COMPLAINT #: NJ00183422, NJ00186468 Based on observation, interviews, medical record review, and review of other pertinent facility documentation on 08/22/25, it was determined that the facility failed to immediately implement their abuse policy to ensure residents were protected from abuse by not removing the accused staff from resident care pending full investigation of an abuse allegation. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #1) and had the potential to affect all residents. According to Facility Reportable Event (FRE), at approximately 6:00 AM on 05/03/2025 Resident #6 (the roommate of Resident #1) reported to Registered Nurse #1 (RN #1) that Resident #1 moaned in pain while a Certified Nursing Assistant (CNA) was providing morning care (turning and repositioning) for the resident. The FRE included that RN #1 assessed the resident and reported the incident to the Nursing Supervisor. No further action was taken to investigate Resident #6's report as an abuse allegation. On 05/05/2025, the Unit Manager (UM) #1 and the Director of Nursing (DON) interviewed Resident #1 about a CNA being rough during care and performed a skin assessment. The resident denied being hurt at that time. No further action was taken to investigate the concern as possible abuse. On 05/13/2025, Resident #6 again reported to facility staff that on 05/02/2025 or 05/03/2025 a CNA caused Resident #1 pain while turning and positioning the resident. On 05/13/2025, an investigation which included conducting staff and resident interviews, obtaining staff statements, and suspension of the accused CNA was conducted. The facility's failure to implement their abuse policy by initiating an investigation and removing the accused CNA from resident care when staff were first alerted to the concern on 05/03/2025 allowed the alleged abuser to continue to have access to residents on 05/05/2025, 05/06/2025, 05/07/2025, 05/08/2025, and 05/10/2025. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 5/03/2025 after Resident #6 alerted RN #1 of their concern that Resident #1 was mishandled by a CNA. The facility Administration was notified of the IJ on 08/22/2025 at 6:05 PM. The facility submitted an acceptable Removal Plan (RP) on 08/25/2025 at 4:07 P.M., indicating the actions the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: the 11-7 nursing supervisor's employment was terminated, all staff were immediately in-serviced on the facility abuse policy with a focus on implementation procedures and resident safety, the administrative team which consisted the DON, Administrator and Medical Director reviewed the facility abuse prevention policy and no change to policy required. All current residents or their designee were interviewed to ensure that they felt safe, and assessments were done on all non-verbal residents. Started 10 weekly staff interviews on the facility abuse policy and 10 weekly resident interviews about resident safety. Resident and staff interviews will be reviewed weekly with the Administrator for 3 months and will be reported monthly to the Quality Assurance Performance Committee. Implementation of the RP was verified during the continuation of the on-site survey on 08/25/2025 and determined that IJ was removed as of 08/23/2025. The evidence was as follows: This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for abuse and was evidenced by the following:The facility policy document titled Abuse dated April 9, 2024, was reviewed. Under POLICY, page 2 of the policy revealed, It is the policy that each resident will be free from Abuse. [.] Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. [.] The facility will strive to educate staff and other applicable individuals in techniques to protect all parties.Under C. PREVENTION page 5 of the facility policy revealed, It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns, incidents and grievances without fear of reprisal or retribution. This section of the facility policy further revealed, The facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse. Under E. INVESTIGATION, page 7 of the facility policy revealed, It is the policy of this facility that reports of abuse' (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. This section of the policy further revealed under PROCEDURE: a. Investigation of abuse: When an incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation may include: [.] iv. Involved staff and witness statements of events [.] ix. Interview of other residents who were cared for by the accused (if applicable). Under F. PROTECTION, page 9 of the facility policy revealed, It is the policy of this facility that the resident(s) will be protected from the alleged offender(s). This section of the facility document revealed under, PROCEDURE, Immediately upon receiving a report of alleged abuse, the Administrator and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of utmost priority. [.] a. Procedures must be in place to provide the resident with a safe, protected environment during the investigation: i. The alleged perpetrator will immediately be removed and resident protected. Employees or visitor accused of alleged abuse will be immediately removed from the facility and will remain removed pending the results of a thorough investigation.Under G. REPORTING AND RESPONSE page 11 of the facility policy revealed under, PROCEDURE: INTERNAL REPORTING: a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator, Director of Nursing, or designee. **Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to unspecified nondisplaced fracture of fifth cervical vertebra (broken bone in the neck that remained in its original position), subsequent encounter for fracture with routine healing; unspecified nondisplaced fracture of fourth cervical vertebra (broken bone in the neck that remained in its original position), subsequent encounter for fracture with routine healing; cognitive communication deficit (breakdown in the cognitive processes that affects how individuals think and communicate); need for assistance with personal care; abdominal aortic aneurism (enlarged area in the lower part of the body's main artery, which can be fatal if ruptured), without rupture, unspecified; and nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissues that cover the brain). According to the Minimum Data Set (MDS), an assessment tool dated 03/27/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that the resident's cognition was moderately impaired. The MDS revealed that Resident #1 required assistance to roll left and right, move from sitting to laying, to move from laying to sitting, and to move from sitting to standing. The MDS also revealed that Resident #1 was occasionally incontinent of urine and was always incontinent of stool. An undated facility document, titled: Investigation Summary, regarding Resident #1 was reviewed. Under Narrative Description of Event: page 1 of the document, on 05/13/2025, Resident #6 reported that staff did not know how to care for Resident #1 and that Resident #1 was in pain. Resident #6 heard the concern but did not witness it. This section of the document further revealed that an immediate investigation was initiated, the physician was notified, the resident's sponsor and facility administration were notified. Under, Interview statements from staff who worked with the resident on 05-03-25 11pm - 7am, page 1 of the document, at approximately 6:00 A.M., RN #1 became aware that Resident #6 heard Resident #1 scream in pain during care. RN #1 assessed Resident #1 and immediately reported the concern to the Supervisor. The Supervisor then assessed Resident #1. The document revealed no further action taken by the Supervisor or other facility staff on the day that Resident #6 expressed concerns that Resident #1 was hurt by a CNA #1 that morning. According to the Investigative Summary/Conclusion: page 2 of the document, CNA #1 was suspended due to the facility's protocol pending the results of the investigation. The same section of the document on page 3 revealed that the allegations made by Resident #6 were unsubstantiated. Page 3 of the document further revealed, Due to the nature and potential risk to all resident facility staff were re-educated on abuse prevention. A facility document titled: Statement form, hand-written by CNA #1, dated 05/02/2025 was reviewed. The statement revealed that Resident #1 did not complain of pain while CNA #1 was providing care, and that the resident was left comfortably in bed. The statement revealed that as CNA #1 was leaving the resident's room, she dropped garbage on the floor which disturbed Resident #6, who then complained to CNA #1 about the noise. A telephone interview was conducted with CNA #1 on 08/22/2025 at 12:05 P.M. CNA #1 stated that she provided a written statement at the request of a Nursing Supervisor and was unsure of when she provided the statement but thought it could have been 05/02/2025. CNA #1 stated that she worked until 7:00 A.M. on the morning that Resident #6 got upset with her for making noise in their room. CNA #1 stated that she was not suspended or sent home on that day. A facility document, titled: statement form, handwritten by RN #1, dated 05/16/2025 and timed 7:00AM, was reviewed. The statement revealed that at approximately 6:00 A.M., Resident #6 reported that they heard their roommate (Resident #1) scream while a CNA was providing care. The statement further revealed that Resident #1 was assessed immediately by RN #1 and the facility Supervisor was immediately notified of the concern.The surveyor attempted to reach RN #1 for an interview without success. Review of the Progress Notes (PN) for Resident #1 revealed that on 05/05/2025 at 2:44 P.M., UM #1 interviewed Resident #1 about a recent complaint of a CNA being rough with them. The PN further revealed that Resident #1 did not recall being treated roughly and denied being hurt by anyone. An interview was conducted with UM #1 on 08/22/2025 at 1:15 P.M. UM #1 stated that the process after an allegation of rough treatment was to immediately interview the resident and their roommate, if possible; assess the resident's skin; and notify the Director of Nursing (DON) or Licensed Nursing Home Administrator (LNHA). UM #1 stated that the process included obtaining statements from staff members who cared for the affected resident. UM #1 stated that nurses, UMs, and Supervisors were responsible for obtaining statements. UM#1 stated that the process included assembling statements and skin assessments in a folder and giving it to the DON. UM #1's statement to the surveyor regarding the accused staff did not follow the facility policy reviewed under F. Protection, which stated that employees or a visitor accused of abuse will be immediately removed and will remain removed pending the results of a thorough investigation. UM #1 stated that the process included changing the assignment of the accused staff member when an accusation was made and sending the staff member home if it was determined that, something really happened. UM #1 further stated that the DON or LNHA made the decision about whether an employee should have been sent home, which is not in accordance with facility policy. During the same interview, UM #1 stated that she recalled that in May 2025, Resident #6 complained that Resident #1 was in pain during care. UM #1 stated that she was made aware of the allegation when she arrived at work at on 05/05/2025 around 7:00 A.M., and that was when she completed a skin assessment of Resident #1. UM #1 stated that she interviewed Resident #1 who denied being hurt by facility staff. UM #1 stated that she believed that the facility's DON or Assistant Director of Nursing (ADON) obtained statements about this allegation. UM #1 further stated that she was familiar with the facility's abuse policy but was not sure if the policy was followed on 05/05/2025. An interview was conducted with the DON on 08/22/2025 at 2:08 P.M. The DON stated that an allegation of rough treatment during care would have been considered an abuse allegation. The DON stated that the expectation was for staff to notify a Nurse or Supervisor immediately when there was an abuse allegation and for the DON or LNHA to be notified immediately. The expectation was for the nurse or Supervisor to assess the resident involved, and for the Supervisor to collect statements as soon as they were made aware of an accusation. The DON stated that the process when an abuse allegation was made included sending the accused staff member home pending the results of the investigation. The DON further stated that this process was important to ensure that residents were not left in the care of someone who was hurting them. During the same interview, the DON stated that she and the LNHA did the investigation of Resident #6's allegation that Resident #1 received rough treatment by a CNA. The DON stated that she was made aware of the accusation on 05/13/2025 and that is when the investigation was started. The DON stated that CNA #1's statement was obtained on 05/13/2025 and the date written on the statement (05/02/2025) refers to the date that CNA #1 started the 11:00 P.M. to 7:00 A.M. shift which was when the 05/03/2025 allegation was made. The DON stated that the statement obtained from RN #1 was dated 05/16/2025 but the statement was about the allegation made on 05/03/2025. The DON stated that it was concluded that the alleged event occurred on 05/03/2025 at approximately 5:30 A.M., RN #1 reported the allegation to the Supervisor right away. The DON further stated that the Supervisor did not report the allegation to the DON, obtain statements, or send the accused CNA home according to facility policy. A 05/05/2025 at 2:44 P.M., Progress Note by UM #1 was reviewed with the DON. The DON stated that her expectation was that she should have been notified right away of the allegation of rough treatment. A follow up interview was conducted with the DON on 08/22/2025 at 4:11 P.M. The DON stated that on 05/03/2025 the Supervisor should have notified her of the accusation made by Resident #6 and the CNA would have been suspended. The DON stated that on 05/05/2025, she (the DON) and UM #1 assessed and spoke with Resident #1 about the allegation that they were hurt by a CNA. The DON stated that no further investigation was done on 05/05/2025. The DON stated that on 05/13/2025 Resident #6 informed the facility's Assistant Administrator of the allegation of rough treatment of Resident #1, and it was on 05/13/2025 that the facility's abuse policy was fully implemented. During the same interview the DON stated that the purpose of the facility's abuse policy was to inform staff of what to do when an abuse accusation was made. The DON further stated that if the abuse policy was not followed, we put the resident in potential danger. During an interview with the LNHA on 08/22/2025 at 5:39 P.M., the LNHA stated that the expectation was that if there was an allegation of abuse the facility's abuse policy, which included starting an immediate investigation, should be implemented quickly. The LNHA stated that there was no need to follow the facility's abuse policy on 05/03/2025 and there was no need to implement the policy related to resident #6's accusation until 05/13/2025 because there were no suspicions or complaints of abuse until that date. The LNHA further stated that that facility's abuse policy is in place to safeguard the residents and because it is a regulation. NJAC 8:39-4.1(a)5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00160765, NJ00160776 NJ00160791, NJ00161051 Based on interview, medical records (MR) review, and review of pertinent facility documents on 1/20/23, 1/23/23, 1/27/23, 2/2/3, and 2/7/23, it was determined that the facility failed to ensure that a.) a resident with known history of behaviors of wandering and repeatedly attempted to open the medication cart was adequately supervised and had appropriate care plan in place and b.) an incident or accident was reported immediately to the nursing supervisor (NS) or the Director of Nursing (DON) in accordance to the facility's reporting policy for incidents and accidents for 1 of 3 residents (Resident #7) reviewed for incident and accident. The deficient practice was evidenced by the following: 1.According to the admission Record (AR), Resident #7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dementia with agitation, Major Depressive Disorder, and Anxiety Disorder. The Minimum Data Set (MDS), an assessment tool dated 10/20/22, revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated a severely impaired cognitive status and the resident required minimal supervision with Activities of Daily Living (ADL). The MDS indicated that Resident #7 exhibited physical and verbal behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, yelling, cursing) 4 to 6 days during the 7 days, counting back from 10/20/22. The Physician's Order Summary Report (OSR) reflected that Resident #7 was receiving the following supplements: Multiple Vitamins-Minerals One a day and Ocuvite-Lutein, Probiotic Acidophilus Bio Beads, Potassium, Vitamin D3, Cranberry tablet, and Glucosamine. A review of the nursing progress notes (PN) revealed the following documentation: On 10/7/22 at 10:10 PM, Licensed Practical Nurse (LPN) #6 documented that Resident #7 tried opening the nurse's medication cart. On 10/15/22 at 3:32 PM, LPN #8 documented that Resident #7 was very aggressive, trying to pull medications from the medication cart several times. On 10/18/22 at 11:01 PM, LPN #5, documented despite all due medications given, the Resident kept asking for more and tried to open the medication cart. Additionally, the PN revealed the Resident attempted to open the medication cart on 10/22/22, 10/27/22, 10/31/22, and tried to enter the medication room on 10/30/22. There was no indication in the MR that the abovementioned recurring behavior of Resident #7 was addressed in the care plan. On 12/6/22 at 10:32 PM, LPN #6 documented the following in the PN: Resident #7 was in bed sleeping, drowsiness when awakened, was unusually calm. Licensed practical nurse (LPN) #6 and LPN #5 found three bottles of supplements, supplements were removed and educated the Resident who had a severe cognitive impairment not to keep medication in his/her room for safety. LPN #6 took the Resident's vital sign (VS) and recorded them in VS section of the MR. There was no documented evidence in the PN that the medication cart was locked at the time of the incident, that an investigation was initiated to ensure that all medication carts and medication room on the unit were secured and locked and determine how the unknown supplements were obtained, that an RN conducted a comprehensive assessment, that the NS or the DON was notified, that the PP or RP was notified, or the care plan was updated. Furthermore, there was no indication in the PN that the LPN provided continued observation of Resident #7 after the incident. A review of the care plan (CP) with a revision date 10/28/22 indicated the resident may do one the following, if it is not a problem for the resident, do not be concerned with: wandering .kicking and hitting med cart. Goals and interventions included but were not limited to: Resident will display positive behaviors and have decreased episodes of inappropriate behavior; Assess potential and trigger for aggression; Leave alone in a safe environment such as his/her room; Have psychiatrist/psychologist evaluate as needed and routinely. The CP did not reflect interventions of Resident #7's recurring behavior of attempting to open the medication cart or enter the medication room when it was initially documented on 10/7/22. The PN reflected that a quarterly interdisciplinary care plan meeting (IDCP) was held on 11/9/22, and it was documented that the care plans have been reviewed and are up to date. However, the behavior was not addressed in the care plan until 1/23/23. Review of the summary on the incident dated 1/24/23 with the DON's name stamp, unsigned, provided to the surveyor via email on 1/24/23 indicated the following: On 1/23/23 this writer was made aware that on 12/6/22 a nurse, LPN #6 discovered 3 bottles of supplements in a drawer of Resident #7. On 1/23/23, Resident #7's belongings were immediately checked, and no supplements of any kind were found. LPN #6 was interviewed and confirmed that she looked at the resident's drawer because the resident seemed drowsy and found the supplements, one was multivitamins with minerals and could not recall the others. Review of the resident's chart confirm that the vital signs were normal. The NS confirmed that she was not notified of the incident. The DON made the RP aware of the incident and the RP was not aware where the supplements came from. The DON asked Resident #7 who could not recall where the supplements came from. There was no documented conclusion, but it was indicated that it was unclear how the supplements arrived in Resident #7's drawer on 12/6/23. The surveyor reviewed the document Full QA Report Incident date/time: December 6, 2022, 5:00 PM forwarded by the DON post survey on 2/10/23. It was indicated on the form that LPN #6 was the assigned care giver and LPN #5 was the witness. The location of the incident was at the resident's room. There was no injury noted. Additionally, the form indicated that there was no staff interview, and the details of the incident was not documented. The form indicated that the Administrator and DON were not notified of the incident until 1/23/23. The surveyor reviewed LPN #6 signed written witness statement dated 1/23/23 forwarded by the DON post survey on 2/10/23. LPN #6 indicated that Resident #7 was sleeping around 5PM but the resident usually paces on the unit. Due to this, she awoke the resident and took his/her VS because Resident #7 was drowsy. LPN #6 indicated that she checked the resident's drawer and found supplements such as multivitamins with minerals and two others. She could not recall. She removed them and put them in the cart. The surveyor reviewed LPN #5's signed and undated written witness statement, forwarded by the DON post survey on 2/10/23. LPN #5 wrote that LPN #6 asked her to check Resident #7's room because she thinks Resident #7 took something from the med carts. LPN #5 indicated nurse searched the room and found bottles of supplements in the drawer. The Resident was awake and responsive and walking on the unit. There was documentation in the MR indicating the Resident #7 was awake and walking in the unit. The document did not indicate that an RN assessed Resident #7, that the LPNs started an incident report, and the RP and PP were notified. On 1/23/22 at 1:20 PM, Resident #7 refused an interview with the surveyor. During a telephone interview with the surveyor on 1/23/23 at 2:01 PM, LPN #6 stated that on 12/6/22, during her medication pass at approximately 5:00 PM, Resident #7 was not wandering out of the room, which she stated was unusual. Because of that, she decided to check on the resident with LPN #5. Resident #7 was found in bed sleepy, drowsy when awakened, not aggressive, and unusually calm, and for that reason, she searched the room. While searching, LPN #6 found three bottles of supplements in the resident's nightstand drawer. LPN #6 explained that she took the Resident's VS, which she stated was normal, and placed the supplements in the medication cart. She said that Resident #7 was not assessed by a RN. She further explained that she left the supplements in the medication cart for the night shift but was unable to confirm that incident was reported to the oncoming nurse. LPN #6 could not confirm if she reported the incident to the NS or the DON and could not answer when the surveyor asked why the supplements were not given to the supervisor at the time when she reported the incident. Additionally, LPN #6 stated that she could not recall the name of the supplements. LPN #6 further stated that Resident #7 had tried opening the medication cart before, but it was locked. It was confirmed during interview that she did not initiate an investigation to determined how Resident #7 obtained the medications or if all the medication carts on the unit were secured and notify the PP or RP. However, she stated that nurses are responsible for informing the PP or RP of changes in condition, incident, accident, and initiating an incident report. LPN #6 acknowledged that she should have called the PP and started an incident report. During a telephone interview with the surveyor on 1/30/23 at 1:10 PM, LPN #5 stated that she was in the room when LPN #6 found bottles of supplements or medications in the nightstand drawer. LPN #5 could not recall how many bottles or the names of the medications, was unaware where LPN #6 placed them and was unsure if LPN #6's medication cart was locked at the time of incident. She was unsure if the incident was reported to the oncoming nurse but confirmed that she did not report the incident to the NS or the DON, notify the PP or RP or initiate an investigation as she was busy with her residents. LPN #5 stated that the incident should have been reported to the NS immediately to ensure the resident's safety. During a telephone interview with the surveyor on 2/6/23 at 11:28 AM, the PP stated that she was unaware of the incident on 12/6/22 when Resident #7 was found drowsy when awakened and at the same time bottles of unknown supplements/medications were found in the resident's nightstand drawer. She explained that some residents can self-administer medications with the PP's order, but not Resident #7, due to his/her cognitive status. She further explained that she expects nurses to call her for any incident or accidents and changes in resident's condition so that she can make appropriate clinical decisions. She added that Resident #7's nurse should have notified her about the drowsiness and the medications found in the resident's room, regardless of the type of medication. During an interview with the surveyor on 1/23/23 at 2:24 PM, RN #2, NS on 12/6/22 confirmed the abovementioned incident was not reported to her. She explained that nurses are responsible for notifying the NS or DON when incidents or accidents occur, calling the PP and RP for changes in condition, and initiating an incident report or investigation and stated that LPN #6 should have immediately reported the abovementioned incident to her. During an interview with the surveyor on 1/23/23 at 11:36 AM and telephone interview on 2/10/23 at 10:24 AM, LPN #3 who was the unit manager (UM) for Resident #7, stated that he was unaware about the incident on 12/6/23 or Resident #7's abovementioned recurrent behavior. He explained that nurses are responsible for initiating or updating care plans. However, not all nurses know how to create or update CP. During an interview with the surveyor on 1/23/23 at 3:50 PM, the DON stated that nurses did not notify her or the NS about the abovementioned incident that occurred on 12/6/22. She explained that nurses are expected to report any incident/accident to the NS and initiate an incident report immediately. Also, nurses are expected to notify the RP and PP of changes in condition and when an incident or accident occurs. The DON acknowledged that LPN #6 should have immediately reported the incident to the nursing supervisor and started an incident report/investigation. During an interview with the surveyor on 1/27/23 at 1:55 PM, the Administrator stated that nursing staff must report incidents and accidents immediately to the supervisor unless it's an emergency then the DON or the Administrator must be notified immediately. The Administrator stated that he was unaware of the abovementioned incident. The surveyor asked if the incident was reported to him since the DON began the investigation on 1/23/23. The surveyor explained the details of the incident to the Administrator then he stated that he would have to look because he was not sure of the specifics. The Administrator confirmed the nurse should have followed the protocol for incident and accidents which include reporting to the NS, and notification of PP and RP. Review of an undated facility policy titled Accidents and Incidents; under Policy Interpretation and Implementation indicated 1. The Nurse Supervisor/Charge Nurse .shall promptly initiate and document investigation of the accident or incident. 2. shall be included in the report .a. the date and time .b. the nature of the injury .g. the date/time attending physician was notified as well as the time the physician responded .h. the date/time the family was notified and by whom .3. The Nurse Supervisor/Charge Nurse .shall complete a Report of Incident/Accident form and submit to the Director of Nursing Services within 24 hours . Review of the facility policy titled, Behavior Assessment and Monitoring undated, under Policy Statement indicated 1. Problematic behavior will be identified and managed appropriately .under Assessment 2. The nursing staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition, including a. onset, duration, and frequency .or changes in behavior, cognition, and mood . Review of the facility policy titled, Acute Condition Changes-Clinical Protocol undated, under Assessment and Recognition indicated that nursing staff will contact the Physician .for emergencies, they will call or page the Physician and request a prompt response. Under Monitoring and Follow-Up it indicated that staff will monitor and document the resident's progress and responses to treatment . Review of the facility policy titled, Care Plans-Comprehensive undated, under Policy Statement indicated that an individualized, patient centered, comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, mental, and psychological needs is developed for each resident consistent with the Resident's rights. Under Policy Interpretation and Implementation indicated 1. Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident .3. Each resident's comprehensive care plan has been designed to: a. incorporate identified problem areas .d. reflect treatment goals and objective and measurable outcomes .5. Care plans are revised as changes in the resident's condition dictate, care plans are reviewed at least quarterly . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the survey on [DATE], the surveyor reviewed the facility's reportable event records for the past 3 months. The surveyor reviewed the RERR dated [DATE] involving Resident #7 and Resident #8. The RERR revealed that a resident-to-resident abuse was reported to the NJDOH on [DATE]. The attached summary indicated that on [DATE] at approximately 2:00 pm, the staff witnessed Resident #7 not allowing Resident #8 to enter their room. Resident #7 pushed Resident #8 and in return, hit Resident #7 in the back. They were separated and neither resident sustained injury. Resident #8 was offered a room change, Resident #8 declined, and the family did not like the room. It further indicated that the facility would actively work on other room options that would be appropriate. The conclusion indicated, this appears to be an isolated event. The residents have been roommates for a few months and have had no issues up until now. The room changes will be done as a precaution. On [DATE], another resident-to-resident abuse/physical altercation involving Resident #7 and Resident #8 was reported to the NJDOH. During the survey on [DATE], the surveyor reviewed the facility's RERR. Review of the RERR revealed that on [DATE] at approximately 11:00 am, staff at the nursing station heard Resident #7 yell. When staff responded, Resident #7, while exiting the room, stated that Resident #8 hit his/her hand. The incident was unwitnessed. Resident #7 was unable to provide context, and Resident #8 asked the staff to leave the room. Neither resident had injury, redness, or bruise. The interventions implemented after the incident included: Resident #8's room will be changed. Both resident's behavior will be monitored and referred for Psychiatric evaluation. It further indicated that this was the second minor incident between the resident. Both residents are ambulatory with Dementia and getting them out of each other's proximity should manage the behavior. During the tour of the unit on [DATE] at 1:20 pm, the surveyor observed Resident #7 and Resident #8 lying in bed in the same room, awake and alert. Both residents refused an interview with the surveyor. Review of MR on [DATE], [DATE], [DATE], and [DATE] revealed the following: 2a). Resident #7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dementia with agitation, Major Depressive Disorder, and Anxiety Disorder. The MDS dated [DATE] and [DATE] revealed a BIMS score of 7, which indicated severely impaired cognitive status, and the Resident was independent and required minimal supervision with ADLs. The MDS indicated that Resident #7 exhibited physical and verbal behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, yelling, cursing) 4 to 6 days during the 7 days, counting back from [DATE]. The Medication Administration Record (MAR) revealed that Resident #7 received Sertraline for Depression from [DATE] to [DATE]. Additionally, the medication Depakote for Dementia with Behavioral Disturbance was started on [DATE] and the dosage was increased on [DATE] and [DATE]. Review of the PN revealed no documented evidence that the nurses consistently monitor Resident #7's behavior after the Depakote was increased on [DATE] and [DATE] when it was indicated in the facility's policy that if a resident is being treated for problematic behavior or mood, the staff will document ongoing reassessments of changes (positive or negative). Furthermore, the PN revealed documentation dated [DATE] at 2:15 pm about Resident #7 and Resident #8 physical altercation. The residents were separated and assessed. The event was reported to the DON, Administrator, and Assistance Administrator. On that same date at 2:53 pm, the SW notified the RP and agreed to move Resident #8 to another room. The PN revealed no documented evidence that the nurses consistently monitored Resident #7's behavior after the physical altercation. The revised care plan dated [DATE] revealed that Resident #7 is possessive of his/her room and does not want people to enter. Goals and interventions included but were not limited to: Resident will not harm self or others; resident will verbalize understanding of the need to control physically aggressive behavior; when the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly, if the response is aggressive, staff to walk calmly away and approach later. The care plan indicated that Resident #7, who had severely impaired cognition and a diagnosis of Dementia, would verbalize understanding of the need to control physically aggressive behavior. However, there was no indication in the CP how Resident #7 would be monitored while in the room with the roommate (Resident #8) where the physical altercations occurred. The facility's policy for behavior management indicate that interventions and approaches will be based on detailed assessment of physical, psychological and behavioral symptoms as well as the potential situational and environmental reasons. Additionally, the policy included that the care plan will include but was not limited to targeted and individualized interventions for the behavioral symptoms, specific, measurable goals for the targeted behavior and how the staff will monitor for effectiveness of the interventions. The PN revealed that on [DATE] at 10:55 am, the UM/LPN #3 documented that Resident #7 and Resident #8 had another physical altercation in the room and unwitnessed. During an interview with the DON on [DATE] at 12:57 pm and UM/LPN #3 on [DATE] at 2:50 pm, they both confirmed that the physical altercation took place in the residents' room, and it was unwitnessed as the residents were not monitored in the room by the nursing staff at that time. The DON further confirmed on that same date at 4:10 pm that the room change for Resident #8 was not attempted again until after the physical altercation recurred on [DATE]. She stated that the physical altercation on [DATE] was considered a minor and isolated incident and Resident #8 refused to transfer to another room. Review of the task form for the month of 11/2022 indicated that CNAs were to monitor for behavior symptoms every shift which included but were not limited to yelling/screaming, kicking/hitting, pushing, and abusive language. Resident #7's task form was not signed/initialed for the following dates and shifts: 7:00 am to 3:00 pm on [DATE], [DATE] to [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; 3:00 pm to 11:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; and 11:00 pm to 7:00 am on [DATE] to [DATE], [DATE], [DATE], [DATE] to [DATE], [DATE], and [DATE] to [DATE]. For the month of 1/2023 for the following dates and shifts: 7:00 am to 3:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; 3:00 pm to 11:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; 11:00 pm to 7:00 am on [DATE], [DATE] to [DATE], [DATE], [DATE], and [DATE] to [DATE]. During an interview with CNA #1 on [DATE] at 11:01 am, she stated that CNAs are expected to monitor residents' behavior and document in the kiosk, ADL records task for behavior monitoring. She further said that CNAs are responsible for completing the task at the end of the shift and if incomplete or blank, it did not happen. During an interview with the DON on [DATE] at 12:57 pm, she stated that CNAs document resident's behavior in the kiosk or ADL record. She further stated that CNA observations and documentations are considered valuable they do not replace nurses observation and documentation. 2b. According to the AR, Resident #8 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dementia and Hypertension. The MDS dated [DATE] and [DATE] revealed a BIMS score of 3, which indicated severely impaired cognitive status, and the Resident required supervision to minimal assistance with ADLs. The nursing PN dated [DATE] at 1:04 pm indicated that Resident #8 was combative with staff and other residents. Resident wanders around the hallway and goes in and out of other residents' rooms. Redirection unsuccessful. The nursing PN dated [DATE] at 8:30 pm indicated that Resident #7 was physically and verbally abusive to staff and residents. The Resident was not easily redirected but finally agreed to go to bed. The CP initiated on [DATE] indicated that Resident #8 may present with a depressed mood related to his/her recent admission to the facility and his/her overall condition. Goals and interventions included but were not limited to: Resident #8 will have improved mood state, such as being happier, having a calmer appearance, and showing no signs and symptoms of depression, anxiety, and or sadness. Behavioral Health consults as needed. Monitor/document as needed risk for harm to self: suicidal plan, a past attempt at suicide, risky actions, intentionally or tried to harm self, sense of hopelessness, and impaired judgment or safety awareness. Monitor/record/report to MD (Medical Doctor) as needed risk for harming others, increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone Review of the PN revealed documentation by the Social Worker (SW) on [DATE] at 10:32 am that Resident #8 was transferred to another room because of incompatibility with the roommate (Resident #7). The RP was made aware of the room change and staff to monitor the adjustment. However, the PN revealed no indication that the room change occurred or Resident #8 was monitored by the nurses for adjustment after the room change. Additionally, there was no documented evidence in the PN explaining what led to the room change. Further review of the PN revealed documentation dated [DATE] at 2:15 pm that Resident #7 and Resident #8 had a physical altercation. They were separated and assessed. The event was reported to the DON, Administrator, and Assistance Administrator. On that same date at 2:53 pm, the SW notified the RP and agreed to move Resident #8 to another room. Review of the MR on [DATE] revealed no documented evidence that the nurses consistently monitored Resident #8 for safety after the physical altercation on [DATE]. In addition, there was no documented evidence that Resident #8 was offered another room change after the resident refused on [DATE] when it was indicated in the RERR summary that the facility staff would actively work on room change options. Review of the PN on [DATE] revealed documentation on [DATE] at 10:55 am about another physical altercation between Resident #7 and Resident #8. The PN indicated that Resident #7 and Resident #8 who had a physical altercation [DATE] continued to share the same room until another resident-to-resident abuse/physical altercation on [DATE]. During an interview with the SW on [DATE] at 11:30 am, she stated that Resident #8 was transferred to another room after the physical altercation on [DATE]. The resident's RP had agreed to the room change but the resident would not stay in the new room, so he/she remained in the same room with Resident #7. The SW confirmed that Resident #8 transferred again to another room after the altercation on [DATE], and Resident #8 had adjusted well to the new room. However, she could not explain why the room change was not attempted again as a precaution when it was indicated in the RERR summary on [DATE] that the facility would actively work on other room options that would be appropriate. Additionally, she could not explain what led to the room change on [DATE] but stated that Resident #7 was very territorial and due to incompatibility During an interview with the surveyor on [DATE] at 11:36 am, LPN #3, unit manager (UM) for Resident #7, could not remember a room transfer for Resident #8 on [DATE]. The revised care plan dated [DATE] for Resident #8 revealed that Resident #8 is at risk for potential negative interaction from or with a resident on the unit who has demonstrated poor impulse control. Goals and interventions included but were not limited to: Resident #8 will be free from danger and injury related to interaction with others; behavior documentation and psychiatric evaluation as needed; maintain a safe distance from the other aggressive or triggered residents; monitor Resident #8 whereabouts for safe interactions with peers. A review of the MR on [DATE] revealed no documented evidence that the nursing staff consistently monitored Resident #8 behaviors, interactions with other residents, and whereabouts as indicated in the revised care plan on [DATE]. Review of the task form for the month of 11/2022 indicated that the following dates and shifts were not signed/initialed: 7:00 am to 3:00 pm [DATE] to [DATE] and [DATE] to [DATE]; 3:00 pm to 11:00 pm on [DATE] to [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], and 11:00 pm to 7:00 am on [DATE] to [DATE], [DATE] to [DATE], [DATE], [DATE], [DATE] to [DATE], and [DATE] to [DATE]. For the month of 1/2023 for the following dates and shifts: 7:00 am to 3:00 pm on [DATE], [DATE], [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]; 3:00 pm to 11:00 pm on [DATE], [DATE], [DATE] to [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; and 11:00 pm to 7:00 am on [DATE], [DATE] to [DATE], [DATE], [DATE], and [DATE] to [DATE]. During an interview with CNA #1 on [DATE] at 11:01 am, she stated that Residents #7 and #8 were roommates. They would sometimes be friends but usually argue. If the residents engage in an altercation, either one will yell. CNA #1 explained that Resident #8 was transferred to another room sometime last year, but it was unsuccessful, so the residents' remained roommates. CNA #1 further explained that she did not witness the altercation on [DATE] but heard about it. She added that nurses and CNAs monitor the residents' behavior, and CNAs report observed behaviors to the nurses. During an interview with LPN #9 on [DATE] at 1:34 pm, she stated that residents' behavior should be monitored every shift for 14 days for changes in medications for behavior and when an incident happened due to behavior. She explained that it is important to document resident's behavior in the PN even when there was no behavior because it shows that the observation happened. The surveyor asked if Residents #7 and #8 were monitored for behavior and whereabouts after the incident on [DATE]. LPN #9 was unsure but stated that nurses and CNAs supervise all residents. She agreed that if the behavior and whereabouts were not documented in the resident's MR, it did not happen. During an interview with the UM/LPN #3, he stated that Resident #7 and Resident #8 do not get along sometimes. He explained that Resident #7 and Resident #8 never had an altercation again after [DATE] incident and could not confirm if another room change was attempted again. The surveyor asked when staff monitor residents for behavior. The UM/LPN #3 stated that residents must be monitored for behavior every shift for 14 days after an altercation and changes in psychotropic medications, even if no behavior was observed. He agreed that if the observation was not documented in the MR, it did not happen. During an interview with the surveyor on [DATE] at 2:24 pm, the Nursing Supervisor (NS) RN #2 stated that residents must be monitored for behavior every shift for 14 days after changes in psychotropic medication to monitor the effectiveness of the medication. During an interview with the DON on [DATE] at 12:57 pm and 3:50 pm, and [DATE] at 4:10 pm, she stated that nursing staff are expected to document observation of resident's behavior in the MR every shift for 14 days when there's new or changes in psychotropic medications and after an altercation. The nurses must document when residents are not displaying behaviors to show that residents are being monitored and to determine the effectiveness of the medication change. She added that behavior monitoring is a protocol that requires no doctor's order. The DON could not explain why there was no consistent documentation in the MR that Resident #7 and Resident #8 were monitored after the physical altercation on [DATE] or after Resident #7 had a psychotropic medication change on 10/14 and [DATE]. However, she stated that the nurses should have documented behavior observations and confirmed that if it was not documented, it did not happen. The surveyor asked the DON if Resident #8 was referred to the Psychiatrist and Psychologist for evaluation after the physical altercation on [DATE]. The DON stated that Resident #8 had adjusted well to the facility, and there was no need to refer every resident with a history of behavior from the hospital. The surveyor asked if the care plan for Resident #7 and Resident #8 should address the altercations or aggression towards each other specifically since they were roommates and the altercation occurred inside the room. The DON stated, I don't know how to answer that, care plans are discussed in the morning meeting with the team. The surveyor asked the DON if Resident #7 was offered a room change after the altercation on [DATE]. The DON stated that Resident #7 was not a candidate for a room change due to prior history. In addition, the DON stated that a room change was not attempted again for Resident #8 despite having it documented that the facility would actively work on room change options as a planned intervention when the resident had altercation on [DATE], because the residents' room was next to the nurse's station where they can be monitored, and the residents did not have an altercation since. However, it was not confirmed during the interview that both residents were consistently monitored despite the room being next to the nurse's station since there was no consistent documentation in the PN to indicate that it was done. The DON confirmed if there was no documentation of behavior observation or monitoring in the PN, it did not occur. During an interview with the surveyor on [DATE] at 1:55 pm, the Administrator stated that incidents, accidents, and abuse must be reported by the nursing staff immediately, and it goes through a chain of command. For emergencies, staff must inform the DON or the Administrator immediately. The Administration stated that the DON reports to him, but the DON would lead the investigation. The surveyor asked if he was informed of the abovementioned physical altercation incident on [DATE]. He stated he was unsure of the specifics of the actual event. The surveyor explained the details of the incident to the Administrator and then said he would have to look, but in general, room change would be attempted. The Administrator could not confirm if the room change occurred but stated that, in general, a room change should be offered after an altercation. Review of the facility policies titled: Abuse, dated [DATE], indicated under .Prevention .The facility leadership will assess the needs of the residents in the facility to be able identify concerns in order to prevent potential abuse .RESIDENT ASSESSMENT The population of the facility includes individuals who meet the criteria for skilled care under the Medicaid and Medicare guidelines including specialty programs provided by the facility .Every resident is unique and may be subject to 'abuse' based on a variety of circumstances, including facility physical plant, environment, the resident's health, behavior or cognitive level .Staff supervision and ongoing monitoring are used to identify resident with a risk behavior .The interdisciplinary team will identify the vulnerabilities and interventions on the resident care plan .POPULATION .The facility will ensure a comprehensive dementia management program to prevent resdient [resident] abuse if applicable . Acute Condition Changes - Clinical Protocol, undated, revealed .MONITORING AND FOLLOW-UP 1. The staff will monitor and document the resident's progress and response to treatment, and the Physician will adjust treatment accordingly. 2. The Physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized . Behavior Assessment and Monitoring undated, indicated Problematic behavior will be identified and managed appropriately .Monitoring 1. If the resident is being treated for problematic behavior or mood, the staff and physician will obtain and document ongoing reassessments of changes (positive or negative) in the individual's behavior, mood, and function . Behavioral Assessment, Intervention and Monitoring undated, indicated POLICY STATEMENT 1. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. 2. Residents who do not display symptoms of, or have not been diagnosed with, a mental, psychiatric psychosocial adjustment or post-traumatic stress disorder will not develop a patter of decreases social interaction or increased withdrawn, angry or depressive behaviors that cannot be explained or attributed to a specific clinical condition that makes the pattern unavoidable. Residents will have minimal complications associated with the management of altered or impaired behavior .Assessment 4. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others .Management .Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying cases, as well as the potential situational and environmental reason for the behavior. The care plan will include, as a minimum: a. A Description of the behavioral symptoms including .Monitoring 1. If the resident is being treated for altered behavior or mood, the IDT [Interdisciplinary Team] will seek and document any improvements or worsening in the individual's behavior, mood, and function. 2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable .Interventions will be adjusted based on the impact on behavior . Care Plans-Comprehensive, undated, indicated An individualized, patient centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs in developed for each resident consistent with the Resident Rights .Care plans are revised as changes in the resident's condition dictate . Charting and Documentation, undated, indicated All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record .All observations .services performed .must be documented in the resident's medical record . RESIDENT ABUSE NEGLECT AND MISTREATMENT THE LAW, undated, indicated under .Prevention .Aggressive care planning of all residents who have needs and/or behaviors that may trigger a negative reaction .psychiatric conditions with history of aggressive behaviors .Identification: Immediate incident reporting (refer to Accident/Incident Policy & Procedure) and investigation of all falls, bruising, skin-tears, increase in depressive, isolative fearful behavior, and occurrences that may constitute abuse . NJAC 8:39-4.1 (a)5 NJAC 8:39-27.1(a) Complaint #: NJ00160765, NJ00160776 NJ00160791, NJ00161051 Based on interviews, review of the Medical Records (MR), and other pertinent facility documentation on [DATE], [DATE], [DATE], [DATE], and [DATE], it was determined that the facility failed to provide the services necessary to avoid physical harm. The facility failed to ensure that residents who are cognitively impaired were protected from a resident-to-resident physical abuse/altercation and recurrence, failed to initiate a care plan (CP) when behaviors started for consistent behavior monitoring, failed to provide adequate supervision and documentation to protect from physical abuse, and to follow their own policies titled: Behavior Assessment and Monitoring, RESIDENT ABUSE NEGLECT AND MISTREATMENT THE LAW, Abuse, Charting and Documentation, Care Plans-Comprehensive, and Behavioral Assessment, Intervention and Monitoring, and Acute Condition Changes - Clinical Protocol, for 4 of 11 residents (Resident #1, #2, #7, and #8) reviewed for abuse; when a.) On [DATE], Resident #2, who had impaired cognition and known history of wandering and aggressive behavior exhibited behaviors of agitation, throwing things/hitting staff with a water bottle, and threatened to kill them. Resident #2 was evaluated at the hospital on [DATE] and returned on [DATE]. On [DATE], the Valproic medication (given for Depression and Dementia with Behavioral Disturbances) was changed when Resident # 2 returned to the facility from the Acute Care Hospital (ACH). The facility did not initiate a formal behavior monitoring process, develop a CP, and/or start interventions for this aggressive behavior. Resident #2's CP and progress notes (PN) lacked documentation that the resident was being supervised or monitored to address his/her aggressive behavior displayed on [DATE]. This deficient practice resulted a resident-to-resident physical abuse/altercation when on [DATE] at 3:05 pm, a staff member witnessed Resident #1 ambulating in the hallway past Resident #2's doorway. Resident #2 was coming out of his/her room and struck Resident #1 in the head, causing Resident #1 to fall. Resident #1 was observed face down and noted with bleeding abrasions to the right eyebrow and temple. Resident #1 was hospitalized with an intracranial hemorrhage and expired on [DATE]. This resulted in an Immediate Jeopardy (IJ) which began on [DATE] and the facility was notified of the IJ on [DATE]. The facility provided an acceptable removal plan and was verified on-site on [DATE]. b.) Resident #7 and #8 who are roommates, both cognitively impaired with a known behavior of aggressiveness and outburst of agitation had a resident-to-resident abuse/physical altercation on [DATE] at 2:00 PM. Resident #7 pushed Resident #8 and Resident #8 hit Resident #7 on his/her back in return. Resident #8 was offered a room change in which the Responsible Party (RP) agreed, however, Resident #8 declined. Resident #7 was not offered a room change because he/she was not a candidate. Although the facility indicated a room change was to be actively worked on as an intervention, there was no documentation to indicate that another room change was attempted, and the residents remained roommates. Consequently, another physical altercation occurred between Resident #7 and Resident #8 on [DATE] at 11:00 AM. The incident occurred in the room and was unwitnessed. The facility's failure to provide supervision, consistently document/monitor resident behavior in the MR, and implement the plan of care posed a serious and immediate risk to the safety and well-being of all the residents in the facility. This deficient practice placed Residents #1, #2, #7, and #8 and all other residents who were at risk for a resident-to-resident physical abuse/altercation in an IJ situation for serious injuries, harm and death. This resulted in an IJ which began on [DATE] and the facility was notified of the IJ on [DATE]. The facility provided an acceptable removal plan and which was verified on-site on [DATE]. The Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Nurse of Operation (CNO) were notified of the IJ and provided with the IJ template on [DATE] at 4:44 pm. The facility provided an acceptable removal plan and was verified on-site on [DATE] during the survey. On [DATE], the Surveyors conducted a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan which included; a. The Resident was no longer at the facility. All facility staff were educated on behavior care plans and behavior monitoring policy. Resident audits were initiated, reviewed and updated on all resident behavior interventions and CPs. b. Residents #7 and #8 CPs were updated on [DATE] and, as a further intervention were separated into different rooms on [DATE] post agreement of RPs. Residents #7 and Resident #8 are being monitored and the responsible parties were notified. All current resident with behaviors were audited and reviewed residents with behavior and their interventions and CPs were updated. The non-compliance remained on [DATE] for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice was further evidenced by the following: Review of the REPORTABLE EVENT RECORD/REPORT (RERR), dated [DATE] at 3:05 pm, revealed a Resident-to-Resident Abuse incident involving Resident #1 and Resident #2 that was reported to the New Jersey Department of Health (NJDOH) on [DATE] at 5:00 pm. Attached with the RERR was the investigation summary report (ISR). The ISR indicated that Resident #1 was ambulating when Resident #2 came toward Resident #1 and slapped Resident #1's face, open handed, causing him/her to fall. First aid was provided to Resident #1. The Nurse practitioner (NP #1) immediately assessed Resident #1. Resident #1 was transferred to an Acute Care Hospital (ACH) via 911 and admitted with an Intracranial Hemorrhage. The ISR further indicated that Resident #2 remained aggressive, hitting, kicking staff, and was kept away from other residents. Resident #2 was transferred to the ACH via 911 at approximately 4:15 pm. On [DATE], [DATE], and [DATE], the surveyor reviewed the electronic medical record (EMR) of Resident #1 and Resident #2. 1.) According to admission Report (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Major Depressive and Dementia. The Minimum Data Set (MDS), an assessment tool dated [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6/15, indicating Resident #1's cognition was severely impaired and the resident required supervision for Activities of Daily Living (ADLs). A PN, dated [DATE] at 3:51 pm, documented by Nurse Practitioner (NP #1) indicated that she responded to a call from Maple unit. When she arrived in the unit, Resident #1 was found on the floor in a prone position, the resident woke up and began to move her/his head. She further indicated that the staff reported that Resident #1 was ambulating in the hallway when Resident #2 randomly slapped Resident #1 causing Resident #1 to fall to the floor. Resident #1 was observed to have several bleeding abrasions to the right eye, right eyebrow, temple area, and right submandibular. Staff was able to stop the bleeding and gently rolled Resident #1 to a supine position. Staff applied oxygen at 2 liters per minute (lpm), vital signs were: Pulse of 82 beats per minute (bpm), respiration of 24 bpm, blood pressure of 190/90, and oxygen saturation was 100 percent. NP #1 further indicated that Resident #1 had an altered mental status after the fall to the floor and a brief loss of consciousness. A PN, dated [DATE] at 10:25 pm, documented by Licensed Practical Nurse (LPN #5) indicated that Resident # 1 was being admitted to the hospital for an Intracranial Hemorrhage. Review of Resident #1's incident report (IR), provided by the DON on [DATE], dated [DATE] at 3:05 pm, revealed that a fall occurred in the hallway while Resident #1 was ambulating, the fall was witnessed by the Certified Nursing Assistant (CNA #1),[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00160765, NJ00160776 NJ00160791, NJ00161051 Based on observation, interviews, medical record (MR) review, and review of other pertinent facility documentation during the on-site investigation on [DATE], [DATE], [DATE], [DATE], and [DATE], it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to follow the facility's Administrator job description and failed to ensure that policies and procedures were implemented by staff under Behavior Assessment and Monitoring, RESIDENT ABUSE NEGLECT AND MISTREATMENT THE LAW, Abuse, Charting and Documentation, Care Plans-Comprehensive, and Behavioral Assessment, Intervention and Monitoring, Accidents and Incidents, and Acute Condition Changes - Clinical Protocol. 1. On [DATE], Resident #2, who had impaired cognition and known history of wandering and aggressive behavior exhibited behaviors of agitation, throwing things/hitting staff with a water bottle, and threatened to kill them. Resident #2 was evaluated at the hospital on [DATE] and returned on [DATE]. On [DATE], the Valproic medication (given for Depression and Dementia with Behavioral Disturbances) was changed when Resident # 2 returned to the facility from the Acute Care Hospital (ACH). The LNHA unable to explain that the facility did not initiate a formal behavior monitoring process, develop a CP, and/or start interventions for this aggressive behavior. Resident #2's care plan (CP) and progress notes (PN) lacked documentation that the resident was being supervised or monitored to address his/her aggressive behavior displayed on [DATE]. This deficient practice resulted a resident-to-resident physical abuse/altercation when on [DATE] at 3:05 pm, a staff member witnessed Resident #1 ambulating in the hallway past Resident #2's doorway. Resident #2 was coming out of his/her room and struck Resident #1 in the head, causing Resident #1 to fall. Resident #1 was observed face down and noted with bleeding abrasions to the right eyebrow and temple. Resident #1 was hospitalized with an intracranial hemorrhage and expired on [DATE]. This resulted in an Immediate Jeopardy (IJ) which began [DATE]. 2.) On [DATE] at 2:00 pm, Resident #7 and #8 who are roommates, both cognitively impaired with a known behavior of aggressiveness and outburst of agitation had a witnessed resident-to-resident abuse/physical altercation. Resident #7 pushed Resident #8 and Resident #8 hit Resident #7 on his/her back. Resident #8 was offered a room change which the family agreed but Resident #8 declined. Resident #7 was not offered a room change because he/she for was not a candidate. Consequently, on [DATE] at approximately 11:00 am, another resident-to-resident abuse/physical altercation involving Resident #7 and Resident #8. When staff responded to the room, Resident #7 reported that Resident #8 hit her/his hand. The incident was unwitnessed. Resident #8 was moved to another room. This resulted in an IJ which began on [DATE] and the facility was notified of the IJ on [DATE]. The LNHA failed to ensure that adequate supervision, and consistently document/monitor resident behavior in the Medical Record (MR) in accordance with their policy and ensure that the physical altercation did not recur. Additionally, there was no indication that Resident #8's revised care plan was implemented. 3.) On [DATE] approximately 5:00 pm, Resident #7 was found in bed sleepy, drowsy when awakened, not aggressive, and unusually calm. LPN #6 found three bottles of supplements in the resident's nightstand drawer. LPN #6 placed the three supplements in her medication cart. Resident #7 was not assessed by a RN. The incident was not communicated to the oncoming nurse, nursing supervisor (NS), DON, primary physician (PP) and/or Resident's responsible party (RP). LPN #6 did not initiate an investigation. The LNHA failed to ensure that: a resident with known history of behaviors of wandering and frequently attempting to open the medication cart was monitored/supervised and failed to ensure the care plan was in place to address these behaviors, an incident or accident was reported immediately to the NS or the DON in accordance to the facility's reporting policy for incidents and accidents, a resident who was found unusually calm and drowsy when awakened was assessed by a RN and the PP was notified about the resident's change in condition, a comprehensive incident investigation was initiated to ensure that all medications were secured and locked, and the Responsible Party (RP) was notified. The LNHA's also failed to ensure that adequate supervision was provided, consistently document/monitor resident behavior in the MR, implement the plan of care, to initiate an investigation to determine how Resident #7 obtained the three bottles of unknown supplements, posed a serious and immediate risk to the safety and well-being of all the residents in the facility. This resulted in immediate jeopardy (IJ) situation which began on [DATE]. The facility was notified of the IJ on [DATE]. This deficient practice has the potential to affect all 57 residents on the memory care unit/third floor/Maple unit as evidenced by the following: The Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Nurse of Operation (CNO) were notified of the IJ and provided with the IJ template on [DATE] at 4:44 pm. The facility provided an acceptable removal plan which was verified on-site on [DATE] during the survey. The facility implemented the Removal Plan which included but was not limited to; review of the policies and procedures for abuse, incidents/accidents and individualized behavior care plans, behavior monitoring for the Administrator and Administrative team. This deficient practice was identified for 4 of 11 residents (Resident #1, Resident #2, Resident #7, and Resident #8) and evidenced by the following: Ref Ftag 600 IJ Review of the REPORTABLE EVENT RECORD/REPORT (RERR), dated [DATE] at 3:05 pm, revealed a Resident-to-Resident Abuse incident involving Resident #1 and Resident #2 was reported to the New Jersey Department of Health (NJDOH) on [DATE] at 5:00 pm. Attached with the RERR was the investigation summary report (ISR). The ISR indicated that Resident #1 was ambulating when Resident #2 came toward Resident #1 and slapped Resident #1's face, open handed, causing him/her to fall. First aid was provided to Resident #1. The Nurse practitioner (NP #1) immediately assessed Resident #1. Resident #1 was transferred to an ACH via 911 and admitted with an Intracranial Hemorrhage. The ISR further indicated that Resident #2 remained aggressive, hitting, kicking staff, and was kept away from other residents. Resident #2 was transferred to the ACH via 911 at approximately 4:15 pm. 1.) According to admission Report (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Major Depressive and Dementia. The Minimum Data Set (MDS), an assessment tool dated [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6/15, indicating Resident #1's cognition was severely impaired and the resident required supervision for Activities of Daily Living (ADLs). A PN, dated [DATE] at 3:51 pm, documented by Nurse Practitioner (NP #1) indicated that she responded to a call from Maple unit. When she arrived in the unit, Resident #1 was found on the floor in a prone position, the resident woke up and began to move her/his head. She further indicated that the staff reported that Resident #1 was ambulating in the hallway when Resident #2 randomly slapped Resident #1 causing Resident #1 to fall to the floor. Resident #1 was observed to have several bleeding abrasions to the right eye, right eyebrow, temple area, and right submandibular. Staff was able to stop the bleeding and gently rolled Resident #1 to a supine position. Staff applied oxygen at 2 liters per minute (lpm), vital signs were: Pulse of 82 beats per minute (bpm), respiration of 24 bpm, blood pressure of 190/90, and oxygen saturation was 100 percent. NP #1 further indicated that Resident #1 had an altered mental status after the fall to the floor and a brief loss of consciousness. 1a.) According to AR, Resident #2 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Major Depressive Disorder and Dementia with Agitation. The MDS dated [DATE], revealed that Resident #2 had a BIMS score of 3/15, indicating Resident #2's cognition was severely impaired and the resident required supervision for ADLs. The CP, dated [DATE], revealed that Resident #2 presented with a depressed mood related to recent admission to the facility as well as overall condition. Interventions included but not limited to: Monitor and record mood to determine if problems seem to be related to external cause. The CP further revealed that Resident #2 had potential for side effects related to psychotropic drug use of Paxil and Valproic Acid for Depression and Dementia with Behavioral Disturbances. The CP also revealed that on [DATE], Resident #2's CP was initiated for Urinary Tract Infection. Interventions were to Administer antibiotics as ordered .Educate (patient/family) on handwashing .On going communication with infection control nurse .strict handwashing . Review of a facility PN, dated [DATE] at 7:25 pm, by the Telehealth Nurse Practitioner (TNP #1) revealed the following: Resident #2 had Change in Condition .Resident became very agitated. Throwing things at staff, danger to self and others .Onset: few minutes ago. wandering in other pt's [patient's] room, became agitated throwing things at everybody and other residents, hot drinks and can of soda, running up and down and not able to contain [Resident #2]. Nurse says sometimes agitated but 'never like this'. Nurse says [Resident #2] tried to hurt others physically .ASSESSMENT/DIAGNOSIS: Unspecified Mood Disorder .Restlessness and Agitation .and Violent behavior .General Assessment/Diagnosis Plan Notes:-stat psyc [psychiatric] eval in ER [emergency room]; 1:1 monitoring until EMS arrives for transport . Review of a facility PN, dated [DATE] at 8:00 pm, Registered Nurse (RN #1) documented &;20pm [7:20] call from third floor for an emergency. When I arrived pt [patient] was screaming 'I'm going to kill them and theyre going to kill me. We attempted to calm pt [patient] down. Hit this writer in head with a full water bottle. All residents placed in their room with doors closed. pt [patient] attempting to get into rooms and screaming 'They're going to kill us'. Call placed to 911, telehealth made aware we were sending [gender for a psych eval at [hospital emergency room]. [Family members] came and [family members] were placed in the day room with the doors closed. Pt [Patient] calmed down with them here. Call placed to [hospital emergency room]. Police and ambulance transported [gender] to [hospital]. Review of the CP did not include any indication that interventions were implemented to address the aggressive behavior displayed on [DATE]. Review of the HR, psychiatry consult, dated [DATE] at 2:54 pm, revealed that Resident #2 was brought in the ED [emergency department] for aggressive and violent behaviors, [gender] has been a resident at [facility] since [DATE], reportedly [gender] has been having physical outburst, according to staffs [gender] has frequent behavioral outbursts. The Order Summary Report (OSR), dated [DATE], reflected that the Valproic 250 milligram (mg), give 5 milliliter (ml) was increased from every 12 hours to every 8 hours for Dementia with Behavioral Disturbance. There was no indication in the MR that behavior monitoring was initiated when the medication was changed on [DATE]. Review of the TASK form for the month of 1/2023 indicated that CNAs were to monitor Resident #2's behavior every shift. The TASK form for monitoring was not signed/initialed as completed on the following dates and shifts after Resident #2 returned from the hospital: [DATE], [DATE], [DATE] during the shift of 7:00 am to 3:00 pm on, [DATE], [DATE], and [DATE] during the shift 3:00 pm to 11:00 pm, and [DATE] during 11:00 pm to 7:00 am which was not according to the Charting and Documentation policy. On [DATE] at 3:15, unit manager LPN (UM/LPN #3), who was the nurse for Resident #2 on [DATE], documented that at 2:30 pm Resident #2 was in his/her room, at 3:05 pm, another resident was walking down the hallway when Resident #2 slapped the resident causing Resident #1 fall to the ground and sustained an abrasion near the right eyebrow and temple area. On [DATE] at 4:53 pm, Nurse Practitioner (NP #1) documented Called to Maple floor stat. Patient seen on bed with 2-3 staff members monitoring and maintaining his position and location in the room after he randomly struck another resident. [Resident #2] appears agitated and restless but otherwise appears medically stable. Of note, patient just returned from the hospital on [DATE] s/p [status post] psych eval for similar aggressive behaviors. [Resident #2] was treated for UTI and completes oral ABT [antibiotic therapy] tomorrow. NP #1 further documented that her Impression/Plan: Patient with mood disorder and dementia exhibiting recurrent agitation and aggression towards staff and another resident. Day #4/5 Keflex for UTI in progress. ER [emergency room] for psych and medical evaluation and treatment. Further review of Resident #2's medical record (MR) revealed there was no documented evidence that Resident #2's behavior was being monitored consistently after the incident on [DATE] when there was a change in condition or when the medication, Depakote was changed on [DATE]. During the tour, the surveyor conducted an interview with residents who were alert and oriented. On [DATE] at 12:59 pm Resident #5 stated that Resident #2 was a difficult resident, he/she walked around the unit and entered other resident's room, Resident #2 would lay down on other residents' beds and staff would just redirect him/her. Resident #2 hit staff and other residents for no reason including him/her. Resident #5 further stated that Resident #2 also threw a chair at one point (unable to recall time and date). Resident #5 revealed that he/she did not report the incident to the facility because the staff were aware of the resident's behavior. During an interview with the surveyor on [DATE] at 12:45 pm. Resident #6 stated that resident #2 walked around the unit, he/she would go into other residents' room and sleep on other residents' beds, he/she gets upset and hits staff and other residents when [he/she] does not get what [he/she] wants. Resident #6 stated, approximately 2-3 weeks ago between 2:30 pm to 3:30 pm, Resident #2 entered Resident #6's room, Resident #6 asked Resident #2 to leave the room, Resident #2 hit Resident #6's shoulder and walked out of the room. Resident #6 stated that he/she never reported the incident to the facility because this was a resident's normal behavior and that the staff were aware of his/her behavior. The surveyor conducted an interview with CNA #1 on [DATE] at 9:27 am. The CNA stated that she documented the residents' behavior in the Kiosks (kiosk or mobile devices that enables care staff to document activities of daily living at or near the point of care to help improve accuracy and timeliness of documentation). She stated that not all residents were being monitored, only those residents that appear in the Kiosks. She explained that a questionnaire would appear, and CNAs had to indicate if behavior occurred by answering Y for yes and N for no. She also explained that the Kiosks had to be answered and cannot be left blank to indicate that the behavior was being monitored. The surveyor conducted an interview with CNA #2 on [DATE] at 2:00 pm. The CNA stated that she documents residents' behavior in the Kiosks but not for all residents, only when being asked in the Kiosks. She explained that a questionnaire will appear, and the CNA had to indicate if behavior occurred by answering Y for yes and N for no. She stated that sometimes she documents in the Kiosks and at times she forgets or had no time to sign the Kiosks. The surveyor conducted an interview with the UM/LPN #3 on [DATE] at 11:07 am. The LPN stated that CNAs should document the task provided at the end of the shift and unit managers should ensure that the CNAs document to indicate that the care was provided to the residents. However, the LPN was unable to explain why the CNAs were unable to complete their documentations. The surveyor conducted the interview with the DON on [DATE], [DATE], and [DATE]. The DON stated that Resident #2's CP was updated for UTI management on return from the hospital on [DATE]. However, the CP for Resident #2's behavior that happened on [DATE] was not created because the residents' behavior was related to the diagnosis of UTI. The DON also stated that if there was a change in medications, staff should monitor and document resident's behavior for 14 days, every shift, in the MR whether the resident's had a behavior or not. The DON was unable to provide a consistent monitoring documentation when the resident's medications were changed on [DATE]. During an interview with the surveyor on [DATE] at 9:00 am, UM/LPN #3 stated that the nurses are only to document residents' behavior in the residents MR when a behavior occurred. He further stated that nurses are not required to document in the MR if the resident had no behavior. He explained that they have no documentation indicating that the residents' behaviors were being monitored every shift consistently. However, on [DATE] at 11:36 am, the LPN stated that when there is a change in condition such as a change in medication or having aggressive behaviors, the staff had to monitor the resident and document in the resident's MR. He further added that documentation is important to see if a new intervention is effective or not and to show that the intervention is being implemented and it is part of communication. UM/LPN #3 was not able to explain why Resident #2's behavior documentation was not done. During an interview with the surveyor on [DATE] at 9:15 am, UM/LPN #3 stated that the CP is a way of communication, as it summarizes the residents overall care, and should be individualized and patient centered. The CP had to be updated by the unit managers (UM), Supervisor, and DON within 48 hours for any change in condition including but not limited to, a fall, any incident, altercation, skin tear, or behavior. He further stated that it is important to update the CP to give proper care and to prevent from any recurrence. UM/LPN #3 explained that Resident #2's CP should have been updated for behaviors and medication change on return from the hospital on [DATE]. LPN was not able to provide an updated CP to address the resident behavior on [DATE]. 2.) During the survey on [DATE], the surveyor reviewed the facility's reportable event records for the past 3 months. The surveyor reviewed the RERR dated [DATE] involving Resident #7 and Resident #8. The RERR revealed that a resident-to-resident abuse was reported to the NJDOH on [DATE]. The attached summary indicated that on [DATE] at approximately 2:00 pm, the staff witnessed Resident #7 not allowing Resident #8 to enter their room. Resident #7 pushed Resident #8 and in return, hit Resident #7 in the back. They were separated and neither resident sustained injury. Resident #8 was offered a room change, Resident #8 declined, and the family did not like the room. It further indicated that the facility would actively work on other room options that would be appropriate. The conclusion indicated, this appears to be an isolated event. The residents have been roommates for a few months and have had no issues up until now. The room changes will be done as a precaution. On [DATE], another resident-to-resident abuse/physical altercation involving Resident #7 and Resident #8 was reported to the NJDOH. During the survey on [DATE], the surveyor reviewed the facility's RERR. Review of the RERR revealed that on [DATE] at approximately 11:00 am, staff at the nursing station heard Resident #7 yell. When staff responded, Resident #7, while exiting the room, stated that Resident #8 hit his/her hand. The incident was unwitnessed. Resident #7 was unable to provide context, and Resident #8 asked the staff to leave the room. Neither resident had injury, redness, or bruise. The interventions implemented after the incident included: Resident #8's room will be changed. Both resident's behavior will be monitored and referred for Psychiatric evaluation. It further indicated that this was the second minor incident between the resident. Both residents are ambulatory with Dementia and getting them out of each other's proximity should manage the behavior. 2a). Resident #7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dementia with agitation, Major Depressive Disorder, and Anxiety Disorder. The MDS dated [DATE] and [DATE] revealed a BIMS score of 7, which indicated severely impaired cognitive status, and the Resident was independent and required minimal supervision with ADLs. The MDS indicated that Resident #7 exhibited physical and verbal behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, yelling, cursing) 4 to 6 days during the 7 days, counting back from [DATE]. The Medication Administration Record (MAR) revealed that Resident #7 received Sertraline for Depression from [DATE] to [DATE]. Additionally, the medication Depakote for Dementia with Behavioral Disturbance was started on [DATE] and the dosage was increased on [DATE] and [DATE]. Review of the PN revealed no documented evidence that the nurses consistently monitor Resident #7's behavior after the Depakote was increased on [DATE] and [DATE] when it was indicated in the facility's policy that if a resident is being treated for problematic behavior or mood, the staff will document ongoing reassessments of changes (positive or negative). Furthermore, the PN revealed documentation dated [DATE] at 2:15 pm about Resident #7 and Resident #8 physical altercation. The residents were separated and assessed. The event was reported to the DON, Administrator, and Assistance Administrator. On that same date at 2:53 pm, the SW notified the RP and agreed to move Resident #8 to another room. The PN revealed no documented evidence that the nurses consistently monitored Resident #7's behavior after the physical altercation. The revised care plan dated [DATE] revealed that Resident #7 is possessive of his/her room and does not want people to enter. Goals and interventions included but were not limited to: Resident will not harm self or others; resident will verbalize understanding of the need to control physically aggressive behavior; when the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly, if the response is aggressive, staff to walk calmly away and approach later. The care plan indicated that Resident #7, who had severely impaired cognition and a diagnosis of Dementia, would verbalize understanding of the need to control physically aggressive behavior. However, there was no indication in the CP how Resident #7 would be monitored while in the room with the roommate (Resident #8) where the physical altercations occurred. The facility's policy for behavior management indicate that interventions and approaches will be based on detailed assessment of physical, psychological and behavioral symptoms as well as the potential situational and environmental reasons. Additionally, the policy included that the care plan will include but was not limited to targeted and individualized interventions for the behavioral symptoms, specific, measurable goals for the targeted behavior and how the staff will monitor for effectiveness of the interventions. The PN revealed that on [DATE] at 10:55 am, the UM/LPN #3 documented that Resident #7 and Resident #8 had another physical altercation in the room and unwitnessed. During an interview with the DON on [DATE] at 12:57 pm and UM/LPN #3 on [DATE] at 2:50 pm, they both confirmed that the physical altercation took place in the residents' room, and it was unwitnessed as the residents were not monitored in the room by the nursing staff at that time. The DON further confirmed on that same date at 4:10 pm that the room change for Resident #8 was not attempted again until after the physical altercation recurred on [DATE]. She stated that the physical altercation on [DATE] was considered a minor and isolated incident and Resident #8 refused to transfer to another room. Review of the task form for the month of 11/2022 indicated that CNAs were to monitor for behavior symptoms every shift which included but were not limited to yelling/screaming, kicking/hitting, pushing, and abusive language. Resident #7's task form was not signed/initialed for the following dates and shifts: 7:00 am to 3:00 pm on [DATE], [DATE] to [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; 3:00 pm to 11:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; and 11:00 pm to 7:00 am on [DATE] to [DATE], [DATE], [DATE], [DATE] to [DATE], [DATE], and [DATE] to [DATE]. For the month of 1/2023 for the following dates and shifts: 7:00 am to 3:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; 3:00 pm to 11:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; 11:00 pm to 7:00 am on [DATE], [DATE] to [DATE], [DATE], [DATE], and [DATE] to [DATE]. During an interview with CNA #1 on [DATE] at 11:01 am, she stated that CNAs are expected to monitor residents' behavior and document in the kiosk, ADL records task for behavior monitoring. She further said that CNAs are responsible for completing the task at the end of the shift and if incomplete or blank, it did not happen. During an interview with the DON on [DATE] at 12:57 pm, she stated that CNAs document resident's behavior in the kiosk or ADL record. She further stated that CNA observations and documentations are considered valuable they do not replace nurses observation and documentation. 2b. According to the AR, Resident #8 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dementia and Hypertension. The MDS dated [DATE] and [DATE] revealed a BIMS score of 3, which indicated severely impaired cognitive status, and the Resident required supervision to minimal assistance with ADLs. The nursing PN dated [DATE] at 1:04 pm indicated that Resident #8 was combative with staff and other residents. Resident wanders around the hallway and goes in and out of other residents' rooms. Redirection unsuccessful. The nursing PN dated [DATE] at 8:30 pm indicated that Resident #7 was physically and verbally abusive to staff and residents. The Resident was not easily redirected but finally agreed to go to bed. The CP initiated on [DATE] indicated that Resident #8 may present with a depressed mood related to his/her recent admission to the facility and his/her overall condition. Goals and interventions included but were not limited to: Resident #8 will have improved mood state, such as being happier, having a calmer appearance, and showing no signs and symptoms of depression, anxiety, and or sadness. Behavioral Health consults as needed. Monitor/document as needed risk for harm to self: suicidal plan, a past attempt at suicide, risky actions, intentionally or tried to harm self, sense of hopelessness, and impaired judgment or safety awareness. Monitor/record/report to MD (Medical Doctor) as needed risk for harming others, increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone Review of the PN revealed documentation by the Social Worker (SW) on [DATE] at 10:32 am that Resident #8 was transferred to another room because of incompatibility with the roommate (Resident #7). The RP was made aware of the room change and staff to monitor the adjustment. However, the PN revealed no indication that the room change occurred or Resident #8 was monitored by the nurses for adjustment after the room change. Additionally, there was no documented evidence in the PN explaining what led to the room change. Further review of the PN revealed documentation dated [DATE] at 2:15 pm that Resident #7 and Resident #8 had a physical altercation. They were separated and assessed. The event was reported to the DON, Administrator, and Assistance Administrator. On that same date at 2:53 pm, the SW notified the RP and agreed to move Resident #8 to another room. Review of the MR on [DATE] revealed no documented evidence that the nurses consistently monitored Resident #8 for safety after the physical altercation on [DATE]. In addition, there was no documented evidence that Resident #8 was offered another room change after the resident refused on [DATE] when it was indicated in the RERR summary that the facility staff would actively work on room change options. Review of the PN on [DATE] revealed documentation on [DATE] at 10:55 am about another physical altercation between Resident #7 and Resident #8. The PN indicated that Resident #7 and Resident #8 who had a physical altercation [DATE] continued to share the same room until another resident-to-resident abuse/physical altercation on [DATE]. During an interview with the SW on [DATE] at 11:30 am, she stated that Resident #8 was transferred to another room after the physical altercation on [DATE]. The resident's RP had agreed to the room change but the resident would not stay in the new room, so he/she remained in the same room with Resident #7. The SW confirmed that Resident #8 transferred again to another room after the altercation on [DATE], and Resident #8 had adjusted well to the new room. However, she could not explain why the room change was not attempted again as a precaution when it was indicated in the RERR summary on [DATE] that the facility would actively work on other room options that would be appropriate. Additionally, she could not explain what led to the room change on [DATE] but stated that Resident #7 was very territorial and due to incompatibility During an interview with the surveyor on [DATE] at 11:36 am, LPN #3, unit manager (UM) for Resident #7, could not remember a room transfer for Resident #8 on [DATE]. The revised care plan dated [DATE] for Resident #8 revealed that Resident #8 is at risk for potential negative interaction from or with a resident on the unit who has demonstrated poor impulse control. Goals and interventions included but were not limited to: Resident #8 will be free from danger and injury related to interaction with others; behavior documentation and psychiatric evaluation as needed; maintain a safe distance from the other aggressive or triggered residents; monitor Resident #8 whereabouts for safe interactions with peers. A review of the MR on [DATE] revealed no documented evidence that the nursing staff consistently monitored Resident #8 behaviors, interactions with other residents, and whereabouts as indicated in the revised care plan on [DATE]. Review of the task form for the month of 11/2022 indicated that the following dates and shifts were not signed/initialed: 7:00 am to 3:00 pm [DATE] to [DATE] and [DATE] to [DATE]; 3:00 pm to 11:00 pm on [DATE] to [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], and 11:00 pm to 7:00 am on [DATE] to [DATE], [DATE] to [DATE], [DATE], [DATE], [DATE] to 11[TRUNCATED]