepam 0.25 mg at 9:00 AM and Lorazepam 0.5 mg at 4:00 PM for anxiety. The surveyor reviewed Resident #35's monthly Psychoactive Documentation (PD) forms from May 2018 through March 2019. According to the PD forms the resident was being monitored for target behaviors that included, talking to self, anxiousness, tearfulness and disrobing in public areas. The PD forms further revealed that Resident #35 had zero episodes of targeted behaviors from May 2018 through February 2019. The surveyor was unable to find the daily behavior monitoring sheet for Resident #35 in the medical record. The Licensed Practical Nurse (LPN) assigned to Resident #35 informed the surveyor that episodic behaviors are documented in the Nurses Notes (NN). The surveyor reviewed Resident #35's NN from 01/03/18 through 03/11/19. The NN on 01/15/18 indicated that Resident #35 had a GDR for Seroquel from 200 mg to 150 mg at bedtime. Following the GDR, Resident #35 had documented behaviors on 04/25/18, 04/26/18, 05/2/18 and 05/8/18. There were no further behaviors documented in the NN from 05/8/18 through 03/11/19. The surveyor reviewed Resident #35's Psychiatric Follow-Up Forms (PFUF). On 10/04/18 the Advance Practice Nurse (APN) documented that Resident #35 was too high a risk for a GDR and was still confused and delusional. The APN also indicated that the resident should be maintained on the current medications. On 02/04/19 the APN documented that Resident #35 behaviors were well maintained but a GDR was not recommended due to Resident #35's past history of Schizophrenia. This was the first time the APN documented on Resident #35 PFUF the diagnosis of Schizophrenia. The diagnosis of Schizophrenia was not documented anywhere else on the medical record. On 03/13/19 at 8:30 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) assigned to the resident. She stated Resident #35 had no significant behaviors over the past year and was stable. On 03/13/19 at 8:40 AM, the surveyor interviewed the LPN who stated that Resident #35 behaviors was stable. On 03/13/19 at 11:20 AM, the surveyor interviewed the APN who assessed Resident #35 by telephone. The APN stated that she was concerned that Resident #35's quality of life would decrease and/or the resident would end up in a Psychiatric hospital if she tried a GDR. The surveyor questioned the APN about the diagnosis of Schizophrenia and she was unable to answer the question as to where the diagnosis came from. On 3/13/19 at 10:55 AM, the surveyor interviewed the Director of Nursing (DON) regarding the diagnosis of Schizophrenia written by the APN on the 02/04/19 and that a GDR had not been attempted since 01/15/18. The DON stated that the resident did not have a diagnosis of Schizophrenia and was started on Seroquel for the diagnosis of Psychosis. The DON further stated that the nursing staff are struggling with documenting targeted behaviors and no further information was provided regarding the concern for the GDR. The surveyor reviewed the facility's policy titled Administration of Psychoactive Medications and Documentation that indicated under the section titled Procedure that Unless Clinically contraindicated, stabilized residents will be referred to consultant psychiatrist for gradual dose reductions with the goal of eventually discontinuing medication. and All residents receiving antipsychotic medication will have appropriate target behaviors for the use of antipsychotic medication. These target behaviors will be quantified monthly. The number of times a target behavior occurred will be taken into consideration for continued use of antipsychotic medication. NJAC: 8:39-27 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to promptly notify the physician of abnormal laboratory results that fall outside of the normal clinical reference range. This deficient practice was identified for 3 of 31 residents reviewed (Resident #52, #117, #128) and was evidenced by the following: 1. The surveyor reviewed Resident #52's medical records. According to the Admitting Face Sheet, Resident #52 was admitted to the facility on [DATE], with diagnoses that included Emphysema, Enlarged Prostate and Cerebral Vascular Accident. A review of the laboratory results dated [DATE], showed documentation that the result was faxed to the facility on [DATE], there was no documentation that the physician was notified of the results: high 140 Glucose level, high 107 Chloride level, low 19 CO2 (Carbon Dioxide) level and high 17 AGAP (Anion Gap) level. The surveyor reviewed the resident's Nurse's Notes (NN) from 02/04/19 to 03/04/19, which did not show any documentation that the physician was made aware of the resident's 02/20/19 laboratory test results. 2. The surveyor reviewed Resident #117's medical records. According to the Admitting Face Sheet, Resident #117 was admitted to the facility on [DATE], with diagnoses that included Congestive Heart Failure and Cerebral Palsy. A reviewed of the laboratory results dated [DATE], showed no documentation that the physician was notified of the results: low 4.43 Red Blood Cell (RBC) level, low 12.8 Hemoglobin (Hgb) level, low 37.7 Hematocrit (Hct) level, high 15.4 RDW (Red Cell Distribution Width) level, and low 6.0 MPV (Mean Platelet Volume) level. The surveyor reviewed the resident's NN from 02/04/19 to 03/12/19, which did not show any documentation that the physician was made aware of the resident's 02/13/19, laboratory test result. 3. The surveyor reviewed Resident #128's medical records. According to the Admitting Face Sheet, Resident #128 was admitted to the facility on [DATE], with diagnoses that included Congestive Heart Failure, Diabetes, Hypertension and History of Dehydration. A review of the laboratory results dated [DATE], showed no documentation that the physician was notified of the results: low 3.34 RBC level, low 8.9 Hgb level, low 27.8 Hct level, and high 16.0 RDW level. A review of the laboratory results dated [DATE], revealed no documentation that the physician was notified of the abnormal results: low 14.4 Lymph Auto level, low 56 Glucose level, high 32.3 BUN level, high 1.16 Creatinine level, high 5.5 Potassium level, high 111 Chloride level, low 19 CO2 level, low 3.43 RBC level, low 9.1 Hgb level, low 28.8, Hct level and high 15.9 RDW level. The surveyor reviewed the resident's NN from 02/04/19 to 03/11/19, which did not show documentation that the physician was made aware of the resident's 02/15/19 or 02/18/19 laboratory test result. On 03/11/19 at 10:59 AM, the surveyor interviewed the South One Registered Nurse (RN) assigned to the resident who stated that she does not do anything with the laboratory test results that they are the responsibility of the Licensed Practical Nurse Unit Manager (LPN UM). On 03/11/19 at 11:09 AM, the surveyor interviewed the South One LPN UM who stated that laboratory test results are faxed or called into the physician by the nurse as soon as they come in and that the nurse should have documented this on the laboratory results. The LPN UM reported that if the results are faxed to the physician the nurse must also follow up with a phone call to the physician. The nurse then would document in the NN or on the laboratory results when the results are reviewed with the physician. The LPN UM stated that the whole process should be completed within an hour. On 03/12/19 at 01:49 PM, the surveyor discussed these concerns with the Director of Nursing and Administrator. No additional documentation was provided. A review of the facility's policy for Notification of Attending Physician of Reports of Consultation, Laboratory, and X-Ray, etc., under procedure number two listed the following: The Unit Nurse: 2. Checks the results and notifies the attending Physician of findings. Results will be faxed to the MD (physician) and a TELEPHONE CALL will be placed to the physician. If the physician does not return the call and the results are grossly a follow up calls must be made at reasonable intervals until the attending MD or his covering doctor responds. Further review of the policy under procedure D listed the following: Also the following must be documented in the Nurse Notes. Date and Time physician notified and name of physician if it was a covering. Orders received or that no orders were received. If follow up calls were placed, date, time placed and who took message (answering service or doctors office). NJAC 8:39-13.1(d)

Based on observation, interview and record review, it was determined that the facility failed to follow proper infection control procedures and perform proper hand hygiene during 1 of 2 wound treatment observations. This deficient practice was observed for Resident #117 and was evidenced by the following: 1. On 3/12/19 at 09:13 AM, the surveyor observed the Licensed Practical Nurse Unit Manager (LPN UM) provide wound care to a pressure ulcer on Resident #117's left ischium. The LPN UM was observed to wash her hands eight times during the above procedures and was observed to be inconsistent with her technique. Twice the surveyor observed the LPN UM apply liquid hand soap and immediately lathered and rubbed her hands together under the running water for a total of five seconds. On four occasions the surveyor observed the UM lather and rub her hands together for 11 seconds or less. On 03/12/19 at 9:30 AM, the surveyor interviewed the LPN UM who stated that the proper procedure for hand washing included lathering and scrubbing her hands together for at least 30 seconds before rinsing off the soap. On 03/12/19 at 01:49 PM, the surveyor discussed these concerns with the Director of Nursing (DON) and Administrator. No additional documentation was provided. A review of the facility's policy for Hand Washing, under procedure number three, four, and five, listed the following: 3. Apply liquid soap to hands. 4. Rub all surfaced of hands, fingers, and wrists. Clean nails by working against the palm of the opposite hand. Continue scrubbing hands with friction for a period of 20-30 seconds with hands pointing down. 5. Rinse hands and wrists thoroughly under running water, fingers pointing downward into the sink. NJAC 8:39-19.4 (a)1

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to provide adequate maintenance to ensure that all the kitchen equipment was in safe operating condition. This deficient practice was evidenced by the following: On 03/07/19 at 10:08 AM, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. A large amount of water was at the threshold of the kitchen that spread over the threshold and into the hallway and back across the floor into the main area of the kitchen. The water trail was traced back and originated from a leak on top of the dish machine where the temperature gauges were located. No wet floor sign was present. 2. The hood lights were off during food preparation and when turned on two of five lights were not working. The cook stated we usually leave the lights off. 3. The air/grease vent and backsplash on the back top of the six burner stove was visibly soiled with a build-up of splattered, dried and caked on food debris. 4. The hot box located to the left of the stove was in poor repair with a two inch gap on the top left side of the door and the interior rubber gasket around the door was visibly melted. 5. Multiple floor tiles by the steamer, kettle and stove were in poor repair with chipped tiles and missing grout between the clay tiles. 6. The walk-in freezer had a soiled white linen sheet on the floor that covered approximately one third of the floor. The cook stated the rag was on the floor because sometimes the floor was slippery. 7. There was a large build-up of ice around the water pipe in the walk-in freezer that measured approximately eight to ten inches in length and height with droplets of semi-frozen ice on the ceiling that dripped onto multiple opened boxes of assorted frozen food items and the surveyor's head. 8. The painted concrete floor in the dry storage room was chipped and in poor repair. On 03/08/19 at 10:05 AM, the surveyor re-entered the kitchen with the Administrator to review the surveyor's findings. The Administrator stated that maintenance issues were verbalized to the Maintenance Director (MD) when he makes his daily rounds. The FSD and the Administrator stated there was no formal documentation available or follow-up documentation and it was unclear if the items observed by the surveyor were previously identified by the MD. On 3/11/19 at 9:45 AM the surveyor reviewed an undated daily Cook's Cleaning Schedule which indicated daily cleaning and sanitizing of the area after use that included the steamtable, steamer, hotbox, stove and can opener. The weekly tasks included sanitizing the thawing refrigerator and de-lime the steam tables. Other specific pieces of kitchen equipment were not included and the FSD stated there is no daily or monthly check logs/lists used to indicate completion of the job assignments. NJAC 31.2 (e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice continued over a two month period of time for 3 of 31 residents (Resident #8, #88, #117) reviewed and was evidenced by the following: 1. On 03/07/19 at 10:20 AM, the surveyor observed Resident #8 laying in bed eating breakfast. The surveyor reviewed Resident #8's medical record. According to the Admitting Face Sheet, Resident #8 was admitted to the facility on [DATE] with diagnoses that included Emphysema, Hypertension and Paraplegia. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 03/03/19, the facility assessed Resident #8 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The surveyor reviewed the January 2019 and February 2019 Physician's Order Form (POF) that revealed Resident #8's physician had not signed or dated these monthly orders. On 03/13/19 at 9:45 AM, the surveyor interviewed Resident #8 who stated they do not recall the last time the physician was in to visit but they didn't' see the physician often. 2. On 03/07/19 at 10:41 AM, the surveyor observed Resident #117 in the doorway of the room self-propelling in the wheelchair. The surveyor reviewed Resident #117's medical records. According to the Admitting Face Sheet, Resident #117 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure and Cerebral Palsy. According to the Comprehensive MDS dated [DATE], the facility assessed Resident #117 as cognitively intact with a BIMS score of 15 out of 15. The surveyor reviewed the January 2019 and February 2019 POF that revealed Resident #117's physician had not signed or dated these monthly orders. On 03/13/19 at 9:49 AM, the surveyor interviewed Resident #117 who reported not remembering the last time physician was in but knows it has been a long time. On 03/12/19 at 1:03 PM, the surveyor interviewed the South One Licensed Practical Nurse Unit Manager (UM) who stated that the night shift checks to make sure physicians orders are signed if they are not signed right away the night nurse notifies the UM and then she would call the physician to come in and sign the orders. 3. On 03/08/19 at 09:33 AM, the surveyor observed Resident #88 in bed with eyes open. The resident was watching television. The surveyor reviewed Resident #88's medical records. According to the Admitting Face Sheet, Resident #88 was admitted to the facility on [DATE] with diagnoses that included Morbid Obesity, Gangrenosum, Diabetes Mellitus and Hepatitis C. According to the Annual MDS dated [DATE], the facility assessed Resident #88 as cognitively intact with a BIMS score of 12 out of 15. The surveyor reviewed the January 2019 and February 2019 POF that revealed Resident #88's physician monthly orders had not been signed or dated. On 03/11/19 at 09:15 AM, the surveyor interviewed the North One LPN UM about the physician not signing and dating the monthly orders. She stated that when the physician comes to the facility it is the responsibility of the nurse was working to make sure the physician had signed and dated the monthly orders and wrote progress notes. If the physician forgets to sign and date the monthly orders and doesn't write progress notes the nurses would notify the DON and Administrator. On 03/11/19 at 09:38 AM, the surveyor interviewed the DON about the lack of signatures. She stated she does an audit every two weeks and was constant communication with the physician. The physician tells her he will come in to sign orders, but when she checks the next day, the orders aren't signed. On 03/12/19 at 01:49 PM, the surveyors discussed the above concerns with the DON and Administrator. The DON stated that there was no policy for physician's signing and dating their monthly POF. She further stated the physician's are expected to come in and sign their monthly POF by the second week of the month. NJAC 8:39-27.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, 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 every 60 days. This deficient practice continued over several months for 4 of 31 residents (Resident #8, #88, #89, #117) reviewed and was evidenced by the following: 1. On 03/07/19 at 10:20 AM, the surveyor observed Resident #8 laying in bed eating breakfast. The surveyor reviewed Resident #8's medical records. According to the Admitting Face Sheet, Resident #8 was admitted to the facility on [DATE] with diagnoses that included Emphysema, Hypertension and Paraplegia. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 03/03/19, the facility assessed Resident #8 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The surveyor reviewed Physician Progress Note that revealed Resident #8's physician had not performed a face to face visit and wrote progress notes since 12/19/18. On 03/13/19 at 9:45 AM, the surveyor interviewed Resident #8 who stated he/she does not recall the last time the physician was in to visit but he/she doesn't see the physician often. 2. On 03/07/19 at 10:41, AM the surveyor observed Resident #117 in the doorway of the room self-propelling in the wheelchair. The surveyor reviewed Resident #117's medical records. According to the Admitting Face Sheet, Resident #117 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure and Cerebral Palsy. According to the Comprehensive MDS dated [DATE], the facility assessed Resident #117 as cognitively intact with a BIMS score of 15 out of 15. The surveyor reviewed Physician Progress Note (PPN) that revealed Resident #117's physician had not performed a face to face visit and had not written progress notes since 12/19/18. On 03/12/19 at 9:49 AM, the surveyor interviewed Resident #117 who reported not remembering the last time physician was in but knows it has been a long time.4. On 03/08/19 09:57 AM, the surveyor observed Resident # 89 sitting in a wheelchair in the day room. The surveyor reviewed Resident #89's medical records. According to the Admitting Face Sheet, Resident #89 was admitted to the facility on [DATE] with diagnoses that included Dementia, Diabetes Mellitus and Hypertension. According to the Significant Change MDS dated [DATE], the facility assessed Resident #89 as cognitively impaired with a BIMS score of 6 out of 15. The surveyor reviewed the PPN that revealed Resident #89's physician had not performed face to face visits from August 2018 to February 2019 and didn't document on the PPN since 07/23/18. The surveyor was unable to interview Resident #89 concerning the frequency of the attending physician's visits due to the resident's cognitive impairment. On 03/12/19 at 01:25 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN UM) who stated she makes sure when Resident #89's physician visits and signs everything, but the physician doesn't always come in during her shift. The RN UM further stated that when the physician does not complete face to face visits she informs the Administrator. She further stated sometimes when the physician comes back to the facility he doesn't do everything. On 03/12/19 at 01:49 PM, the surveyor discussed these concerns with the DON and Administrator. The DON stated that the physicians are expected to come in for face to face visits with the residents, documenting the visit in the PPN at least every 30 days and as needed. The surveyor reviewed the facility's policy and procedure for Physician Assessments and Follow up that indicated under Procedures, section II titled Visits and Documentation the physician or Advanced Practice Nurse (APN) shall visit each resident every 30 days and following the initial visit, alternate 30 day visits may be delegated by a physician to a New Jersey licensed physician assistant. NJAC 8:39-27.1 3. On 03/08/19 at 09:33 AM, the surveyor observed Resident #88 in bed with eyes open. The resident was watching television. The surveyor reviewed Resident #88's medical records. According to the Admitting Face Sheet, Resident #88 was admitted to the facility on [DATE] with diagnoses that included Morbid Obesity, Gangrenosum, Diabetes Mellitus and Hepatitis C. According to the Annual MDS dated [DATE], the facility assessed Resident #88 as cognitively intact with a BIMS score of 12 out of 15. The surveyor reviewed PPN that revealed Resident #88's physician had not performed a face to face visit and did not write progress notes since 12/19/18. On 03/11/19 at 09:15 AM, the surveyor interviewed the North One LPN UM about the physician not signing and dating the monthly orders. She stated that when the physician comes to the facility it is the responsibility of the nurse who was working to make sure the physician had signed and dated the monthly orders and wrote progress notes. If the physician forgets to sign and date the monthly orders and doesn't write progress notes, the nurses would then notify the DON and Administrator. On 03/11/19 at 09:30 AM, the surveyor interviewed Resident #88 about how often the physician visits. The resident stated that they couldn't recall how often and wasn't sure if they were seen by the physician in the month of January or February. On 03/11/19 at 09:38 AM, the surveyor interviewed the DON about the lack of documentation. She stated she does an audit every two weeks and was in constant communication with the physician. She stated the physician tells her he will come in to do the monthly orders and PPN, but when she checks the next day the physician didn't do it.