Based on observations, interview, and policy review, the facility failed to clean and disinfect glucometers per the manufacturer's recommendation. This facility failure to properly clean and disinfect multi-use glucometers has the potential to increase the likelihood of transmission of blood-borne pathogens for two of 30 residents (Resident (R) 351 and R 11) receiving blood sugar monitoring. On 7/13/23 at 2:59 PM, the Administrator and the Director of Nursing (DON) were notified of immediate jeopardy (IJ) in the following area: at F880-: Infection Control. The Immediate Jeopardy began on 07/13/23 when the licensed nursing staff failed to properly clean and disinfect multi-use glucometers for R351 observed on 07/12/23 and R11 observed on 07/13/23. The facility provided an acceptable plan for removal of the immediate jeopardy at F880 on 07/14/23 at 1:45 PM. On 07/14/23 at 3:00 PM, the immediacy was removed after the plan was verified to have been implemented. The deficient practice remained at a scope and severity of a D (Isolated, no actual harm with potential for more than minimal harm) The removal plan included: Administrator completed a root cause analysis. Director of Nursing/designee began education on 07/13/23 at 3:30 PM and will continue until education on disinfecting the glucometer per facility policy with the competency to show return demonstration and comprehension and will continue education until all nurses have been educated. Compliance on competencies to determine knowledge will be audited/monitored for completion by the Director of Nursing or designee weekly for four weeks, every two weeks for two months and monthly for three months. Audits will be discussed during Quality Assurance Performance Improvement (QAPI) meeting. Regional Director of Nursing/designee completed hand washing education and competency to show return demonstration and comprehension on 07/13/23 and will continue until all nursing staff have been educated prior to the next shift. The Director of Nursing identified all residents at risk, and those residents requiring blood glucose monitoring. A full house audit was completed on residents receiving blood glucose monitoring to ensure there are no known blood-borne infections with the identified residents. All glucometers were removed from the medication carts and disinfected according to the facility policy on 07/13/23. All medicine carts were disinfected with the Environmental Protection Agency (EPA) approved disinfecting solution. The removal plan was verified through interviews and observations. On 07/14/23, on the 2 North Unit at 2:29 PM; 1 [NAME] unit at 2:30 PM; 2 South unit at 2:51 PM; Penthouse unit at 3:00 PM; and 1 South Unit at 3:01 PM licensed nursing staff were interviewed regarding the removal plan and facility expectations for the cleaning/disinfecting of resident glucometers. The staff were able to verbalize the process for cleaning, with the correct number of disinfecting wipes and type, to be used. Findings include: During observation on the One [NAME] Unit on 07/12/23 at 4:46 PM, Licensed Practical Nurse (LPN) 2 was observed to remove a multi-use glucometer kit from the medicine cart located in the hallway. The glucometer kit contained a blood glucose meter, blood sugar test strips, lancets, and testing solution which were stored in a zippered pouch. LPN2 took the glucometer kit into R351's room, donned gloves, and performed R351's blood sugar test. With her gloves still on, LPN2 returned the glucose meter and container of test strips to the zippered pouch and left R351's room failing to remove her gloves and perform hand hygiene prior to leaving R351's room. LPN2 placed the glucometer kit on top of the medication cart located in the hallway and removed her gloves and performed hand hygiene at that time. After observing LPN2 document R351's blood sugar results in the electronic medical record, continued observation revealed LPN2 placed the glucometer kit in the medication cart drawer without cleaning or sanitizing it. During interview via telephone of LPN2 on 7/13/23 at 11:41 AM, LPN2 stated that before use the glucometer should be disinfected with a wipe from the purple container (Micro-Kill One Germicidal Alcohol Wipes). After use, she wipes everything before it is used for the next resident. LPN 2 stated one wipe is used to wipe front, back, and side of the glucometer. LPN2 stated gloves should be removed, and hands washed with soap and water after performing a blood glucose test. LPN2 confirmed that she failed to remove her gloves and sanitize her hands after performing R351's blood glucose test and prior to leaving the resident's room. LPN2 further confirmed she left R351's room after performing the blood glucose test and discarded her gloves at the medication cart. LPN2 would not confirm that she failed to clean and sanitize the glucometer before placing it back into the medication cart. During an interview on 07/12/23 at 4:54 PM the Penthouse Unit regarding cleaning and disinfection of glucometers, LPN4 stated that prior to performing a blood glucose test, he wipes the glucometer with an alcohol swab and after performing the blood glucose test, he wipes the glucometer with an alcohol swab. During an interview on 07/12/23 at 5:16 PM, LPN Unit Manager for the One [NAME] Unit (LPN1) stated that after glucometer use, staff should clean the glucometer with antiseptic bleach wipes and let sit for 1 minute. When asked about the policy and procedure for disinfecting glucometers, LPN1 was unable to locate it. During observation and interview on 07/13/23 at 7:33 AM, on the One South Unit, LPN5 performed a blood sugar test on R11. After performing the blood sugar test, LPN5 cleansed the glucose meter with a Micro-Kill One Germicidal Alcohol Wipe. LPN5 then wrapped the glucose meter in a Micro-Kill One Germicidal Alcohol Wipe and stated he lets it dry and then puts it away. Review of residents receiving blood glucose monitoring provided by the DON on 07/13/23 revealed there were 30 residents in the facility that used shared glucometers, and there were no residents with a confirmed blood-borne pathogen infection, such as Hepatitis B, Hepatitis C, or HIV infection. Observation of medication carts on 07/12/23, 07/13/23, and 07/14/23, revealed germicidals available for cleaning and disinfecting glucometers were: Micro-Kill One Germicidal Alcohol Wipes and Micro-Kill Bleach Germicidal Bleach Wipes. The alcohol wipes kill most pathogens after 1 minute. Continued review of the manufacturer's information revealed the alcohol wipes did not kill clostridioides difficile (C. difficile) spores. The bleach wipes kill most pathogens after one minute, and the C. difficile spore after 3 minutes. Therefore, if a resident has a C. difficile infection, the alcohol wipes were not effective in killing the C. difficile spore placing other residents at risk of contamination. Review of the manufacturer's guidelines entitled, Cleaning and Disinfecting Procedures for the Meter revealed: Cleaning Instructions: Cleaning is the removal of visible dirt and debris. Whenever your glucose meter is dirty, clean the outside of the meter with a new CaviWipes towelette or an EPA-registered disinfecting wipe. The cleaning process does not reduce the risk for transmission of infectious diseases. Disinfection Instructions: The meter must be disinfected between patient uses by wiping it with a CaviWipe towelette or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. The Disinfection process reduces the risk of transmitting infectious diseases if it is performed properly. Review of the facility's policy and procedure, Glucometer Disinfection dated 01/2012, and revised on 05/2023 revealed: Under Policy Explanation and Compliance Guidelines The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected, then the meter should not be used for multiple patients. The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against, at the minimum, HIV, Hepatitis C and Hepatitis B virus. Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Under Procedure the following is included after obtaining blood sampling: Remove and discard gloves, perform hand hygiene prior to exiting room. Reapply gloves is there is visible contamination of the device or if the resident is HIV or Hepatitis B or C positive. Retrieve (2) disinfectant wipes from container. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Discard disinfectant wipe in waste receptacle. Perform hand hygiene. The facility's policy and procedure does not specify whether to use the alcohol wipe or bleach wipe. NJAC 8:39-19.4(a)1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT#: NJ161036, NJ161038 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 2/3/2023, 2/6/2023, 2/7/2023, and 2/14/2023, it was determined that the facility failed to appropriately supervise and monitor a severely cognitively impaired resident (Resident #2), with a known history of wandering, and Aggressive Behavior. The facility failed to ensure Resident #2, who has a known diagnosis of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Syncope, Collapse, Unspecified Lack of Coordination, and Wandering In Diseases Classified plan of care was implemented for monitoring the Resident's location every shift and as needed and to document observed behaviors and attempted intervention in the Behavior log, on 1/4/2023 on the 3-11 shift, at approximately 8:00 p.m. to 8:30 p.m., when the Resident was last seen by Certified Nursing Assistant (CNA #2) and Licensed Practical Nurse (LPN #2) in the dining room, watching television through approximately 9:30 p.m. when Resident #2 was seen again standing in the hallway by the Nurse's station with swelling and bruising to the left side of the face by LPN #1. LPN #1 notified LPN #2, the Resident's assigned Nurse, of the injuries. 911 was called, and the Resident was sent to the emergency room (ER), admitted , and hospitalized with a Subdural Hematoma. The facility also failed to follow its policies titled Abuse, Neglect and Exploitation, Behavioral Health Services, Documentation In Medical Record, and Incident/Accident Reporting. The facility's failure to keep Resident #2 safe on 1/4/2023 placed Resident #2 and all other residents with a history of wandering, aggressive behaviors, and falls who require monitoring/supervision at risk for an injury of unknown origin and in an Immediate Jeopardy (IJ) situation. This IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) on 2/7/2023 at 2:08 p.m. The Administrator was presented with the IJ template that included information about the issue. This Immediate Jeopardy ran from 1/4/2023 when Resident #2 was last seen at approximately 8:00 p.m. to 8:30 p.m., through approximately 9:30 p.m. when LPN #1 saw the Resident with injuries. On 2/14/2023, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating Staff on elopement, behavior monitoring, documenting behaviors, wandering with behaviors, updating the care plan for each Resident, and rounding every two hours. So, the noncompliance remained on 1/4/2023 at a lower scope and severity for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice was identified for 1 of 4 residents ( Resident #2) and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 01/04/2023 and a time of event of 9:30 p.m., revealed the following: On 01/04/2023 at approximately 9:30 p.m., Resident #2 was noted wandering the hallway on the adjacent unit, the Nurse [LPN #1] escorted patient [Resident] back to assigned unit and alerted primary Nurse that patients [Resident's] face noted with swelling and bruising. The FRE also revealed Resident #2 initially stated that someone hit him/her, then later said someone threw something at him/her. Resident #2 was sent to the hospital, admitted with a subdural hematoma, and has not returned to the facility. According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Syncope, and Collapse, Unspecified Lack of Coordination and Wandering In Diseases Classified Elsewhere. According to the Minimum Data Set (MDS), an assessment tool dated 10/13/2022, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 00/15, which indicated the Resident had severely impaired cognition. The MDS also showed Resident #2 only needed supervision with all Activities of Daily Living (ADLs), and the Resident had a wander/elopement alarm. A review of the Resident's Care Plan (CP) initiated on 1/11/2021 revealed under Focus: that Resident #2 is an elopement risk/wanderer AEB (as evidenced by) the Resident wanders aimlessly, Significantly intrudes on the privacy of other residents by entering their room. Under Goal, indicated Resident will not leave facility unattended through the review date. Target Date 1/11/2023. Under Interventions included: Assess for fall risk, Distract Resident from wandering by offering pleasant diversions, structured activities, food conversation, television, book, Monitor location every shift and as needed, Document wandering Behavior and attempted diversional interventions in Behavior log, Wander alert: . Left ankle q (every) shift . Exp 10/2023/Monitor and document placement of wander guard q shift. Further review of Resident #2's CP initiated 09/10/2020, included under Focus: Resident #2 has potential to demonstrate physical and verbal behaviors AEB pushing another resident and yelling r/t (related/to) Confusion and Dementia with Behavioral Disturbance. Under Goal, included: Resident will not harm self or others through the review date, Target Date 1/11/2023. Under Interventions: included: Analyze of key times, places, circumstances triggers, and what de-escalates Behavior and document, Assess and address for contributing sensory deficits, Cognitive Assessment, Evaluate for side effects of medications, Monitor (every shift). Document observed Behavior and attempted interventions, Monitor/document/report to MD (Medical Doctor) of danger to self, and others, Psychiatric/Psychogeriatric consult as indicated, Room change to from 2 North 268B to 2 South 243B, Will continue to encourage and provide opportunities for active participation in acts of interest & socialization w (with)/peers. A review of Resident #2's Incident Reports (IRs) revealed the following: On 3/21/2022 at 3:00 a.m., revealed Under Incident Description (ID),: the Resident was asleep in bed. VSWNL (vital signs within normal limits), no s/s of distress. The Resident slept well until 3 a.m. (3:00 a.m.). The IR showed the Resident was noted walking in the hallway, holding his/her right arm. The Nurse asked the Resident to show the arm, pulled up the long sleeve sweater, and skin discoloration was noted in the Resident's arm, with no opening to the skin and no bleeding. Resident #2 was alert with confusion. The IR further showed a nurse asked Resident #2 what happened, but the Resident could not say. He/She was unable to give a Description. The Supervisor and Physician were notified. The Resident was administered pain medication with positive results. Under Predisposing Situation Factors: revealed wanderer. Under Other Info (information) revealed, Resident is on behavior monitoring due to medication increased to 75mg (milligrams). On 07/15/2022 at 11:23 p.m., revealed Under ID: Nursing Description: Activity aide reported to the nurse resident's Lt [left] hand bruise. No open wound or discharge was noted. Under Resident Description,: . Notes dated 7/16/2022 revealed Conclusion S/P (status/post) (after) Left-Hand Discolored Area: Activity aide called the Nurse as she noted a discolored area to the Resident's left hand; he/she is able to move the hand with no c/o [complaint] of pain at this time. According to the IR, the NP (Nurse Practitioner) was called and made aware and ordered an x-ray of the L left hand to r/o (rule/out) a fx (fracture)/family was made aware of above. The IR also included that Resident #2 was awake and confused to place and time/he/she ambulated freely around the unit. He/She would wander into other residents' rooms and be redirected by the Staff not to go into other residents' rooms. Resident #2 has the tendency to wheel other residents around and out of the dining room. The Resident has been observed hitting the door frame with his/her hand and the handle of the w/c (wheelchair) as he/she exits the dining room. The Resident receives an anticoagulant medication po [by mouth] and is at a higher risk of discoloring his/her skin by hitting an object. Resident #2 is reminded /redirected often by the Nurse and spoken to not to be wheeling or removing anyone from the dining room, but due to the Resident's decreased cognition r/t [related/to] Dementia; he/she continues to wheel residents into the hallway. The IDCP (interdisciplinary) team met and concluded this discolored area was not due to any abuse as Resident #2 has been noted to hit the hand on the door frame, which caused the discolored area to the hand. Further review of the IR showed the X-ray results were negative for a fx (fracture), and the Resident continued to deny any pain. He/She should not be wheeling the residents out of the DR (Dining Room). The CP was reviewed and updated. On 1/4/2023 at 10:43 p.m., written by LPN #2 revealed Under ID: Nursing Description: Unwitnessed occurrence at 9:30 p.m., LPN #1, RN advised LPN #2, LPN that he saw 2 South resident (Resident #2) ambulating by 2N nurse station and brought him/her to 2S (South), that is when her Nurse (LPN #2) notice the left side of [Resident 2's] check [cheek] was swollen with discoloration to the bridge of his/her nose and under his/her left eye. The IR also showed that Resident #2 spoke another language which was translated by the 2N Nurse (LPN #1). According to the IR, Resident #2 was unsure of how the injuries happened. The Resident refused skin assessment and vital signs, and his/her breathing was easy and nonlabored. Staff member stood with the Resident in the 2N dayroom while Dr. [Physician], Nurse Supervisor, and the Resident's family were made aware. A Doctor's [Physician's] order was received to send Resident #2 to the hospital for evaluation. 911 was called, and Resident #2 was transported via [by] ambulance to the Emergency Room. The Resident seemed his/her normal self, alert, confused, and verbally responsive. Able to follow simple commands with little resistance. Under Resident Description: Resident advised she does not know how it happened. A review of Resident #2's Progress Notes (PNs) revealed the following: On 12/1/2022 at 7:44 a.m. written by the Licensed Practice Nurse (LPN #3) revealed, Received elder [Resident] in bed. No s/s [signs/symptoms] of distress[,] [Resident] VSWNL (vital signs within normal limits), no complain [complaint] voiced. [Resident] refused to go back to bed [and was] redirected with negative results. [Resident] stayed in [the 2 North] dining room [and] slept intermittently. Refused x 2 urine collection(s). Wander guard in place. Will continue to monitor. On 12/8/2022 at 6:48 a.m. written by LPN #3 revealed, [Received] Resident in bed asleep no s/s of distress no complain [complaint] voiced. [Resident] stayed in his/her bed until 2 a.m. [2:00 a.m.], then [the] [Resident] wander(ed) in hallways calms (calm), no facial grimacing noted. Resident stayed in [the 2 North] dining room watching a show. The Staff attempted to redirect Resident #2 to his/her room, but the Resident refused. On 12/15/2022 at 8:35 a.m. written by LPN #3 revealed, Received [Resident] sitting in other Resident room eating fruit. [Resident] refused to go back to his/her room, wander in units, get into other residents' ['] room(s), and take other residents' ['] belongings. Several attempts to take supplies from [the] medication cart. Very difficult to redirect and does not follow direction(s). Denied pain or discomfort attempts to sleep in other residents' ['] bed and become [became] aggressive when redirected, yells, scream(s), and curses as per [unit] Staff. After several attempts, [the Resident] agreed to go to [2 North] dining room and stayed there most of [the] shift [,] slept intermittently sitting on a chair. Close monitoring [is] ongoing. Will continue to monitor. On 12/20/2022 at 6:41 a.m., written by LPN #3 revealed, Received [Resident] in bed asleep. [Resident] at 12:30 a.m., [was] noted wandering in [the] 2nd-floor units,[;] [Resident] gets into other residents ['] room and take(s) their belongings, [;] [Resident] became aggressive when this Nurse redirected yells, scream curses as per Staff also attempts to kick, punch and scratch to any staff that redirected, [Resident] is difficult to redirect and does not follow direction, Assist [Resident] to [2 North] dining room. Slept in a chair intermittently. Close monitoring ongoing. On 12/21/2022 at 7:13 a.m. written by LPN #3 revealed, Received [Resident] sitting at the edge of his/her bed. Noted talking with roommate [roommate] in their room, wander[wandering] in units, get into other residents' ['] room(s), and take [taking] other residents' ['] belongings. Several attempts to take supplies from [the] medication cart. [Resident] is very difficult to redirect and does not follow direction. Become aggressive when redirected, yells, screams, and curses as per [unit] Staff. After several attempts, [Resident] agreed to go back to his/her room (and) slept intermittently[,] sitting on a chair. Close monitoring [is] ongoing. Will continue to monitor. On 12/25/2022 at 6:52 a.m., written by LPN #3 revealed, Received [Resident] in bed asleep. [Resident] at 1:30 a.m. [a.m.] noted wandering in [the] 2nd-floor units, [;] [Resident] gets into other residents' room[s] and take[s] their belongings, [Resident] became very aggressive when this Nurse redirected yells, scream, curses as per[unit] Staff also attempts to kick, punch and scratch to any staff that redirected, [Resident] is difficult to redirect and does not follow direction . Assist [Resident] to [2 North] dining room. Slept in a chair intermittently. Close monitoring ongoing. On 12/29/2022 at 7:29 a.m. written by LPN #3 revealed, [Received Resident] in bed asleep no s/s of distress no complain [complaint] voiced. [Resident] stayed in his/her bed until 2 a.m. [2:00 a.m.], then Resident wander(ed) in the hallway calms, no facial grimacing noted. Resident stayed in [2 North] dining room talking with other Resident (s), slept intermittently [in] sitting chair, [and attempted] to redirect to his/her room but refused. Will continue to monitor. On 12/30/2022 at 5:30 a.m. written by LPN #3 revealed, eceived [Received] [Resident] in [2 North] dining room sitting in a chair, no s/s of distress no complain [complaint] voiced. Resident wander(s) in the second-floor unit. Episode x 1 of disturbing other Resident, redirected with positive results, no c/o [complaint] of pain or discomfort, no facial grimacing noted. Resident stayed in the dining room calmly watching . show, slept intermittently sitting in the chair, and was redirected to his/her room with negative results. On 1/3/2023 at 7:44 a.m. written by LPN #3 revealed, Received [Resident] in [2 North] dining room sitting in a chair, no s/s of distress no complain [complaint] voiced. Resident wander(s) in the second-floor unit. Episode x 3 of Resident getting agitated when other [Residents] went to the 2 North dining room, redirected each time with positive results, no c/o [complaint] of pain or discomfort, no facial grimacing noted. Resident stated in the dining room, he/she was calm, watching [2 North] show, slept intermittently sitting in the chair, and was redirected to her room several times with negative results. Refused snacks. Will continue to monitor. On 1/4/2023 at 11:22 p.m., written by the Licensed Practice Nurse (LPN #2), revealed Unwitnessed occurrence- at 8:30 p.m. 2 North Nurse (LPN #1), RN advised 2 South nurse (LPN #2) that he saw 2 South Resident ambulating by 2N (North) nurse station and brought him/her to 2S (South), that is when his/her Nurse (writer) notice the left side of his/her check [cheek] was swollen with discoloration to the bridge of his/her nose and under his/her left eye. The Resident spoke another language and was translated by 2N Nurse (LPN #1). Resident stated he/she is unsure of how it happened. The Resident refused skin assessment and VS (vital signs). Resident break [breath] easy and nonlabored. Staff member stood with Resident in 2N dayroom with Doctor. [Physician], Nurse Supervisor, and family made aware. Received Doctor's order to send Resident out for evaluation. 911 was called and transported [the] Resident out to ER via ambulance. Further review of the PN revealed the Resident seemed to be his/her normal self, alert, confused, and verbally responsive. Able to follow simple commands with little resistance. As requested, a follow-up call was given to the family member and advised her mother/father went to the hospital, and we will follow up with her regarding her mother/father status. On 1/5/2023 at 5:15 a.m., the PNs revealed at 5:00 a.m. A call was placed to the hospital regarding the Resident's status. Resident #2 was admitted DX (diagnosis): Subdural Hematoma. Further review of Resident #2's MR showed no evidence that the CP was followed for monitoring the Resident's location every shift and as needed; to document observed Behavior and attempted intervention and documented in the Behavior log. Also, no evidence was provided during the survey that a behavior log was implemented to document the Resident's Behavior. At the time of the survey, the facility could not provide monitoring sheets or assignment sheets that showed what Staff was assigned to monitor the residents in the dining/day room on 1/4/2023. During an interview on 2/3/2023 at 2:12 p.m., LPN #2 assigned to Resident #2 at the time of the 1/4/2023 incident stated the following: Resident #2 was in the 2 North dining room, the 2 North Nurse, LPN #1, notified me at [the] Nurse's station that something happened to the Resident. LPN #2 explained that he met LPN #1 and Resident #2 in the corridor by the elevator. Resident #2 was sitting on the bench with swelling to the face on the left cheek, [a] bruise by the bridge of [the] nose. He further stated, [the] Resident was calm and could not recall what happened or how it happened. He/she didn't say someone hit me or I fell. The last time I saw him/her was sitting in the dining room at 8:00 p.m.-8:30 p.m. Staff were in there [dining room] monitoring either an aide CNA or a nurse, and other residents were in there, but I don't know what Staff were in there that night. [The] Nurse (RN) brought this to my attention at 9:00 p.m.-9:30 p.m. I don't recall giving him/her meds [medications] or treatment that night. He/She would be sporadic with outbursts. I'm a float nurse . During the same interview, LPN #2 continued to say, Resident #2 got along with his/her roommate. He/She went into other Residents' rooms. I don't recall behaviors with other residents. When asked if there were any altercations with other residents, LPN #2 stated, No, I did not notice any altercation between other residents. The Resident has a wander guard and had it on that night. We monitor all our residents with rounds. The LPN further stated, rounds are done every hour, every half hour, by the Nurse or aide. We redirect [the Resident] from going into other rooms. The CP says to monitor and document; then it should be documented in the Nurse's PN on the computer. As far as I know, there is no behavioral monitoring sheet for him/her. I assessed him/her after the incident, Nursing Supervisor, Doctor [Physician] were made aware, and the family was also made aware. He further stated, between 8:30 p.m.-9:30 p.m.; I don't know where he/she was sitting or where he/she was between this time. I don't know [if] we are supposed to be monitoring all our residents. It's his/her home. He/She walks freely in his/her home. I don't recall the aides' name who worked with me that night. I saw him/her in the dining room sitting in an individual chair between 8:00 p.m.-8:30 p.m. During an interview on 2/3/2023 at 3:23 p.m., when the Surveyor asked about the incident with Resident #2, LPN #1 stated, around 9:00 p.m., after I did med [medication] pass, I saw the Resident standing on the side of the Nurse's station of 2 North. He/She wanders for 24 hours, and then I called over to 2 South Nurse (LPN #1). I didn't hear any yelling prior to seeing the Resident. I didn't hear anything . LPN #1 told the Surveyors that We have schedules of the Staff assigned in the dining room. He stated, it's either [an] aide or Nurse is in the dining room. However, the facility could not provide the assignment schedule during the survey. In the same interview, LPN #1 continued to say, After [the] med pass, I saw him/her, [the] Resident just standing there, took [the] Resident to 2 South, called ambulance and Supervisor. I asked [the] Resident what happened several times, [Resident] gave different answers, [said] bank person coming in, not reasonable. I couldn't understand what he/she was saying; he/she didn't make any sense, [the Resident] story [didn't make any sense]. I called 2 South Nurse (LPN #2) to come [to] get him/her. [Resident #2] just stood there. There was swelling on [the] left side and [a] light bruise on the left cheek area . No crying, [the] Resident said nothing. I just saw [the] face. I didn't check anywhere else. I didn't assess him/her. During a telephone interview on 2/6/2023 at 10:44 a.m., when the Surveyor asked the CNA assigned to Resident #2 about the incident, she stated, I was assigned to the Resident on 1/4/2023; Resident was walking around at 3:30 p.m., at 5:00 p.m. eating in the dining room, then at 8:00 p.m., he/she was sitting, watching TV then I was caring for other residents. Then at 9:40 p.m., Nurse (LPN #2) informed me of the incident. In the same interview, the CNA continued, in [the] dining room; there's the other aide that works on 2 North; I don't know the other aide's name. I was on 2 South with another aide giving care. I only know what I just told you. You need to talk to the DON. I only documented with my statement. When asked by the Surveyor if she documented on the Behavior Log for Resident #2, the CNA stated for monitoring, we do that, but I don't document on the Resident. I only document shower(s) and baths. If assigned to [a] Resident, document every 15 minutes, but I'd have to be told to do it, but I wasn't told to document [the Resident's] Behavior. The Nurse gives me a report on him/her. I don't know if I can see a care plan for him/her. I don't have access to the CP. We [aides] have just ADLs we document. From 8:00 p.m.- 9:00 p.m., I didn't see patient [Resident] because I was providing care. When Surveyor asked the CNA who was monitoring Resident #2 from 8: 00 p.m. through 9:00 p.m., I told [the] Nurse I was giving care. The CNA stated it was only her and the Nurse on the unit. So she assumed the Nurse was monitoring the patient [Resident]. During a second interview on 2/6/2023 at 11:47 a.m., LPN #2 stated, the only documentation I know for residents is the ADL(s) book; I don't know of a behavioral log; as long as the Resident is in the dining room, there should be Staff in there. The Resident was free to walk in this unit, 2 South, and the other unit, 2 North. No one was monitoring him/her. I was not aware. I last saw the Resident at 8:00 p.m.-8:30 p.m. When the Surveyor asked him what does the code 2 mean on the (MAR), the LPN replied, refused. I don't recall where I saw him/her when he/she refused the [9.00 p.m.] medication. If an aide [CNA] went to provide care or take a lunch break, another aide or activities [Staff] would monitor or watch a resident. Another staff should be monitoring him/her. He/She gravitates to the [other] 2 North dayroom. During an interview on 2/6/2023 at 12:30 p.m., in the presence of the Administrator, the DON stated, I know the nurses would monitor behaviors and document in [the] progress notes. The aides [CNAs] would note any behaviors and report it [them] to the Nurse. On the day of [the] incident, [Resident #2] was found in the dining room at 8:30 p.m., [the] last time he/she was seen in [the] dining room. The incident was at approximately 9:30 p.m. The dining room does connect both units. [Resident #2] was seen walking around the unit. Per the documentation, [there was] no aggressive behaviors noted, no need for redirection. In the same interview, the DON stated the Nursing Supervisors and other Nurses stated the patient [Resident] said initially he/she had been beaten up, [someone] hit him/her, then later he/she said someone threw something at him/her, always a different story stayed with the patient [Resident], called the Doctor [Physician], [due to the] extent of injuries, called 911 and sent out to the hospital. It had to have just happened. I don't remember the exact time. Another floor nurse came to help. Both nurses called me. LPN #2 was the Nurse that day. Normally, the Staff, CNAs take turns and monitor residents in the dining room at that time of night. When the Surveyor asked the DON what Staff was assigned to Resident #2 that day/night, the Administrator and DON replied, I can't say who was assigned to the Resident in the dining room that day/night. The DON continued to say, While the patients [residents] are in the dining room, yes, someone, a CNA usually, [is assigned] at that hour or could be a nurse should be in there. During a telephone interview on 2/7/2023 at 11:13 a.m., when asked about the behavioral log, the previous Unit Manager/Licensed Practical Nurse (UM/LPN) stated she created the behavioral log when she was the UM so that Staff could document Resident #2's wandering Behavior. She explained to the Surveyors that the CNAs documented and signed on the Behavior log every shift. When asked where the binder was located and about documenting in the binder, the UM stated the binder was located at the Nurse's station, and the CNAs would document. She said, Resident #2 did not stay in one place, the Resident would wander around the unit, and we [Staff] would divert him/her. If the Resident (Resident #2) went to the elevator or exit, we (Staff) would redirect him/her. Staff will always monitor his/her location during the shift and document any wandering behaviors in the Behavior log. A review of facility policy titled Abuse, Neglect and Exploitation dated 9/2022 revealed the following: Under Policy: included: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under Definitions: included: Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program and students from affiliated academic institutions, including therapy, social and activity programs. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Under Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes but is not limited to hitting, slapping, punching, biting and kicking. It also includes controlling Behavior through corporal punishment.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Under Serious Bodily Injury means an injury involving extreme physical pain; involving substantial risk of death, involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty, requiring medical interventions such as surgery, hospitalization, or physical rehabilitation or an injury resulting from criminal sexual abuse . Under Mistreatment means inappropriate treatment or exploitation of a resident. A review of facility policy titled Behavioral Health Services dated 9/2022 revealed the following: Under Policy: included: It is the policy of this facility that all residents receive care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. Under Policy Explanation and Compliance Guidelines, included: 1. The facility will ensure that each Resident receives the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral health includes a resident's entire emotional and mental health, which includes the prevention and treatment of mental and substance use disorders. 3. The facility must have sufficient Staff who provide direct services to residents with the appropriate competencies and skill sets to provide nursing and related services to assure Resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each Resident determined by resident assessments and individual plans of care and considering the number, acuity, and diagnosis of the facility's resident population. 4. These competencies include but are not limited to knowledge of and appropriate training and supervision for: Caring for residents with mental and psychosocial disorders identified in the facility assessment and implementing non-pharmacological interventions 5. All residents who display or are diagnosed with mental disorders or psychosocial adjustment difficulty, or have a history of trauma or post-traumatic stress disorder will receive appropriate treatment and services to attain the highest practicable and psychosocial well-being . A review of the facility's policy titled Documentation In Medical Record with a revised date 10/2022 revealed the following: Under Policy: included: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Under Policy Explanation and Compliance Guidelines, included: Policy Explanation and Compliance Guidelines: 1. Licensed Staff and interdisciplinary team members shall document all assessments, observations, and services provided in the Resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service but no later than the shift[TRUNCATED]