**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe physical environment to prevent the likelihood of serious injury, harm, or death, by failing to: a.) ensure that two (2) janitor closets containing hazardous materials were securely locked and free from the likelihood of resident access, b.) ensure that two (2) treatment supply rooms which contained caustic, hazardous supplies and chemicals were locked and free from the likelihood of residents access, and c.) follow their facility's Storage of Chemicals Policy and Procedure. The 2 of 2 janitor closets and 2 of 2 treatment supply rooms throughout the facility, were observed to be in unsafe conditions and contained items that would be detrimental to the health and safety of the residents. This deficient practice was identified for 3 of 50 residents (Resident #44, #46, and #53), who were cognitively impaired and had the capability to ambulate independently throughout the facility. The likelihood of a serious adverse outcome could occur through contact, inappropriate handling, or ingestion of the supplies observed in the unlocked janitor and treatment supply closets with confused, ambulatory residents gaining access to dangerous supplies and caustic chemicals which resulted in an Immediate Jeopardy (IJ) situation. The facility's Licensed Nursing Home Administrator (LNHA), Interim/Director of Nursing (I/DON), and Regional Licensed Nursing Home Administrator (R/LNHA) were made aware of the IJ situation on 10/19/23 at 4:14 PM. On 10/19/23 at 4:45 PM, the facility provided the New Jersey Department of Health (NJDOH) with an acceptable Removal Plan and the immediacy was lifted. The survey team verified the validity of the Removal Plan on site throughout the duration of the survey. The deficient practice was evidenced by the following: On 10/19/23 at 10:15 AM, Surveyor #1 observed a door labeled Janitors closet on the A unit that was open/unlocked and ajar. The surveyor did not observe staff in the hall at that time. The surveyor opened the door and observed a large bottle of disinfectant cleaner sitting on a shelf. The surveyor also observed chemical dispensers on the wall containing boxes of chemicals such as floor cleaners and disinfectants that the housekeepers utilize to clean. On 10/19/23 at 10:20, Surveyor #1 entered an unlocked room on A Unit labeled Supplies. Inside the unlocked door was another unsecured/unlocked room containing razors, nail trimmers, deodorant, glycerin swabs, shaving cream, odor eliminator, denture adhesive and denture cleaning tabs that residents had access to. On 10/19/23 at 10:36 AM, Surveyor #1 observed a staff member in a room across from the janitors closet on the A Unit. The staff member identified himself as the Housekeeping Director (HD). The surveyor interviewed the HD at that time regarding the unlocked janitors closet. The HD explained to the surveyor that the janitors closet door should be kept locked at all times because residents could enter the closet and ingest the toxic chemicals that were stored in the closet and they could also get the chemicals in their eyes. The HD specified to the surveyor during the interview that the janitors closet door should be locked at all times. On 10/19/23 at 10:41 AM, Surveyor #1 interviewed the staff member that was stationed at medication cart on A unit. The staff member identified herself and the Registered Nurse/Minimum Data Set Coordinator (RN/MDSC). The RN/MDSC stated that she was, just helping out on the unit but did not have any specific task that she was doing. The RN/MDSC explained to the surveyor that there was a Licensed Practical Nurse Manager/ Unit Manager (LPN/UM) however, she was out of the building today. The RN/MDSC stated that some confused residents wandered throughout the unit. She continued to explain that the residents that wandered were easily redirected and had the diagnoses of of dementia. On 10/19/23 at 11:10 AM, Surveyor #2 entered B hall unit and observed an unlocked janitor closet door. The surveyor observed one resident seated in a wheelchair by the janitor closet door at the time of the observation. The surveyor further observed that staff were present, walking by, but unaware that the door was unlocked and that the surveyor was in the janitor closet. The surveyor opened the door and observed chemicals attached to the wall. The chemicals were identified as bathroom cleaner, disinfectant cleaner, and window shine cleaner. The window shine cleaner was observed to have a non-child proof twist lid. The disinfectant cleaner and the bathroom cleaners' tops were open with tubes coming out of them. On 10/19/23 at 11:15 AM, while Surveyor #2 was standing in the janitor closet, inspecting the area, a housekeeping staff member walked by and shut the door on the surveyor, leaving the surveyor in the unlocked closet. The housekeeping staff member did not turn a key at that time to lock the door and was unaware that the surveyor was in the janitor closet. The surveyor exited the closet and requested an interview with the gentleman who identified himself as a housekeeper/floor tech. The Housekeeper (HK) stated that the janitor's closet was used by the housekeeping staff to fill up the chemicals they used to clean the facility. The HK stated that the door was always locked. The surveyor asked if the door was currently locked, and the HK stated that he did not know because he wasn't in there today. At that time, the surveyor asked the HK to inspect the door to see if it was locked. The HK opened the door and stated, No, but it is now. The surveyor asked the HK how he had locked the door, and the surveyor observed the HK take a key from his pocket and he proceeded to show the surveyor how to appropriately lock the door. The HK stated that it was important for the door to remain locked so no residents could open it and have contact with the chemicals. The HK further stated that some of the residents were somewhat confused and would congregate in the area because they sat at the tables across from the janitor's closet and could watch the television that was there. The HK told the surveyor that at times activities were conducted in the immediate vicinity of the janitor's closet. On 10/19/23 at 11:44 AM, the surveyor observed an unlocked treatment supply closet door on the A Unit across from the resident activities room which contained multiple bottles and items in non child proof containers such as 9 (nine) - 16 ounce (oz.) bottles of bleach solution, 5 (five) -8 (eight) oz. bottles of wound cleanser solution, 25 count box of iodine swabs, 3 (three)-16 oz. jars of skin protectant creams, 8 (eight) bottles of skin prep spray, 2 (two)-500 milliliter (mls) bottles 0.25% acetic acid irrigation solutions, 4 (four)-tubes of 4 oz. medi-honey, 3 (three)-3 oz. tubes of wound gel, 6 (six) tubes of 1 (one) oz. 1% hydrocortisone cream, and 1 box of 144 packets of antibiotic ointment. On 10/19/23 at 11:23 AM, Surveyor #2 interviewed Certified Nursing Aide (CNA) #1 who stated that the importance of the janitor closets being locked was because there were chemicals and substances in there and the facility did not want the residents to go into the closet and have contact with the chemicals and the substances. CNA#1 further stated that there were confused and ambulator residents who resided on the unit. On 10/19/23 at 11:32 AM, Surveyor #2 interviewed the RN/MDSC who stated that inside the janitor closets were mops, bags, and cleaners. The RN/MDSC told the surveyor that the doors to the janitor closets were locked because chemicals were stored in the closets and the doors were required to be locked due to resident safety. The RN/MDSC further stated that there were confused and ambulatory residents who resided on the units throughout the facility. The RN/MDSC stated, That's why the doors are locked to protect the residents. The only people who go into the room are the housekeeping staff. The RN/MDSC explained to the surveyor that because she was a nurse, she would not be able to enter the janitor closets without communicating to a housekeeping staff member first because the doors to the janitor's closets would be locked. On 10/19/23 at 11:36 AM, Surveyor #2 interviewed the Regional/Director of Nursing (R/DON) who stated that there were three hallways in the facility, a skilled nursing unit, and two Long Term Care units. The R/DON was unsure of the number of janitor closets and treatment supply rooms in the building. She told the surveyor that she would imagine mops, pails, supplies, and disinfectants were stored in the janitor closets. The R/DON stated that the doors were locked so residents didn't go in. She stated, We wouldn't want the residents to be in contact with dirty equipment or cleaning supplies. The surveyor asked why, and the R/DON further stated, Because it would be a contamination issue for bacterial contamination. Surveyor #2 asked, Would access to the chemicals be considered harmful? The R/DON stated, Yes. She further stated that there were confused and ambulatory residents residing in the facility. On 10/19/23 at 11:47 AM, Surveyor #2 toured the C unit hallway and did not observe a janitor or treatment supply closet located in the area. On 10/19/23 at 11:57 AM, Surveyor #1 interviewed Licensed Practical Nurse (LPN)#1 on the A Unit who stated that she had been employed for approximately 6 months. LPN#1 stated that the treatment supply room door on A unit should be secured and locked at all times for the safety of the residents. LPN#1 added that the nurses, janitors and maintenance department had keys to the treatment supply room. She stated that it was important to assure the treatment supply room was locked at all times to protect the residents. She stated that there were medications, solutions, creams and gels that needed to be ordered by a physician that should be kept locked up so the resident didn't get into the supplies and hurt themselves. On 10/19/23 at 12:25 PM, Surveyor #2 interviewed the Housekeeping Director (HD) who stated that the facility stored chemicals such as cleaning supplies, disinfectant, glass cleaner, and toilet bowl cleaner in the janitor closets. The HD told the surveyor that the janitor closets were locked, and the housekeeping department was responsible for locking them. The surveyor asked, What's the purpose of keeping them locked? The HD stated that the janitor closets were locked due to safety purposes because there were chemicals, sharp objects stored in them, and a resident could go into the area and drink the chemicals or spray other residents with them. The HD further stated that he tried to make rounds two or three times a day to make sure the doors were locked. The surveyor asked the HD if he checked the closets. The HD stated that he did first thing in the morning and identified that one was unlocked, but at that time he had not checked the second janitor closets. The HD explained that everyone was responsible to check and make sure the doors were locked. The HD further stated that the nurses had keys to the treatment storage rooms and the nursing staff was responsible for making sure those doors were locked. The HD stated that he was, pretty sure that there were confused and ambulatory residents in the area. On 10/19/23 at 01:43 PM, Surveyor #2 interviewed the I/DON who stated the janitor closets contained cleaning supplies. She further stated that the janitor closets should be kept secured for resident safety to prevent residents from accessing contents within the closets. The I/DON told the surveyor that the nursing treatment supply rooms were locked due to safety reason to prevent residents from accessing the contents within. The I/DON stated that she considered razors something that could hurt a resident who was not alert and oriented and items such as Dakins solution should kept under lock and key as well. The I/DON stated that there were residents who were confused and ambulatory on the unit, but most of the residents were wheelchair bound. On 10/19/23 at 01:48 PM, Surveyor #2 interviewed the facility's LNHA who stated that after the housekeeper went into the closet and removed items, the door should be locked and any items that they take with them should also be kept under supervision. The LNHA further stated the treatment supply rooms should not be unlocked, the items in the rooms were potentially hazardous and that was the purpose of keeping the doors locked. Surveyor #2 reviewed the medical record for Resident #44. Review of the resident's admission Record (an admission Summary) reflected the resident had resided at the facility for over a year and had diagnoses which included, but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, depression, otalgia (pain in the inner or outer ear that may interfere with ability to hear, often caused by excess fluid or infection), anemia, restless leg syndrome, and hypertension. Review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 09/19/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 05 out of 15 which indicated the resident had severely impaired cognition. A further review of the resident's MDS, Section E - Behavior, indicated that the resident had behaviors of wandering one to three days during the seven days look back period. Section G - Functional Status indicated that Resident #44 ambulated independently throughout the corridors of the facility and on the unit. Review of the resident's Care Plan (CP), dated 07/20/23, reflected a focus area that the resident was at an elopement risk, as the resident liked to purposely exit seek related to the diagnosis of dementia. The goal of the resident's CP was that the resident's safety would be maintained through the review date. Interventions included to provide structured activities such as toileting, walking inside and outside with reorientation strategies including signs, pictures, and memory boxes. On 10/25/23 at 10:12 AM, Surveyor #2 surveyor observed Resident #44 in their room. The resident was observed walking around his/her bed carrying diapers, towels, clothes, and popcorn all in their hands at the same time. The resident was well dressed and told the surveyor that he/she was able to take care of himself/herself. The resident was very pleasant and friendly and told the surveyor that he/she would love to take one hundred dollars and go shopping together because it would be a lot of fun. The resident was observed wearing a pair of well fitted shoes and was observed ambulating freely around their room. On 10/20/23 at 12:15 PM, Surveyor #2 interviewed CNA#1 who stated that she was not the resident's current CNA but had cared for the resident in the past. CNA#1 stated that the resident was alert and oriented with moments of confusion and utilized a walker to ambulate throughout the facility. CNA#1 told the surveyor that the resident would ask why they were at the facility and say things like, Why am I here? She explained that the resident would ask questions like that about once a week and the staff needed to monitor the resident because he/she was at risk for elopement. On 10/25/23 at 10:18 AM, Surveyor #2 interviewed the resident's CNA#2 who stated that the resident was alert and oriented, with forgetfulness and confusion. CNA#2 told the surveyor that the resident was independent when it came to activities of daily living, however needed to be redirected. CNA#2 gave the example that the resident would sleep in their daytime clothes if the staff was not there to guide the resident to care for himself/herself independently. CNA#2 further stated that the resident would clean up their room, like they would if it was their own house. CNA#2 explained to the surveyor that at times the resident would have to be redirected back into their room because the resident would lose awareness of his/her surroundings at times and needed staff assistance. Surveyor #1 reviewed the medical record for Resident #46. According to the admission Record, Resident #46 was admitted to the facility with the diagnoses that included but was not limited to Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills). The quarterly MDS dated [DATE], indicated that Resident #46 had scored a 3 (three) on the BIMS which indicated that the resident had severe cognitive impairment. The MDS indicated that the resident independently ambulated and was able to perform self care. The MDS also indicated that the resident used a wander-guard (monitoring device utilized to ensure resident's safety). Surveyor #1 reviewed Resident #46's CP, dated 10/24/22, which indicated that the resident was at risk for wandering related to (r/t) intermittent confusion. Interventions on the CP included the following: wander-guard in place on the left wrist and revised CP indicated the wander-guard was now in place of the right ankle. The CP indicated that the the staff checks the wander-guard for placement and proper functioning. On 10/25/23 at 11:32 AM, Surveyor #1 observed Resident #46 sitting in the dayroom with other residents. The surveyor observed that the resident was wearing a wander-guard bracelet on the left wrist. The resident appeared pleasantly confused. The resident appeared clean, well dressed and was participating in activities. On 10/25/23 at 11:46 AM, Surveyor #1 interviewed LPN#2 who stated that she was familiar with Resident #46 and decribed the resident as being very forgetful and only oriented her his/herself. LPN#2 stated that the resident had good and bad days, was able to independently able to walk throughout the unit and perform most acitivities of daily living for herself. LPN#2 stated that Resident #46 was not able to leave the building by himself/herself and was not exit seeking but wore a wander-guard to assure that he/she was kept safe. Surveyor #2 reviewed the medical record for Resident #53. Review of the resident's admission Record indicated that the resident had diagnoses which included, but were not limited to, Alzheimer's Disease, need for assistance with personal care, anxiety disorder, insomnia, and cognitive communication deficit. Review of the resident's quarterly MDS dated [DATE], indicated that the resident had a BIMS score of 03 out of 15 which reflected the resident had severely impaired cognition. A further review of the resident's MDS, Section G - Functional Status indicated that the resident was independently capable of walking throughout the facility with supervision. Review of the resident's CP revised 05/04/23, reflected a focus area that the resident was an elopement risk due to wandering, the resident was disoriented to place, had impaired safety awareness, and wandered aimlessly. The goal of the CP was that the resident would not leave the facility unsupervised. Interventions included to provide the resident with programs and activities that would minimize the potential for wandering. On 10/20/23 at 12:16 PM, Surveyor #2 observed Resident #53 walking independently throughout the C unit hallway. The resident was observed taking slow, deliberate steps and looking around the hallways. On 10/20/23 at 12:37 PM, Surveyor #2 observed Resident #53 walking slowly and independently around the main dining room area in the facility and back up and down the hallways of C unit. The resident was wearing a clothing protector in anticipation for lunch. The resident appeared confused and unaware of his/her surroundings. At that time, the surveyor observed a staff member walk up to the resident, tell the resident that it was lunch time, and walk the resident down the hallway to his/her room. On 10/20/23 at 12:43 PM, Surveyor #2 made an additional observation of Resident #53 walk up to another resident in the main dining room area. The resident was confused. The alert and oriented resident who was eating their lunch told the resident his/her lunch was in their room. The surveyor observed a staff member re-direct the resident toward their room again. On 10/20/23 at 12:20 PM, Surveyor #2 interviewed CNA#3 who stated that she was the assigned CNA to the resident that day. CNA#3 further stated that the resident was confused and could ambulate independently throughout the facility. Review of the facility first floor, floor plan (map), indicated that there were two treatment supply closets and two janitor closets in the facility. Review of the facility's undated Housekeeper Job Description/Competency/Evaluation indicated, The primary purpose of the job position is to implement required housekeeping procedures in an efficient, cost effective manner meeting all federal, state, and local requirements while providing a safe environment for our residents. The Housekeepers Job Description/Competency/Evaluation further indicated, Is involved with residents, personnel, visitors, government agencies/personnel, etc , under all conditions and circumstances. Review of the undated Director of Housekeeping (Housekeeping Director) Job Description indicated, The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a clean, safe, comfortable manner. The Director of Housekeeping's Job Description further revealed Administrative Functions included, Assume the administrative authority, responsibility, and accountability of directing the Housekeeping Department. Review of the facility's Storage of Chemicals Policy and Procedure revised 01/2023 indicated, All hazardous/toxic substances used in our facility will be stored in a secure location. Review of the Storage of Treatment Policy and Procedure revised 12/2022, indicated, The facility shall store treatment supplies in a safe, secure, and orderly manner The nursing staff shall be responsible for maintaining treatment supply storage and preparation areas in a clean, safe, and sanitary manner . and Storage areas (including, but not limited to, drawers cabinets, rooms, refrigerators, carts and boxes) containing treatment supplies shall be locked when not in use, and trays and carts used to transport such items should not be left unattended if open or otherwise potentially available to others . NJAC 8:39-27.1(a)