Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 1 of 22 residents reviewed for accommodation of needs (Resident #96), and was evidenced by the following: On 09/04/25 at 8:07 AM, the surveyor observed Resident #96 in bed. The surveyor observed the Resident's call light pull cord (used to summon staff for assistance) affixed to the upper aspect of the right-side rail, not within his/her reach. The resident stated, There should be a string around here somewhere, but I can't seem to find it, so I can't call for help. The surveyor reviewed the medical record for Resident #96. A review of the admission Record reflected the Resident was admitted to the facility with diagnoses that included but were not limited to; diabetes mellitus (too much sugar in the blood), malignant neoplasm of the breast (cancer of the breast), and osteoarthritis (a degenerative joint disease) of the right knee. A review of Resident #96's Quarterly Minimum Data Set (MDS), an assessment tool dated 8/25/25, revealed Resident #96 had a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed that the resident required maximum assistance from staff for activities of daily living care. A review of Resident #96's Individualized Care Plan (CP) initiated on 7/13/25 had a focus that indicated the resident was at risk for falls, with interventions that included but were not limited to: ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 9/4/25 at 8:18 AM, the surveyor showed the Certified Nursing Assistant (CNA) assigned to Resident #96's care the call light pull cord affixed to the upper aspect of the right-side rail, not within the resident's reach. The CNA confirmed that she should have placed the pull cord within the resident's reach. On 9/8/25 at 12:28 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, and VP of Clinical Operations to discuss the above observations and concerns. A review of the facility's policy, Call Lights, dated 1/25, revealed:Always position the call light conveniently for use and within the reach of the resident. NJAC 8:39-27.1 (a); 31.8 (c) (9)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #NJ 401472 Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to a.) maintain a homelike environment that was clean, safe, and sanitary in 3 out of 24 resident rooms (rooms 114,116, and 123) and b.) ensure that personal clothing items, specifically socks, were returned after being laundered to 5 out of 5 residents who attended the resident council meeting (Resident #25, 67, 70, 83, 85). Additionally, Resident # 96 complained that their socks were not returned after being laundered. This deficient practice was evidenced by the following:1. On 9/2/2025 at 11:06 AM, the surveyor observed in room [ROOM NUMBER] a broken dresser drawer, peeling paint with exposed plaster and sheet rock to the right of the sink. On 9/2/25 at 12:00 PM, the surveyor observed in room [ROOM NUMBER]-2 a portable oxygen tank heavily soiled with rust and a brown substance, with a swarm of flying insects around the oxygen tank. The surveyor observed the wall by the headboard was cracked with exposed sheet rock and was heavily soiled with a brown substance. The armoire was observed to have had broken drawers and large cracks with missing pieces. On 9/4/25 at 8:07 AM, the surveyor observed that the bathroom floor in room [ROOM NUMBER] was heavily soiled with a brown substance around the base of the toilet. Additionally, the toilet was soiled with a yellow substance, and the toilet paper dispenser was heavily rusted. The metal panels on the bottom of the door, both inside and outside, were also heavily soiled with a brown material. On 9/4/25 at 8:43 AM, the surveyor and the Director of Housekeeping (DHK) entered room [ROOM NUMBER] and observed an unpleasant, offensive smell in the bathroom. They noted the floor was soiled with a yellow material, and a large plastic bag was on the floor full of soiled linens, with insects swarming the bag. The DHK and the surveyor also observed that the garbage can was overflowing with trash, which was also scattered on the floor. The surveyor and DHK further observed that in room [ROOM NUMBER]-3 the floor was soiled with food and liquids, and the bedside table had a sticky yellow substance on it with flying insects swarming the area. On 9/4/25 at 8:45 AM, during an interview with the surveyor, the maintenance staff member acknowledged the broken armoire in room [ROOM NUMBER] and the disrepair of the wall behind the bed. The maintenance staff member stated that the facility was aware of the broken dresser and had ordered a new one about 2 months ago and had also ordered new panels for the areas behind the headboards. On 9/4/25 at 8:50 AM, during an interview with the surveyor, the Director of Maintenance (DOM) stated that the facility staff were responsible for listing repairs that needed to be done in the book that was kept at the nurses' station. At that time, the surveyor and DOM reviewed the book and observed that no repairs had been documented for rooms 114, 116, or 123, but confirmed that the concerns in all three rooms should have been addressed. On that same date, at that same time, the DHK confirmed that rooms [ROOM NUMBERS] needed cleaning and that the rooms and bathrooms failed to meet the clean, comfortable, homelike environment standards. 2.) On 9/4/25 at 8:07 AM, during an interview with the surveyor, Resident #96 stated that they were missing all of their socks. The resident further stated that he/she had mentioned it to the housekeeping staff and nursing staff many times, but they still had not returned the socks. On 9/4/25 at 10:30 AM, the surveyor conducted the Resident Council meeting with 5 residents whom the facility chose to attend. All 5 residents stated that they were missing socks. They further stated that they had informed the housekeeping staff and the nursing staff but still had not received their socks back. The 5 residents stated it had been over a month since their socks went missing. On 9/8/25 at 8:10 AM, during an interview with the surveyor, in the presence of the Housekeeping Director (HKD), the housekeeping staff member responsible for laundry stated that several residents had complained to her that their socks were not returned after being laundered. The housekeeping staff stated that she was very busy and had not had time to pair or deliver the residents' socks in over a month. At that time, the HKD also confirmed that the residents had complained to her several times about their missing socks. The surveyor toured the laundry room and observed five large plastic bags full of residents' personal socks, which the DHK and housekeeping staff member acknowledged was unacceptable. On 9/8/25 at 10:05 AM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing, and the VP of Clinical Operations. The VP of Clinical Operations stated that she had observed the five large bags of residents' socks in the laundry room and that it was unacceptable. A review of the facility's policy, Laundry Delivery, reflected .Laundry is done and returned within 24-72 hours . A review of the facility's policy, Handling Clean Linen, dated 9/1/24, reflected .It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary manner . A review of the facility's policy, Safe and Homelike Environment, dated 10/1/24, reflected .In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing residents to use their personal belongings . A review of the facility's policy, Environmental Services Inspection, reflected .It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis. NJAC 8:39 31.4 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to protect resident's right to be free from resident-to-resident physical abuse four of five residents (R)7, R8, R13, and R14) reviewed for abuse out of 14 sampled residents. This had the potential to cause injuries to the residents. Findings include: 1. Review of R7's Face Sheet, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia, dysphagia, major depressive disorder, adjustment disorder, mood disorder, and anxiety disorder. Review of R7's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R7's Care Plan, dated 10/01/24 and located in the residents' EMR under the Care Plan tab, revealed, Staff were called to the room due to R7 pulling on R8's sweater and R8 swung and hit R7 in the face. Interventions put in place the residents were immediately separated, body assessment, police notified, continue to redirect resident and psychological evaluation. Review of R8's Face Sheet, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder-bipolar type, mood disorder, anxiety disorder, adjustment disorder and depressive disorder. Review of R8's quarterly MDS with an ARD of 10/05/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of R8's Care Plan, dated 10/01/24 and located in the residents' EMR under the Care Plan tab, revealed, The resident was screaming for security, staff observed R7 pulling R8's sweater, R8 swung his/her hand to R7's face. Intervention in place the residents immediately separated, body assessment, notified police, stop sign placed on resident's door. Review of the Self-Report Form provided by the facility, dated 10/01/24 revealed, R7 pulled R8's sweater from his/her back and in response R8 swings his/her hand to R7's face. During an interview on 01/27/24 at 12:20 PM with Registered Nurse/Unit Manager (UM) said during the afternoon on 10/02/24 she heard yelling coming from R8's room and went into the room and observed R7 pulling R8's sweater and in response R8 pushed his/her arm and told him/her to get back. UM could not remember if R8 hit R7 anywhere. Staff immediately separated them and completed a full body assessment. A stop sign was placed outside R8's door to prevent other residents from going into the room. This was the first incident UM was aware of with these two residents. 2. Review of R14's Face Sheet, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, bipolar depression, anxiety, borderline personality disorder, adjustment disorder and mood disorder. Review of R14's quarterly MDS with an ARD of 02/09/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS' score of 8 out of 15, which indicated the resident was moderately cognitively impaired. Review of R14's Care Plan, dated 03/04/24 and located in the residents' EMR under the Care Plan tab, revealed, Resident ran over .resident's (R13) foot with wheelchair and he/she reacted by hitting him/her in the head. Interventions in place, residents separated, body assessment completed, police notified, psychological evaluation, and smoking scheduled adjusted to prevent residents from smoking at the same times. Review of R13's Face Sheet, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included schizophrenia, anxiety disorder, major depressive disorder, unspecified mood disorder, and major depressive disorder. Review of R13's quarterly MDS with an ARD of 02/15/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS score of 5 out of 15, which indicated the resident was severely cognitively impaired. Review of the Self-Report Form provided by the facility, dated 03/04/24 revealed the resident-to-resident altercation was substantiated. The incident was witnessed by other residents and staff. During an interview on 01/28/25 at 9:22 AM Certified Nursing Aide (CNA)2 said on 03/04/24 residents were going to smoke area when R14 got too close to R13 and hit his/her foot and the R13 punched R14 in the head. Residents were separated. She was unable to remember what happened after the incident. During an interview on 01/28/25 at 9:31 AM Licensed Practical Nurse (LPN)2 revealed on 03/04/24 R14 was heading to the smoke area and was in a rush trying to be the first to smoke. R14 stepped on R13's toes and he/she punched him/her in the head. Staff separated them and after that they were assigned to different smoke groups. During an interview on 01/28/25 at 2:36 PM the Director of Nursing (DON) stated the investigation between R7 and R8 revealed R7 pulled the sweater of R8 and R8 turned around and swung at R7's face. She said R7 was a wander, who would accidentally enter other resident rooms. They put up door stops on residents' room including R8 to prevent R7 or other residents who may wander from entering their rooms and there being a confrontation. She said the incident between R13 and R14 was substantiated. There were residents and staff that saw R13 hit R14 in the head after he/she ran over his foot. Review of the Facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 01/2025 revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on interview, and record review, it was determined that the facility failed to ensure that the responsible physician supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 1 of 25 residents, Resident #45 was reviewed for physician visits and was evidenced by the following: On 6/23/24 at 10:59 AM, the surveyor observed Resident #45 lying in bed who was noted to be alert and responsive. On 6/24/24 at 9:33 AM, the surveyor reviewed the admission Record for Resident #45 which revealed the resident was admitted to the facility with diagnoses that included but were not limited to end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant); dependence on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly); and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/31/24, reflected that Resident #45 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. A review of the physician's progress notes reflected there was no documented evidence that the physician visited and examined Resident #45 at least every 60 days from March 2024 through May of 2024. On 6/26/24 at 11:10 AM, the surveyor interviewed the Unit Manager (UM) on the first floor, License Practical Nurse (LPN), who has been working in the facility for 10 years. The UM stated, The last progress note from the primary doctor was February 20, 2024. Notes were done for December 2023 and January 2024, but March, April, and May of 2024, I didn't see any notes from the doctor in the computer or the chart. The Nurse Practitioner (NP) does not see this patient. On 6/26/24 at 11:30 AM, the surveyor interviewed the Director of Nursing (DON), Registered Nurse (RN), regarding physician visits, she stated, The doctor comes in and visits his patients frequently and he just started documenting in the computer. The surveyor requested to provide documentation of any notes from the doctor from March-May of 2024. On 6/26/24 at 12:50 PM, the DON acknowledged in the presence of the survey team that Resident's #45 physician did not complete progress notes for three months. The facility did not provide any additional documentation. On 6/26/24 at 1:15 PM, the survey team discussed the above concern with the facility's Licensed Nursing Home Administration (LNHA), DON, [NAME] President of Regional Operations, and two Regional of Clinical Services. On 6/27/24 at 9:25 AM, the surveyor reviewed the most current facility policy and procedure titled, Physician Visits which revealed, The Attending Physician must make visits in accordance with applicable state and federal regulations. NJAC 8:39-23.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R7's profile, located in the Profile tab of the EMR revealed R7 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, type 2 diabetes, and dysphagia. Review of R7's POLST, located under the Miscellaneous tab of the EMR, revealed under the signatures section revealed a physician's stamp denoting the physician's printed name, signature, license number, and DEA (Drug Enforcement Administration), but failed to reveal the physician's phone number, date, and time. During an interview with the SSD1 on 05/23/23 at 3:59 PM, SSD1 acknowledged there was no date and time with the physician's stamp and the document lacked a date indicating when it was signed by the physician. Review of the facility's policy titled Advance Directives:(Revised December 2016), Updated 01/2019, reviewed 12/2022, failed to reveal the facility's policy on completing the POLST. Review of a policy provided by the facility titled Advanced Directives dated 12/22 indicated . Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. NJAC 8:39-9.6(a)(e) Based on interview, record review, and review of facility policy, the facility failed to ensure 1.Code Status and Advance Directives were in place for one (Resident (R) 54) and 2. the physician completed documentation on the POLST for one resident (Resident (R) 7) of eight residents reviewed for Advance Directives and Code Status out of a total sample of 28 residents. This failure increased the risk the residents' wishes would not be followed. Findings include: 1. Review of R54's electronic medical record (EMR) admission Record, located under the Profile tab, indicated the resident was initially admitted to the facility on [DATE] and recently readmitted on [DATE]. Review of R54's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/23 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed R54 was cognitively intact. R54 refused to be interviewed by this surveyor. Review of R54's EMR Care Plan, located under the Care Plan tab, failed to address the resident's code status. Review of R54's paper chart failed to indicate the facility provided the resident with information on Advance Directives, nor did the clinical record contain Code Status documentation. During an interview on 05/25/23 at 8:42 AM, the Director of Nursing (DON) stated the Advance Directives would be placed by Social Services in the resident's clinical record. A request was made for the Advance Directive information provided to R54's and/or the resident's representative. During an interview on 05/25/23 at 8:54 AM, Director of Social Services (DSS) 1 stated she meets with the resident and explains the Advance Directive form and the POLST (Physician Orders for Life Sustaining Treatment) which was on the same form. DSS 1 stated the resident's POLST was then discussed/updated during their care conference. During an interview on 05/25/23 at 12:40 PM, the DON confirmed R54 did not have a POLST on his chart, either electronically or in his paper chart. During an interview on 05/26/23 at 12:25 PM, Licensed Practical Nurse (LPN) 1 and LPN 4 confirmed if a resident did not have a code status posted in the EMR or in the hard paper chart, the resident would be considered a full code status. Review of a policy provided by the facility titled Advanced Directives dated 12/22 indicated . Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of facility reported incidents (FRI), and review of the facility policy, the facility failed to protect the rights of two of eight residents reviewed for abuse (Resident (R) 28 and R63) to be free from physical abuse by R38 out of a total sample of 28 residents. Findings include: 1. Review of R38's Face Sheet in the electronic medical record (EMR) revealed that R38 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (hallucinations and delusions [firmly held beliefs not based on reality]), psychosis (out of touch with reality) and vascular dementia with behavioral disturbances. Review of the EMR medical record revealed that R38 had a history of physical aggressiveness with other residents. Interview on 05/26/23 at 9:40 AM with R38, he denied having any concerns with other residents. 2. Review of R28's Face Sheet in the EMR revealed that R28 was admitted to the facility on [DATE] with a diagnosis of schizophrenia and anxiety. Review of the Progress Note, dated 03/21/23 and located in the EMR, revealed At 12:50 PM, writer was called by CNA [Certified Nursing Assistant] into R28's bedroom. Upon arrival observed R28 sitting in his wheelchair holding the right side of his face. Upon assessment of R28 noted redness to the right side of his face with no swelling or bleeding. R38 was wheeling himself towards his room, stopped by R28. R28 called R38 a Bitch. R38 got up and hit R28 on the right side of his face. R28 denied any pain or distress. Ice pack applied, R28 was educated about not using offensive or abusive language towards his peers and staff. R28's mother, physician, and psych nurse practitioner (NP) made aware. Review of the Reportable Event Record/Report, (initial report) dated 03/21/23, revealed R38 overheard another resident [R28] curse (B---h) and thought it was meant for him. He got upset and punched the other resident [R28] in the face. The residents were separated by staff immediately. Staff noted redness on the cheek of resident [R28] during assessment and ice compress was applied to right cheek as first aid. R38 refused body assessment. Administrator, Director of Nursing (DON), social worker (SW), primary care provider (PCP), Psych nurse NP and families were made aware of the incident. [name of city] police department (PD) and police officers (PO) [name of officers] came and interviewed the staff and the residents. Interventions: 1. Residents were separated right away. 2. Body assessment was done on R28, and no injuries were noted. R38 refused to be assessed. 3. Police department was called, and two police officers (PO) came and interviewed the staff. 4. Administrator, DON, SW, PCP, psych NP, and families were notified of the event. 5. R28 was moved to another room, and 6. Psychological and psychiatric follow-up were ordered for both residents. Review of [name of city] Police Department Investigation Report, dated 03/21/23, revealed On 03/21/23 at approximately 1:23 hour PM, officer [name of officer] was dispatched to [address of the facility] on reports of a dispute. Upon arrival, met with disputing parties R28 and R38. The two male parties had a physical altercation regarding R28 using profanity. While speaking with both parties I did not observe any physical signs of injury. Both parties agreed to respect each other's boundaries. No further police action taken. Review of the Witness Interview Record for R28, dated 03/21/23, revealed R38 hit me. I just want to go to [name of hospital]. Review of the Witness Interview Record for R38, dated 03/21/23, revealed R28 called me a b---h, that is why I hit him. Review of the Witness Interview Record for Registered Nurse (RN) 1, dated 03/21/23, revealed Was in the nursing station and saw security get up from his post and ran towards the male hallway. Then he came back and told me about the incident. I went to room [number] right away and saw [R28] being assessed and left the room to check on the other resident [R38] across the hall. [R38] was in his room sitting on his bed and stated that he got upset when resident [R28] called him a B---h and punched him in the face. Review of the Witness Interview Record for security guard (SG) 2 dated 03/21/23 revealed I was in my post in the hallway near the elevator monitoring the activities on both hallways and the elevator area. I saw [R38] get up from his wheelchair and approach [R28] who was sitting in his wheelchair near the doorway of his room. I ran towards them, but the event happened before I could reach them. [R38] struck [R28] on the face. Review of the Witness Interview Record for Certified Nursing Assistant (CNA) 6, dated 03/21/23, revealed Saw [R38] in wheelchair toward his room. [R38] got up from his wheelchair and punched [R28] in the face when he heard [R28] say b---h. The incident happened very fast and was unable to redirect them before the incident could happen. [R38] hit [R28] on the face. Another CNA was close by and took [R28] inside his room. Review of the Witness Interview Record for CNA 5, dated 03/21/23, revealed Was in the hallway handing another resident a cup of water and saw [R38] get up from his wheelchair when [R28] said something. I ran towards them, but the event occurred before I could reach them. I moved [R28] away from [R38] and took him inside his room. I called the nurse to the room to check on [R28]. Review of the Witness Interview Record for RN 2, dated 03/21/23, revealed I was called to room [number] by CNA to check on [R28] in the room. [R28] was seen in his wheelchair holding the right side of his face. Assessment noted redness on the right side of face. Per CNA, [R38] was wheeling toward his room and overheard [R28] who was sitting by his doorway curse b---h and [R38] got upset. [R38] got up from his wheelchair, punched [R28] in the face. CNA took [R28] inside his room and then called me to the room. Review of Summary of Reportable Event Record/Report, (final report) dated 03/29/23, revealed [R38] was wheeling himself toward his room when he overheard [R28] who was sitting in his wheelchair outside his door, curse (B---h) and thought it was meant for him. [R38] got upset and punched [R28] in the face. Staff separated the residents immediately. [R28] was noted with redness on the right cheek during assessment. Ice compress was applied as first aid. [R38] refused to be assessed. Conclusion: [R38] punched [R28] in the face upon overhearing [R28], curse (B---h) thinking it was meant for him. Interventions: 1. Residents were separated right away 2. Body assessment was done on [R28], and redness was noted on the right cheek and ice compress was applied with relief. [R38] refused to be assessed. 3. [name of city] PD was called, and two POs came to interview the staff and the residents 4. Administrator, DON, SW, PCP, Psych NP and families were notified of the event 5. Resident was moved to another room 6. Psychological and psychiatric follow up ordered for both residents 7. Provide 1:1 interaction during episodes of increased anxiety and redirect him away from noisy environment. Interview on 05/25/23 at 11:23 AM, RN 1, said that R38 is high temper, low tolerance. Went on to state that hitting is his baseline behavior. Unsure that she could recall any details about this specific incident. Interview on 05/25/23 at 12:05 PM, SG 2, said that there were many incidents involving R38. Said that R38 gets easily agitated and tends to focus on his money. Said that he does not recall the incident between R38 and R28 since there is so many incidents with R38. Interview on 05/25/23 at 12:38 PM, the DON said that a behavioral facility in another city was transferred here when that facility closed. R38, along with other residents, were transferred here after that facility was closed. Said that the second floor was turned into a behavior unit, back in August 2022. Said that R38 is usually okay until someone invades his space. Said that R38 is focused on money, and soda. Said that R38 gets irritated when people are talking loudly. Indicated that there has been different interventions put into place for R38 such as room change, psych follow ups right away, psychological follow ups, seating in the dining room far away from the other residents that R38 has gotten into an altercation with, sat a monitor by the elevator to ensure that both halls could be seen at all times, and the monitor could call for help if an incident would occur, and behavioral training with initial training and refreshment courses. Said that something triggers R38, but he was not a continuous threat to self and/or others. Said that the facility staff uses a reward system by using soda, and redirection especially when the events happened in the hallway R38 is redirected back to his room. Confirmed that the facility has not considered placing R38 on a 1:1. Said that psych will either recommend a 1:1 or sometimes the facility staff will place the residents on 1:1. Interview on 05/26/23 at 9:25 AM, R28 was confused and unable to answer questions. Said he was going to the group home today. On 05/26/23 at 10:46 AM, an attempted interview with CNA 5, with a voice mail left; however, by the end of the survey process, no return phone calls. Interview on 05/26/23 at 10:54 AM, RN 2, said that she did not see the actual incident, but wrote a statement due to working that shift. Said that R38 is always focused on money, looking for the bank lady all the time. When you tell R38 something that he does not understand, he gets flustered and goes off. R38 has a bad temper. Interview on 05/26/23 at 11:02 AM, CNA 6, she said that she was sitting in the hallway with R28 at the time of the incident when R38 came rolling down the hallway and jumped up and hit R28 when R38 thought R28 said something to him. The residents were separated. R38 only hit R28 once, and there were no injuries to either resident. This incident was reported to the nurse as well as the supervisors. 3. Review of R63's Face Sheet in the EMR revealed that R63 was admitted to the facility on [DATE] with a diagnosis of dementia, depression, and legal blindness. Review of the Progress Note dated 04/27/23 in the EMR revealed Security staff heard somebody calling for help from room[number], when security went to the room, found [R63] sitting on [R38's] bed bleeding from the left lip. [R38] was standing near the bathroom door. Security called for help and residents were separated. Head to toe assessment was done on [R63] who was bleeding from the lip. [R63's] lip was cleaned with normal saline (NS) and bacitracin applied. There was a cut to the left side of [R63's] lip. Pressure was applied until bleeding stopped and no swelling was noted at this time. [R63] was transferred to another room. When [R63] was interviewed, [R63] reported that [R38] hit him with no reason. [R38] reported that [R63] touch his -ss and hit him on the back and chin, that is why he hit him. [R63] stated that [R63] did not do anything. [name of city] PD was called, came out and interviewed residents of the altercation. The PCP, psych NP, Administrator, DON, SW, and families were informed of the incident. Review of the Reportable Event Record/Report, (initial report) dated 04/27/23, revealed Security staff heard somebody calling for help from room [number], when he went to the room, he found [R63] sitting on resident's bed bleeding from the left lip and resident standing near the bathroom door. Security staff called for help and staff responded right away. When [R63] was interviewed. He reported that resident [R38] hit him for no apparent reason but unable to tell why he was sitting on roommate's bed. [R38 ]reported that [R63] touched his -ss and hit him on the back and chin that is why he hit his roommate. Both residents are from the second-floor behavior unit. Residents were separated right away. Body assessment was completed on both residents and no injuries noted on [R38]. [R63] was noted bleeding from the lip further assessment revealed a cut on the lower lip. Pressure applied till bleeding stopped. No swelling was noted at this time. [R63] was transferred to another room right away. [name of city] PD was called and police officer [name of officer] responded to the center and interviewed the staff and [R38]. PCP, psych NP, Administrator, DON, SW, and families were notified of the event. Seen and evaluated by psych NP, no new recommendations given. Review of [name of city] Police Department, dated 04/27/23, revealed On 04/27/23, dispatched to [facility address] second floor on a report of a simple assault fight between two patients. Upon arrival, met with the caller/nurse [name of nurse] who stated the two patients/residents [R63 and R38] got involved in a fist fight. [R38] advised [name of staff] that he punched[R63] in his face because [R63] hit him first on his back. [R63] was bleeding from his mouth due to the fight. [staff member name] stated [R63 and R38] are mentally ill, and they both were given medical attention after this incident which occurred at 07:30 AM this morning. [R63 and R38] are fine. No further police action was needed. Review of the Witness Interview Record, dated 04/27/23, for R38 revealed He touched my -ss then hit me on the back and chin. Review of Witness Interview Record, dated 04/27/23, for R63 revealed He hit me on the face, I did not do anything. Review of Witness Interview Record, dated 04/27/23, CNA 3, revealed Responded to the room when security called for help with other staff members and found [R63[]sitting on roommates [R38's] bed bleeding from the lip and reported that he was hit by roommate. Roommate [R38] was found standing near the bathroom door. [R38] was assisted out of the room by security right away. Review of Witness Interview Record, dated 04/27/23, for Licensed Practical Nurse (LPN) 3, revealed Responded to the room with other staff members and found [R63] sitting on [R38's] bed bleeding from the lip and reported that [R38] hit him on the face. [R38] was redirected out of the room by security. Body assessment was done on [R63] and noted a cut on lower lip left side with bleeding. Pressure applied. No other injuries noted at this time. Review of Witness Interview Record, dated 04/27/23, for SC 1, revealed Heard somebody calling for help, responding to room and found [R63] sitting on the bed of [R38] bleeding from the lower lip and reported that [R38] hit time on the face. [R38] who was found standing by the bathroom door reported that he was hit first by [R63]. Called for help right away. Residents were separated right away. Review of the Summary of Reportable Event Record/Report, (final report) dated 04/28/23, revealed Security staff heard somebody calling for help from room[number], when he went to the room, he found [R63] sitting on [R38's] bed bleeding from the left lip and [R38] standing near the bathroom door. Security staff called for help and staff responded right away. When [R63] was interviewed, he reported that [R38] reported that roommate [R63] touched his -ss and hit him on the back and the chin that is why he hit his roommate. Both residents are from the second-floor behavior unit. Conclusion: [R38 hit R63] on the face. As a result, [R63] sustained a cut on the left side area of the lower lip. Interventions: 1. Residents were separated right away. 2. Body assessment completed on both residents and no injuries noted on [R38]. [R63] was noted bleeding from the lip further assessment revealed a cut on the lower lip. Pressure applied till bleeding stopped. No swelling was noted at this time. 3. [R63] was transferred to another room right away. 4. [name of city] PD was called and police officer [name of officer] responded to the center and interviewed the staff and [R38]. 5. PCP, psych NP, Administrator, DON, SW, and families were notified of the event. 6. Seen and evaluated by psych NP, no new recommendations given. Interview on 05/25/23 at 11:48 AM, CNA 3, revealed that R38 is focused on money to buy sodas with. She remembers the incident, and residents were separated. Said that this incident (04/27/23) was the only incident that she calls involving R38. Said that R38 said that R63 hit him. Interview on 05/25/23 at 11:41 AM, LPN 3, revealed that this incident, there was a cut observed on R63's lip, residents were separated and R63's room changed. Said that this was over an argument in their room. Said that different interventions have been used for R38 such as medication changes, comfort room, and using sodas as a reward. Interview on 05/25/23 at 11:35 AM, SG 1, said that he was assisting another resident in their room, when he heard R63 screaming. When he went into the room of R63 and noticed that there was blood on the floor, and bed. Said that R63 was sitting on the bed of R38. Both residents were separated. R38 was standing next to the bathroom. Removed R63 from the room and R63 said that he was trying to use the bathroom, and R38 punched him. R38 said that he punched R63. Said that R38 is mostly independent but does focus on his money. Said that the comfort room has been used with R38; however, does get agitated with that. R38 is short tempered. Interview on 05/26/23 at 9:30 AM, R63 was confused and unable to answer questions. Review of undated facility policy titled Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revealed To ensure the proper management of conduct between residents and the staff of [name of facility] to facilitate the resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation. It is the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Responding to allegations of abuse, neglect, exploitation, or mistreatment the reports of all investigations to the Administrator or his or her designated representative and to other officials in accordance with state law, within five working days of the incident. The facility must have evidence that all alleged violations are thoroughly investigated. NJAC 8:39-4.1(a)5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, staff interviews, record review, and policy review, the facility failed to ensure the right of one resident (Resident (R) 91) one resident to be free from physical restraints imposed for the purposes of convenience out of a total sample of 28 residents. Findings include: Review of R91's Face Sheet in the Profile tab, located in R91's electronic medical record (EMR), revealed R91 was admitted to the facility on [DATE]. Review of R91's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 05/15/23, revealed R91 had a Brief Interview for Mental Status(BIMS) score of 99, indicating severe cognitive impairment. A review of the facility reported incident (FRI), dated 05/10/23 and completed by the Administrator, revealed on 05/09/23 at 5:30 PM, the head of security (SG)2 observed the following: security Guard (SG) 4 assigned to R91 was in R91's room. R91 was in a wheelchair and the shirt R91 was wearing was draped over the back of the wheelchair. SG4 informed SG2 that R91 kept getting out of his wheelchair so SG4 placed R91's shirt over the wheelchair. The report further revealed SG2 was removed from R91's room and sent home and was suspended pending the completion of the investigation. During an interview on 05/25/23 at 1:07 PM, the Director of Nursing (DON) stated the SG2 was making rounds on 05/09/23 when he went into R91's room and observed SG4 in R91's room sitting. SG4 was assigned to watch R91 1:1 (staff was performing continuous observation of resident to prevent resident from self-harm). R91 was wearing a shirt that was tucked over the back of his wheelchair. SG4 stated he restrained R91 because R91 kept getting out of his wheelchair. The DON further stated SG4 had since been terminated. The DON admitted SG4 was using R91's shirt as a restraint. During an interview on 05/25/23 at 11:59 AM, SG2 stated he was doing his rounds on 05/09/23 at about 5:50 PM when he observed SG4 in R91's room. SG4 was on his phone and was sitting with his foot on another chair, and R91 was in his wheelchair, not moving, with the shirt he was wearing tucked over the back of the wheelchair. SG4 stated R91 kept trying to get out of his wheelchair and had to be restrained. SG2 stated he immediately removed SG4 from the situation, sent him home pending investigation. SG4 was later terminated. SG2 stated he and all his security staff had abuse prevention training. Observation of R91 on 05/23/23 at 12:46 PM revealed resident was confused, agitated, and moved constantly. R91 had a continuous 1:1 security monitor. Observation on 05/24/23 at 1:47 PM revealed R91 during activities with 1:1 monitor. Review of facility's policy titled Abuse Prevention Program revealed .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy further provided, .the facility will ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. NJAC 8:39-4.1(a)6

Based on record review, interview, review of Facility Reported Incidents (FRI), and policy review, the facility failed to ensure that a thorough investigation was documented regarding two resident-to-resident altercations involving one resident (Resident (R) 38), out of a sample of 28 residents. There was no evidence that the facility interviewed other current residents regarding the allegations. Findings include: 1. Review of the Reportable Event Record/Report (initial report) dated 03/21/23 revealed R38 overheard another resident [R28] curse (B---h) and thought it was meant for him. He got upset and punched the other resident [R28] in the face. The residents were separated by staff immediately. Staff noted redness on the cheek of resident [R28] during assessment and ice compress was applied to right cheek as first aid. [R38] refused body assessment. Administrator, Director of Nursing (DON), social worker (SW), primary care provider (PCP), Psych nurse, nurse practitioner (NP) and families were made aware of the incident. [name of city] police department (PD) and police officers (PO) [name of officers] came and interviewed the staff and the residents. Interventions: 1. Residents were separated right away. 2. Body assessment was done on [R28], and no injuries were noted. [R38] refused to be assessed. 3. Police department was called, and two police officers (PO) came and interviewed the staff. 4. Administrator, DON, SW, PCP, psych NP, and families were notified of the event. 5. [R28] was moved to another room, and 6. Psychological and psychiatric follow-up were ordered for both residents. Review of the Witness Interview Record for R28 dated 03/21/23 revealed [R38] hit me. I just want to go to [name of hospital]. Review of the Witness Interview Record for R38 dated 03/21/23 revealed [R28] called me a b---h, that is why I hit him. During further review of the FRI, there was no evidence of other residents being interviewed regarding the abuse allegation. 2. Review of the Reportable Event Record/Report, (initial report) dated 04/27/23, revealed Security staff heard somebody calling for help from room[number], when he went to the room, he found [R63] sitting on resident's bed bleeding from the left lip and resident standing near the bathroom door. Security staff called for help and staff responded right away. When [R63] was interviewed. He reported that resident [R38] hit him for no apparent reason but unable to tell why he was sitting on roommate's bed. [R38] reported that [R63] touched his -ss and hit him on the back and chin that is why he hit his roommate. Both residents are from the second-floor behavior unit. Residents were separated right away. Body assessment was completed on both residents and no injuries noted on [R38]. [R63] was noted bleeding from the lip further assessment revealed a cut on the lower lip. Pressure applied till bleeding stopped. No swelling was noted at this time. [R63] was transferred to another room right away. [name of city] PD was called and police officer [name of officer] responded to the center and interviewed the staff and [R38]. PCP, psych NP, Administrator, DON, SW, and families were notified of the event. Seen and evaluated by psych NP, no new recommendations given. Review of the Witness Interview Record dated 04/27/23 for R38 revealed He touched my -ss then hit me on the back and chin. Review of Witness Interview Record dated 04/27/23 for R63 revealed He hit me on the face, I did not do anything. Interview with the Director of Nursing (DON) on 05/25/23 at 12:38 PM, said that other residents would only be interviewed if they were witness to the event. Does not recall in either incident if other residents were interviewed; however, confirmed no evidence in the report that other residents were interviewed. Cross Reference: F600-Free from abuse Review of undated facility policy titled Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revealed To ensure the proper management of conduct between residents and the staff of [name of facility] to facilitate the resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation. It is the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Responding to allegations of abuse, neglect, exploitation, or mistreatment the reports of all investigations to the Administrator or his or her designated representative and to other officials in accordance with state law, within five working days of the incident. The facility must have evidence that all alleged violations are thoroughly investigated. NJAC 8:39-4.1(a)5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to make a referral for a Level II Preadmission admission Screening and Resident Review (PASARR) evaluation for one (Resident (R) 54) of three sampled residents reviewed for PASARR Level II evaluations in a total sample of 28 residents after receiving new diagnoses of psychosis (out of touch with reality) and delusional disorder (firmly held beliefs not based in reality). Findings include: Review of R54's electronic medical record (EMR) admission Record, located under the Profile tab, indicated the resident was initially admitted to the facility on [DATE] with a diagnosis of COVID-19 and readmitted on [DATE]. Review of a document provided by the facility titled, NEW JERSEY DEPARTMENT OF HUMAN SERVICES Pre-admission SCREENING AND RESIDENT REVIEW (PASRR) LEVEL I SCREEN, dated 01/17/19, indicated R54 had a negative PASRR. The document revealed R54 had no history of a major mental illness. Review of R54's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/23 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed R54 was cognitively intact. The assessment indicated R54 had a diagnosis of psychotic disorder and no primary diagnosis of dementia. Review of R54's EMR Nurse Practitioner Progress Notes, located under the Prog (Progress) Notes tab and dated 05/21/23, indicated R54 had a diagnosis of unspecified psychosis and major depressive disorder. Review of a document provided by the facility titled, Wayne Behavioral Services, dated 08/10/22, indicated R54 was newly diagnosed with major depressive disorder and psychosis. During an interview on 05/24/23 at 9:09 AM, Licensed Practical Nurse (LPN) 2 who was also the first floor Unit Manager confirmed she could only locate the 01/17/19 PASRR. During an interview on 05/24/23 at 2:03 PM, Social Services Director (SSD) 2 stated R54 was followed by mental health services. During an interview on 05/24/23 at 2:42 PM, SSD 1 and SSD 2 stated R54 came into the facility with the diagnosis of major depressive disorder, and it was not until the state came in and conducted an audit of the second floor (a secured behavioral unit) and ordered the resident be transferred to the first floor. DDS1 stated R54 did not meet the criteria for a Level II PASRR review since the resident had a psychological evaluation in August 2022. An interview was conducted on 05/26/23 at 8:24 AM, the Director of Nursing (DON) stated R54 was hospitalized and came back with the new diagnosis of major depressive disorder in May 2022. The DON was asked for the hospital records which would indicate this information. No hospital documents were presented during the survey. Review of a policy provided by the facility titled Preadmission SCREENING AND RESIDENT REVIEW (PASRR) OVERVIEW dated 01/2019 .Specialized Services are determined by the PASRR Level II Authority and outlined in the PASRR Level II determination. NJAC 8:39-5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure one resident (Residents (R) R54) and/or their representative was invited to participate in their quarterly care plan meetings out of a total sample of 28 residents. This failure would affect all residents and/or representatives who were scheduled for quarterly care plan meetings. Findings include: Review of R54's electronic medical record (EMR) admission Record, located under the Profile tab, indicated the resident was initially admitted to the facility on [DATE] and recently readmitted on [DATE]. Review of R54's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/23 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed R54 was cognitively intact. Review of R54's EMR and hard paper chart failed to contain information that R54 and/or his representative were invited to his care conferences. During an interview on 05/23/23 at 11:31 AM, R54 stated he was not invited to his care conferences. During an interview on 05/24/23 at 2:03 PM, Director of Social Services (DSS) 2 stated she did not invite R54 to his care conferences but did invite his family members. DSS 2 was unable to show where the resident and/or his family members were invited to the resident's care conference in the EMR. During an interview on 05/26/23 at 1:40 PM, the Director of Nursing (DON) stated R54 and/or his representatives were to be invited to the care conferences and this was to happen either quarterly or when there was a significant change in the condition of the resident. The DON confirmed the invitation process was to be documented in the clinical records. Review of a policy provided by the facility titled Care Planning, dated 11/2018, indicated .The resident, the resident's family and/or the resident's legal guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. NJAC 8:39-4.1(a)3 NJAC 8:39-11.2(h)

Based on observation, interview, and facility policy review, the facility failed to ensure one of 32 residents (Resident (R)25) reviewed during initial pool did not have an ill-fitting mattress. This failure had the potential to create an entrapment risk. Findings include: During an observation on 05/23/23 at 11:49 AM, R25 was noted to be in bed. The mattress was snug to the foot of the bed with a large gap at the head of the bed. R25's pillows and head were noted to be hanging off the mattress into the gap. During an observation and interview on 05/25/23 at 9:45 AM with the Regional Maintenance Director (MD) in R25's room, the mattress was centered on the bed frame with a gap at both the head and foot of the bed. When asked to estimate the foot of the bed gap, MD stated, Maybe five inches. Measurement marks were completed using paper at the foot of the bed and repeated at the head of the bed. MD stated that the gap is an entrapment risk. There is supposed to be foam block or the bed needs to be closed. MD verified no foam block was present and demonstrated how the frame could be / was extended and could be collapsed. When asked if any staff had advised the maintenance department of the gapping of the mattress, MD responded, Nobody has said anything. When asked how maintenance was to be notified of issues, MD stated, Nursing pages me, or calls by walkie talkie, or gets the receptionist to page me. At 9:55 AM with MD present and observing, the gap for the foot of the bed was 6.25 inches and the head of the bed was 4.5 inches, for a total gap of 10.75 inches if the mattress was flush to the foot of the bed. In an interview on 05/25/23 at 11:45 AM, R25 stated he put the put the pillows in the gap and that he had put pillows back there every day since he's been here. During an interview on 05/26/23 at 2:05 PM with the Director of Nursing (DON) and [NAME] President of Operations (VPO) regarding expectations about mattress fitting bed frames, Do you have an expectation about a mattress and bed frame? the DON stated, Expect mattress to fit frame. In an interview on 05/26/23 at 2:15 PM, MD stated The policy was in place but not being done. Review of the undated facility policy titled Bed Safety Policy showed: Monthly bed inspection: -Ensure that the power cord is in good conditions [sic] (not frayed). -lnspect the metal frame for any cracks. -Ensure that the mattress is not ripped or stained. -Ensure that head and foot boards are free of splinters. -Ensure that beds are evaluated for gaps that may increase a resident's risk of entrapment. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure that one of one resident (Resident (R) 42) reviewed for bed rail use out of a total sample of 28 residents had required documentation completed prior to the use of the side rails. Findings include: Review of R42's Face Sheet in the electronic medical record (EMR) revealed that R42 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, and Alzheimer's. Review of the Progress Notes, dated 10/14/22 to 05/25/23 in the EMR, revealed no evidence of documentation regarding side rails, such as an entrapment assessment, consent, physician orders, alternative interventions used and/or discussion of risks vs benefits. During observation on 05/24/23 at 8:30 AM and at 1:15 PM, revealed R42 was lying in her bed with bilateral upper side rails raised in the up position, with the right side padded with a pool noodle. On 05/25/23 at 8:39 AM, revealed R42 was lying in her bed with bilateral upper side rails raised in the up position, with the right side padded with a pool noodle. Interview on 05/24/23 at 4:00 PM, the Director of Nursing (DON), confirmed that R42's EMR did not show any evidence of side rail documentation and was unsure why the bilateral upper side rails were raised. Interview on 05/25/23 at 8:45 AM, Licensed Practical Nurse (LPN) 1, confirmed that R42 was a transfer from the second floor, with the bed that came with the side rails. LPN1 stated that the side rails were up for safety reasons, since R42 was a fall risk. The pool noodle was on the right-side rail because R42 preferred that side. LPN1 denied that R42 had had any entrapment issues from the use of the side rails. LPN1 confirmed that before using side rails, an assessment should be completed. Review of the facility policy titled Proper Use of Side Rails, revised 10/19, revealed The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. bed mobility; b. ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. risk of entrapment from the use of side rails; and d. that the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. 6. Less restrictive interventions that will be incorporated in care planning include: a. providing restorative care to enhance abilities to stand safely and to walk; b. providing a trapeze to increase bed mobility; c. placing the bed lower to the floor and surrounding the bed with a soft mat; d. equipping the resident with a device that monitors attempts to arise; e. providing staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom; and/or f. furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information. 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 8. The risks and benefits of side rails will be considered for each resident. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 10. Manufacturer instructions for the operation of side rails will be adhered to. 11. The residents will be checked periodically for safety relative to side rail use. 12. If side rail use is associated with symptoms of distress, such as screaming or agitation, the residents' needs, and use of side rails will be reassessed. 13. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). 14. Side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders but are still restraints if they meet the definition of a restraint. 15. Facility staff, in conjunction with the attending physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions. NJAC 8:39-27.1(a) NJAC 8:39-31.8(c)1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R91's Face Sheet in the Profile tab, located in EMR revealed R91 was admitted to the facility on [DATE]. Review of R91's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 05/15/23, revealed R91 had a Brief Interview for Mental Status (BIMS) of 99, indicating severe cognitive impairment. A review of the facility reported incident (FRI), dated 05/10/23 and completed by the Administrator revealed on 05/09/23 at 5:30 PM, the head of security (SG2) observed the following: security Guard (SG)4 assigned to R91 was in R91's room. R91 was in a wheelchair and the shirt R91 was wearing was draped over the back of the wheelchair. SG4 informed SG 2 that R91 kept getting out of his wheelchair so SG4 placed R91's shirt over the wheelchair. The report further revealed SG4 was removed from R91's room and sent home and was suspended pending the completion of the investigation. Cross Reference: F604 Right to be free from Physical Restraint. Review of the facility's investigation in the incident revealed the summary of reportable event was faxed to the state survey agency on 05/19/23, 10 days after the incident occurred. During an interview on 05/25/2023 at 1:07 PM, the DON admitted the facility failed to send the summary of the reportable event within 5 working days of the incident. The DON stated she was waiting for the police report. Based on interview, record review, and policy review, the facility failed to ensure allegations of abuse / neglect and/or the investigations were submitted to the New Jersey Department of Health (NJDOH) within the time limits of the policy and federal regulation for five of eight residents (Resident (R)14, R25, R91, R38, and R28) reviewed for abuse in a total sample of 28 residents. Findings include: 1. Review of R14's admission Record from the facility electronic medical record (EMR) Profile tab showed a facility admission date of 04/04/23 with medical diagnoses that included schizophrenia (hallucinations and delusions). During an interview on 05/23/23 at 2:52 PM, R14 stated that 15 staff jumped on him and sprayed [NAME] in his eyes. The Administrator was advised of R14's allegation on 05/23/23 at 4:30 PM and stated they (facility staff) were unaware of the allegation previously. On 05/25/23 at 9:15 AM the Administrator was asked for any documentation related to the allegation. On 05/25/23 at 11:00 AM, the Administrator provided two printed Progress Notes (from the EMR) and stated, This is my investigation. Review of the Progress Notes revealed a note dated 05/23/23 at 8:40 PM by a Registered Nurse (RN) that stated R14's allegation, that a body assessment was completed, and the psychiatric Nurse Practitioner (NP) was advised; the second note was dated 05/25/23 at 10:35 AM by Social Services that stated she met with R14 regarding the allegation (re-stated in note) and that the resident stated it happened at a hospital where he was told to leave it alone. On 05/25/23 at 1:35 PM the Administrator was asked if R14's statement had been considered an allegation of abuse and responded Asked [named the Director of Nursing (DON)] and she reports everything. She [DON] felt very strongly that this was a behavior. When clarified about the investigation, the Administrator stated, We did an investigation, well, we asked psych to eval him and the social worker talked to him [R14] and found out it happened at [hospital name]. We didn't feel it was an allegation of abuse. During an interview on 05/25/23 at 3:15 PM regarding the decision not to report R14's statement as an allegation of abuse, the DON stated, It's because the history and the story itself. He [R14] said 15 people maced him, we checked him and no evidence, and we interviewed him later and he said it happened elsewhere. Basing [sic] on the report itself 15 people jumped on him, I'm not saying - I'm being honest because if he says 15 people how he didn't even tell us, he wasn't able to tell us how and where. We did call the psychiatrist though and he did follow up. Once again, based on the story - we have to investigate first because the policy says okay so, if there is an allegation of abuse - you investigate first you don't just jump [clarified jump was to call in to the State Agency] you have to get the whole story. When asked if anyone had interviewed R14 on 05/23/23, the DON responded, He was actually interviewed but the nurse did not document. They did interview, they did not document, I'm just being honest. On 05/26/23 at 8:50 AM, the DON advised that she did call R14's allegation into the State Agency, It's late but it's called in. Review of the file regarding the report to the NJDOH provided by the DON showed handwritten notes that the police department was notified on 05/25/23 at 4:30 PM, and the NJDOH was notified on 05/25/23 at 4:40 PM. 2. Review of R25's admission Record from the EMR Profile tab showed a facility admission date of 12/23/22 with medical diagnoses that included dementia, glaucoma, heart failure, hypertension, and legal blindness. Review of R25's Progress Notes from the EMR tab of the same revealed: Effective Date: 02/16/2023 18:44 [6:44 PM] Type: . Change of Condition Situation: Found resident sitting down on the floor on morning shift . Assessment: Vital signs stable, complain of back pain . Effective Date: 02/20/2023 09:59 Type: General Note Note Text: @ [at] 7:00 am . Resident c/o [complained of] pain to L [left] hip 9/10 scale with slight movement during morning care, screaming of pain while turning to the side. . ordered to send resident to ER [emergency room of named hospital] for further evaluation. @8:30 resident was picked up by stretcher x 2 person assist . Effective Date: 02/20/2023 13:14 [1:14 PM] Type: General Note Note Text : @1:15PM received a phone call from [NP name] . resident will be admitted with multiple fractures on the pelvic area. Review of facility NJDOH incident report showed the incident happened 02/16/23, one x ray report on 02/16/23 showed a negative acute examination except for right pubic bone fracture, and an x ray on 02/17/23 showed an old fracture of the right pubic ring; the resident was sent to the hospital on [DATE] and the report to the NJDOH was dated 02/21/23. The five-day investigation summary was dated 03/01/23 but the fax to the NJDOH was dated and sent on 03/03/23. During an interview on 05/24/23 at 4:23 PM regarding the reporting timeline, the DON stated the state agency and state Ombudsman were notified on 02/21/23 after the hospital admission. When asked about the 03/01/23 date on the summary, and the fax receipt date of the investigation summary being faxed to the NJDOH, the DON responded, Well the fax machine dates were off. Upon reviewing the handwritten date on the fax face page of 03/03/23, the DON stated, Oh, well, I guess I sent it in on that date. When asked if that was within the five-day investigation timeline, the DON responded, Well I sent it on 3/3 so not five days. 4. Review of R38's Face Sheet in the Electronic Medical Record (EMR) revealed that R38 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder, psychosis and vascular dementia with behavioral disturbances. 5. Review of R28's Face Sheet in the EMR revealed that R28 was admitted to the facility on [DATE] with a diagnosis of schizophrenia and anxiety. Review of the Reportable Event Record/Report, (initial report) dated 03/21/23, revealed R38 overheard another resident [R28] curse (B---h) and thought it was meant for him. He got upset and punched the other resident [R28] in the face. The residents were separated by staff immediately. Staff noted redness on the cheek of resident [R28] during assessment and ice compress was applied to right cheek as first aid. [R38] refused body assessment. Administrator, Director of Nursing (DON), social worker (SW), primary care provider (PCP), Psych nurse NP and families were made aware of the incident. [name of city] police department (PD) and police officers (PO) [name of officers] came and interviewed the staff and the residents. Interventions: 1. Residents were separated right away. 2. Body assessment was done on [R28], and no injuries were noted. [R38] refused to be assessed. 3. Police department was called, and two police officers (PO) came and interviewed the staff. 4. Administrator, DON, SW, PCP, psych NP, and families were notified of the event. 5. [R28] was moved to another room, and 6. Psychological and psychiatric follow-up were ordered for both residents. Review of Summary of Reportable Event Record/Report, (final report) dated 03/29/23, revealed [R38] was wheeling himself toward his room when he overheard [R28] who was sitting in his wheelchair outside his door, curse (B---h) and thought it was meant for him. R38 got upset and punched [R28] in the face. Staff separated the residents immediately. [R28] was noted with redness on the right cheek during assessment. Ice compress was applied as first aid. [R38] refused to be assessed. Conclusion: [R38 punched R28] in the face upon overhearing [R28], curse (B---h) thinking it was meant for him. Interventions: 1. Residents were separated right away 2. Body assessment was done on [R28], and redness was noted on the right cheek and ice compress was applied with relief. [R38] refused to be assessed. 3. [name of city] PD was called, and two POs came to interview the staff and the residents 4. Administrator, DON, SW, PCP, Psych NP and families were notified of the event 5. Resident was moved to another room 6. Psychological and psychiatric follow up ordered for both residents 7. Provide 1:1 interaction during episodes of increased anxiety and redirect him away from noisy environment. Review of the Fax sheet, dated 03/29/23, revealed Attached please find summary of reportable. Review of the Email, dated 03/29/23, revealed Summary of Reportable Event Record/Report for event dated 03/21/23 was submitted on 03/29/23. Interview on 05/25/23 at 12:38 PM, the DON said that she notifies the State Survey Agency (SSA) As soon as possible (ASAP). She gets the whole story first then reports, usually on the day of the incident. Said that the initial report is within 24 hours. Said that the summary is completed by five days. Said that sometimes it takes longer than five days to complete the summary and send into the SSA due to waiting on police reports, and/or witness statements. Confirmed that the summary report was greater than five days when it was sent to the SSA. Review of undated facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure, revealed, To facilitate efforts to prevent, detect, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation. Alleged violations under 42 CFR 483.12 (c) immediately (for alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) but not later than: i. Two hours if the alleged violation involves abuse or results in serious bodily injury. ii. 24 hours-if the alleged violation does not involve abuse and does not result in serious bodily injury. iii. Results of all investigations of alleged violations-within five working days of the incident. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: a. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported in the proper timeframe pursuant to this policy. b. Have evidence that all alleged violations are thoroughly investigated. c. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. d. Report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with state law, including to the State Survey Agency, within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure three of three residents and their representatives (Resident (R) 25, R28, and R161) reviewed for facility initiated emergent hospital transfer, from a total sample of 28 residents, were provided with written transfer/discharge notice. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: 1. Review of R14's admission Record from the facility electronic medical record (EMR) Profile tab showed a facility admission date of 04/04/23 with medical diagnoses that included schizophrenia, hepatic encephalopathy, and chronic obstructive pulmonary disease (COPD). Review of R14's EMR Progress Notes tab showed on 02/20/23 at 9:59 AM .Resident c/o [complained of] pain to L [left] hip 9/10 scale with slight movement during morning care, screaming of pain while turning to the side. PCP [Primary Care Physician].made aware and ordered to send resident to ER [emergency room] . for further evaluation. @ [at] 8:30 [AM] resident was picked up by stretcher x 2 person assist and left awake, alert and verbally responsive. and at 1:39 PM a Progress Note that the daughter was called and updated that R14 had been admitted to the hospital. Further review of the EMR Progress Notes, Assessments, and Misc [Miscellaneous] tabs did not show evidence R14 and his RR was provided with a written notice of transfer with all the required information. A request for the documentation of written transfer notice was made on 05/23/23 at 12:30 PM with the RNC. During an interview on 05/24/23 at 2:50 PM regarding the process for emergent transfers, Licensed Practical Nurse (LPN) 4 stated, We call the MD and update, get an order to send to hospital. We do a New Jersey Transfer Form [clarified and showed tab in EMR] then get all the papers [clarified to be legal paperwork, POLST [physician's order for life sustaining treatment], studies like lab / x ray, MAR/TAR [Medication Administration Record/Treatment Administration Record], physician orders and face sheet]. Then we call the hospital to give report, then call the ambulance or 911, and alert the family by telephone. When asked if anything written was given to the resident regarding the transfer, LPN4 responded If they are alert, we will tell them. On 05/24/23 at 2:55 PM, LPN4 was asked what happened to all the paperwork and responded, It all goes into the yellow envelope and goes to the hospital with them. This was clarified by asking if the envelope was for the resident or for the hospital, LPN 4 stated, It is for the hospital. In a telephone interview on 05/24/23 at 3:44 PM regarding receipt of a written notice of transfer with the required information, R14's RR stated, No, I got called. I never got anything written. I never got an incident report either. When an explanation that incident reports are often used for quality improvement in a facility, R14's RR stated, Oh, I used to get them from the other facility all the time. When clarified as to what was on the incident report, such as where the resident was being transferred to, the reason for transfer, and the Ombudsman contact information, R14's RR responded, Yeah - that is what I got. When queried if she had ever received a form like that for R14's transfer on 02/20/23, the RR stated, No, I've never received anything. Verified bed hold policy - No, not received that either. A request for the documentation of written transfer notice was made on 05/23/23 at 12:30 PM with the RNC. A form was provided Notice of Emergency Transfer on 05/25/23 at 8:45 AM that contained the date of transfer, resident name, the facility transferred from and to, and the reason for transfer; and the Ombudsman information for an appeal. In a follow-up interview on 05/25/23 at 1:30 PM with LPN4 and LPN1, they reviewed the Notice of Emergency Transfer form and LPN4 stated she was not familiar with the form. LPN1 stated, We fill that out and one goes to the social worker and one to the chart. When asked if the resident or RR received a copy, LPN1 stated, No, nothing to resident or family. 2. Review of R28's admission Record from the EMR Profile tab showed a facility admission date of 08/10/22 with medical diagnoses that included schizophrenia, acute and chronic respiratory failure with hypoxia (low oxygen levels), convulsions, , major depressive disorder, anxiety, glaucoma, and dysphagia. Review of R28's EMR Progress Note tab showed on 02/21/23 at 11:26 PM that .4:50 PM Resident, [sic] difficult to arouse and not able to take his medications. MD [physician] notified and he ordered to transfer to . hospital for evaluation. 11:05 PM .Hospital ER was called and was told resident admitted with Dx: [diagnosis] hypoxia. Further review of R28's EMR Progress Notes, Assessments, and Misc tabs did not showed evidence of a written notice of transfer or discharge was provided to the resident or RR. A request for the documentation of written transfer notice was made on 05/23/23 at 12:30 PM with the RNC. A form was provided Notice of Emergency Transfer on 05/25/23 at 8:45 AM that contained the date of transfer, resident name, the facility transferred from and to, and the reason for transfer; and the Ombudsman information for an appeal. 3. Review of R161's admission Record from the EMR Profile tab showed a facility admission date of 11/18/22, a discharge date of 01/30/23, with diagnoses that included pneumonia, encephalopathy, hypotension, schizoaffective disorder - bipolar type, liver disease, and spondylosis. Review of R161's EMR Progress Notes tab showed on 12/17/22 at 9:17 AM Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs . Pulse: P 115 - 12/17/2022 09:18 Pulse Type: Irregular - new onset . Recommendations: Primary MD made aware and orders to send resident for further evaluation. Review of R161's EMR Census tab showed R161 status was discharged to the hospital on [DATE]. A request for the documentation of written transfer notice was made on 05/23/23 at 12:30 PM with the RNC. A form was provided Notice of Emergency Transfer on 05/25/23 at 8:45 AM that contained the date of transfer, resident name, the facility transferred from and to, and the reason for transfer; and the Ombudsman information for an appeal. An attempt to contact R161's RR failed. R161 and the RR passed away within weeks of each other. During an interview on 05/26/23 at 2:05 PM with the Director of Nursing (DON) and [NAME] President of Operations (VPO) the query of 'Had anyone identified that written transfer and discharge notices are not being sent to the RR? The DON responded that that would fall to social services or admissions. When asked about an expectation of the form being provided to the resident and RR, the DON responded, Expectation is that everybody who goes out [to the hospital] should be completed the notification should be given to the resident or family member. Review of the facility policy titled Transfer or Discharge Notice, reviewed 02/2023, showed: . 3. The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge; b .The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. A statement of the resident's rights to appeal the transfer or discharge, including: (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; d. The facility bed-hold policy; e. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; . NJAC 8:39-4.1(a)31 NJAC 8:39-5.3(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility failed to ensure three of three residents (Resident (R) 25, R28 and R161) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information from a sample of 28 residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: 1. Review of R14's admission Record from the facility electronic medical record (EMR) Profile tab showed a facility admission date of 04/04/23 with medical diagnoses that included schizophrenia, hepatic encephalopathy, and chronic obstructive pulmonary disease (COPD). Review of R14's EMR Progress Notes tab showed on 02/20/23 at 9:59 AM .Resident c/o [complained of] pain to L [left] hip 9/10 scale with slight movement during morning care, screaming of pain while turning to the side. PCP [Primary Care Physician].made aware and ordered to send resident to ER [emergency room] . for further evaluation. @ [at] 8:30 [AM] resident was picked up by stretcher x 2 person assist and left awake, alert and verbally responsive. and at 1:39 PM a Progress Note that the daughter was called and updated that R14 had been admitted to the hospital. Further review of the EMR Progress Notes, Assessments, and Misc [Miscellaneous] tabs did not show evidence R14 and his RR was provided with a written bed hold notice upon transfer. During an interview on 05/24/23 at 2:50 PM regarding the process for emergent transfers, Licensed Practical Nurse (LPN) 4 stated, We call the MD and update, get an order to send to hospital. We do a New Jersey Transfer Form [clarified and showed tab in EMR] then get all the papers [clarified to be legal paperwork, POLST [physician's order for life sustaining treatment], studies like lab / x ray, MAR/TAR [Medication Administration Record/Treatment Administration Record], physician orders and face sheet]. Then we call the hospital to give report, then call the ambulance or 911, and alert the family by telephone. In a telephone interview on 05/24/23 at 3:44 PM R14's RR stated she had never received a written notice regarding a bed hold. In an interview on 05/25/23 11:45 AM, the resident stated he did not remember getting anything in writing. During a follow-up interview on 05/25/23 at 1:30 PM, LPN1 was shown a bed hold form provided by the facility and stated, first time I've seen this form. Bed holds are usually done when they get admitted and it will say in [EMR] if they want a bed hold. I've never seen these (form). Clarified if LPN4 was providing the form to the resident upon transfer, LPN4 stated, No, we're not providing it. 2. Review of R28's admission Record from the EMR Profile tab showed a facility admission date of 08/10/22 with medical diagnoses that included schizophrenia, acute and chronic respiratory failure with hypoxia, convulsions, major depressive disorder, anxiety, glaucoma, and dysphagia. Review of R28's EMR Progress Note tab showed on 02/21/23 at 11:26 PM that .4:50 PM Resident, [sic] difficult to arouse and not able to take his medications. MD [physician] notified and he ordered to transfer to . hospital for evaluation. 11:05 PM .Hospital ER was called and was told resident admitted with Dx: [diagnosis] hypoxia. Further review of R28's EMR Progress Notes, Assessments, and Misc tabs did not showed evidence of a written bed hold notice was provided to the resident or RR. A request for the documentation of written bed hold notice was made on 05/23/23 at 12:30 PM with the RNC. A form was provided Notice of Emergency Transfer on 05/25/23 at 8:45 AM that contained bed hold policy but not the daily charge for an informed consent. 3. Review of R161's admission Record from the EMR Profile tab showed a facility admission date of 11/18/22, a discharge date of 01/30/23, with diagnoses that included pneumonia, encephalopathy, hypotension, schizoaffective disorder - bipolar type, liver disease, and spondylosis. Review of R161's EMR Progress Notes tab showed on 12/17/22 at 9:17 AM Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs . Pulse: P 115 - 12/17/2022 09:18 Pulse Type: Irregular - new onset . Recommendations: Primary MD made aware and orders to send resident for further evaluation. Review of R161's EMR Census tab showed R161 status was discharged to the hospital on [DATE]. A request for the documentation of written bed hold notice was made on 05/23/23 at 12:30 PM with the RNC. A form was provided Notice of Emergency Transfer on 05/25/23 at 8:45 AM that contained a written bed hold notice but did not contain a daily rate for an informed consent or declination. An attempt to contact R161's RR failed. R161 and the RR passed away within weeks of each other. During an interview on 05/26/23 at 2:05 PM with the Director of Nursing (DON) and [NAME] President of Operations (VPO) , the DON was asked her expectation regarding the provision of a written bed hold notice to the resident and RR upon emergent transfer, stated, Expectation is that everybody who goes out [to hospital] should have the notification completed and should be given to the resident or family member. Review of the facility policy titled Bed-Holds and Returns, reviewed 12/2022, showed: . 3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed- hold period (Medicaid residents); and d. The details of the transfer (per the Notice of Transfer). NJAC 8:39-5.1(a) NJAC 8:39-5.4(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R14's admission Record from the EMR Profile tab showed a facility admission date of 04/04/23 with medical diagnoses that included schizophrenia, hypertension, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and hepatic encephalopathy. Review of R14's EMR Orders tab showed physician orders for: -Anti-Anxiety Medication Use - Observe resident closely for significant side effects: Sedation, Drowsiness, Ataxia(drunk walk), Dizziness, Nausea, Vomiting, Confusion, Headache, Blurred Vision, Skin Rash. - Special Attention: If given with other sedatives, hypnotics or alcohol -Anti-Psychotic Medication Use - Observe resident closely for significant side effects: Common - Sedation, Drowsiness, Dry Mouth, Constipation, Blurred Vision, Extra Pyramidal Reaction, Weight Gain, Edema, Postural Hypotension, Sweating, Loss of Appetite, Urinary Retention.- Special Attention For: Tardive Dyskinesia, Seizure Disorder, Chronic Constipation, Glaucoma, Diabetes, Skin Pigmentation, Jaundice. -Ativan (an anxiolytic medication) 2 MG (Milligrams) tablet (generic name lorazepam) three times a day for anxiety Clozaril (an atypical antipsychotic) 200 MG tablet (brand name Clozapine) two times a day for Schizophrenia -Haloperidol 5 MG - three tablets (15 MG) (brand name Haldol, a conventional antipsychotic) three times a day for schizophrenia -Zyprexa 10 MG tablet (generic name Olanzapine) two times a day for Schizophrenia Review of R14's care plan showed focus (F), goals (G) and interventions (I) of: 1.F: Potential for drug related complications associated with use of psychotropic medications related to: Anti-psychotic medication G: Will be free of psychotropic drug related complications I: Will receive lowest therapeutic dose for control of symptoms by/through review date Medication last attempted for reduction within next review -Monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention -Monitor for target behaviors/symptoms of H/O assaultive behavior, property destruction and document. Report behavior changes to physician . -Provide Medications as ordered by physician and evaluate for effectiveness -Refer to psychologist/psychiatrist for medication and behavior intervention recommendations 2.F I sometimes have behaviors which include H/O Hitting during care, H/O Tearing things up G I will calm down with staff intervention I My behavior will stop with staff intervention -Attempt interventions before my behaviors begin -Give me my medications as my doctor has ordered -Help me maintain my favorite place to sit -Let my physician know if my behaviors are interfering with my daily living . During an interview on 05/26/23 at 2:05 PM with the Director of Nursing (DON) and [NAME] President of Operations (VPO), the DON was asked where target behaviors are identified to monitor for each psychoactive medication's efficacy and responded, Our process is, like before we opened our behavior unit - we have behavior monitors for specific medication. Now, we did some changes so now nurses chart every time behavior on each shift. So, if you observe specific behavior you will answer the section yes, if you answer yes, you have to do a chart now. When asked where the behavior that each medication is being used to manage was identified and monitored, the DON replied, We just monitor all behaviors and that is by the nurses. When the question was clarified, At this time, do you have a way to monitor each psychoactive medication for efficacy related to an identified target behavior? the DON stated at 2:18 PM In the summaries we document if observed for all behaviors. If an increase in behaviors observed we refer to psych and they manage the medications. At 2:19 PM the VPO stated, No, no target behaviors are identified to monitor for efficacy [for each medication]. Review of a policy provided by the facility titled Tapering Medications and Gradual Drug Dose Reduction, dated 02/2023, indicated .Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.The resident's target symptoms returned or worsened after the most recent attempt at tapering the dose within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. NJAC 8:39-29.3(a)1 NJAC 8:39-33.2(c)2 Based on record review, interviews, review of the Food and Drug Administration (FDA) warning (www.fda.gov), and policy review, the facility failed to ensure two (Resident (R) 33 and R14) of five residents reviewed for unnecessary medications out of a total sample of 28 residents, had adequate indications, behavior monitoring, and/or a Gradual Dose Reduction (GDR) while on psychotropic medications. Findings include: Review of an FDA document indicated .Olanzapine is an atypical antipsychotic medicine used to treat schizophrenia and bipolar disorder (manic or mixed episodes). For bipolar disorder, olanzapine can be used alone or in combination with other drugs.Olanzapine can decrease hallucinations, in which people hear or see things that do not exist, and other psychotic symptoms such as disorganized thinking. Olanzapine can also decrease the mania of bipolar I disorder.ZYPREXA (Olanzapine) may cause serious side effects, including: 1. Increased risk of death in elderly people who are confused, have memory loss and have lost touch with reality (dementia-related psychosis) . 1. Review of R33's electronic medical record (EMR) admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of a document provided by the facility titled Physician Report, dated 11/14/22, revealed the consultant pharmacist indicated R33's use of Olanzapine would trigger inappropriate use on the quality indicator report and to review the diagnosis and usage in considering a gradual dose reduction (GDR). The report revealed the Nurse Practitioner (NP) directed that there would be no GDR and signed the document. The NP failed to provide clinical indications for the continued use of Zyprexa. Review of R33's EMR titled Clinical Physician Orders, located under the Orders tab and dated 11/16/22, indicated the resident was ordered Olanzapine 5 milligrams (mg) to be administered by mouth at bedtime for psychosis (out of touch with reality). Review of a document provided by the facility titled, Progress Notes, written by a NP and dated 12/19/22, indicated R33 was being given Olanzapine 5 mg at bedtime for psychosis. The progress notes revealed there were no associated behaviors by the resident for the past two months. Review of a document provided by the facility titled Progress Notes, written by a NP and dated 05/24/23, indicated R33 was on Olanzapine for major depressive disorder and was having hallucinations about getting kids ready for school at 2:00 AM and no GDR at this time. Review of R33's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/23 indicated a Brief Interview for Mental Status (BIMS) score of eight out of 15 which revealed R33 was moderately impaired cognitively. The assessment indicated R33 had no hallucinations or delusions and was not a threat to himself or to others. The assessment indicated R33 took an antipsychotic and had no GDR and the GDR .has not been documented by a physician as clinically contraindicated. Review of R33's EMR Care Plan, located under the Care Plan tab and dated 03/18/23, indicated the resident was on Olanzapine and there was potential for drug related complications. A review was conducted of R33's EMR and paper chart and there was no indication the resident was actively hallucinating or had behaviors which would be a threat to self or to others. Review of documents provided by the facility referred to as behavior logs, dated 01/2022 through 04/2023, failed to indicate R33 had any behaviors. During an interview on 05/24/23 at 1:56 PM, Licensed Practical Nurse (LPN) 2 who was also the Unit Manager on the first floor, stated the behavior notes were under a General Note heading of the EMR. During this interview LPN 2 stated there were no behavior notes in the EMR and would need to follow up. During a subsequent interview on 05/25/23 at 11:38 AM, LPN 2 confirmed there were no behaviors associated with R33 in the EMR and stated behavior monitoring was to be done by the staff. During an interview on 05/25/23 at 2:57 AM, Certified Nurse Aide (CNA) 1 stated R33 was not dangerous to himself or to others. CNA 1 stated she was not afraid of the resident, and he did not yell out constantly. During an interview on 05/26/23 at 1:40 PM, the Director of Nursing (DON) and the [NAME] President (VP) of Operations were present. The DON stated the staff do monitor the behavior of residents who were on psychotropic medications and if there was a negative response in the behavior log, this prompts the EMR to direct the clinical staff to make a note of the specific behavior. The DON confirmed there were no target behaviors for the resident while he was taking Olanzapine. During an interview on 05/26/23 at 2:41 PM, the Consultant Pharmacist stated she bases her GDR recommendations on the behaviors documented in the clinical record. The Consultant Pharmacist stated if there were no associated behaviors with the use of psychotropic medication, she would request a GDR.

**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 one (Resident (R) 36) of five residents reviewed for flu/pneumonia vaccinations and/or their representatives out of a total sample of 28 residents, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to re-offer R36 the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) in accordance with nationally recognized standards. The facility failed to re-offer R36 the opportunity to be vaccinated with Pneumococcal conjugate vaccine (PCV13) and/or Pneumovax [Pneumococcal Polysaccharide Vaccine (PPSV23)] prior to 10/21/21 and/or offer one dose of Prevnar 20 (PCV20) after 10/21/21. The facility failed to update their most current policies to reflect current standards on pneumococcal vaccinations. This practice had the potential to increase the risk for residents to contract pneumonia. Findings include: Per CDC, For those who have never received any pneumococcal conjugate vaccine, CDC recommends PCV15 or PCV20 for adults 65 years or older .Adults 65 years or older have the option to get PCV20 if they have already received.PCV13 (but not PCV15 or PCV20) at any age and.PPSV23 at or after the age of [AGE] years old.These adults can talk with their doctor and decide, together, whether to get PCV20. Review of R36's electronic medical record (EMR) titled admission Record, located under the Profile tab, indicated the resident was initially admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. The resident was not [AGE] years of age after his initial admission. The resident turned [AGE] years of age while a resident at the facility. Review of a document provided by the facility titled, Clinical Immunizations indicated R36 refused the PPSV23 undated entry. There was no other entry on this document which would reflect the facility offered the resident additional opportunities for vaccination. During an interview on 05/25/23 at 9:23 AM, the Infection Control Preventionist (ICP) and Regional Nurse were both present. The ICP stated she only offers residents the PVC13. During an interview on 05/25/23 at 9:54 AM, the ICP confirmed R36 was not offered another opportunity to be vaccinated with PVC20. During an interview on 05/25/23 at 10:25 AM, the Director of Nursing (DON) stated she could not obtain the clinical records for R36 to see if the resident was offered additional opportunities for pneumococcal vaccinations. The DON stated the previous nursing homeowners took all of the resident's clinical records. The DON stated she was not aware the pneumococcal policies were not updated. Review of a policy provided by the facility titled Pneumococcal Vaccine, dated 03/21, indicated .All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.Administration of the pneumococcal vaccines or revaccination will be made in accordance with current Centers for Disease Control Prevention (CDC) recommendations at the time of the vaccinations. NJAC 8:39-19.4(h)(i)

Based on observation, interview, record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility. As part of this failure, the facility did not have an effective antibiotic stewardship program, which had the potential to affect all residents of the facility. (Cross Reference F881) Findings include: Review of a document titled, Centers for Disease Control (CDC) . National Healthcare Safety Network (NHSN) . Long Term Care Facility Component Tracking Infections in Long-Term Care Facilities, dated 01/2020, indicated, Surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data. A facility infection prevention and control (IPC) program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents, staff, and visitors. Information collected during surveillance activities can be used to develop and track prevention priorities for the facility. When conducting surveillance, facilities should use clearly defined surveillance definitions that are collected in a consistent way. This method ensures accurate and comparable data regardless of who is performing surveillance. A review of documents provided by the facility and referenced at the facility's infection control logs, failed to include evidence the facility tracked, trended, identified the potential for clusters of infections, and failed to include any corrective action taken by the facility to address the potential clusters of infections. During an interview on 05/26/23 at 1:40 PM, the Director of Nursing (DON) and the [NAME] President (VP) of Operations were present. The DON stated there was no tracking and trending and it was the Assistant Director of Nursing (ADON) who was the Infection Control Preventionist (ICP) and the current ICP began a few months ago. The DON confirmed the facility used to track and trend infections but currently did not based on what she saw in the infection control logs. Review of a policy provided by the facility titled Infection Prevention and Control Program, dated 11/2019, indicated .The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.The elements of the infection prevention and control program consists of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection.surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics.detecting unusual pathogens with infection control implications.Standard criteria are used to distinguish community-acquired from facility-acquired infections.Data gathered during surveillance is used to oversee infections and spot trends. NJAC 8:39-19.1(a)1 NJAC 8:39-19.4(f)

Based on interview, document review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of facility policy, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. The failure to have a system in place that monitors antibiotic use in accordance with established protocols had the potential to affect all 106 residents of the facility. Findings include: Review of a CDC document undated titled, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority.Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use'. CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Below are examples of antibiotic use and outcome measures.Process measures: Tracking how and why antibiotics are prescribed.Antibiotic use measures.Tracking how often and how many antibiotics are prescribed.Antibiotic outcome measures.Tracking the adverse outcomes. Review of documents provided by the facility titled, Monthly Infection Control Report, for the months of 02/2022 through 06/2022 (there was no document available for 07/2022), 08/2022,09/2022 (there were no documents for 10/2022 and 11/2022), and 12/2022 through 03/2023 and then one for 04/2023 failed to identify who the residents were with infections, failed to identify which room the residents were in, failed to identify the date of onset of the infection(s), if the criteria was met or not by Loeb (a set of criteria if a resident had an infection or not and if an antibiotic might be indicated to treat), and if there were cultures, laboratory blood work taken or an x-ray completed to determine a true infection and the need for antibiotics. The documents provided by the facility had several columns which were titled community or hospital acquired infections. There was no method to determine potential clusters nor was there information which would identify how each infection was treated. Review of a document provided by the facility titled, Infection Log, for the month of 03/2023 revealed resident names, room numbers, date of onset of an infection, site of the infection, if the criteria was met or not, if there were cultures, laboratory blood work taken or an x-ray completed, who the prescriber was, the antibiotic name and the prescription duration, and the date of the resolution of the infection. During an interview on 05/26/23 at 11:35 AM, the Regional Nurse stated the Infection Control Preventionist (ICP) was able to communicate the tracking and trending of infections identified in the facility but did not have it documented appropriately. During an interview on 05/26/23 at 1:33 PM, the Medical Director confirmed he attended Quality Assurance (QA) meetings on a quarterly basis. The Medical Director stated each resident was clinically assessed, such as urine and blood work, for the need of antibiotics and stated the facility had an ICP. Review of a policy provided by the facility titled Antibiotic Stewardship, dated 03/21, indicated .The facility will educate and train staff and practitioners about the facility Antibiotic Stewardship, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes. NJAC 8:39-19.4(d)