**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: 2562900 Based on interviews, medical record reviews, and review of pertinent facility documentation on 7/22/25 and 7/23/25, it was determined that the facility failed to ensure the safety of a resident (Resident #3) with a known history of illicit drug use with multiple overdoses in the facility who overdosed in the facility on 7/11/25, by: A) monitoring and supervising the resident to ensure illicit drugs were not obtained or used and B.) developing and/or implementing care plan interventions to protect the resident from obtaining illicit drugs and preventing overdoses. This deficient practice was identified for 1 of 14 residents reviewed (Resident #14). On 7/11/25 at approximately 4:30 PM, the Registered Nurse (RN) Supervisor was called to main lobby regarding Resident #3 being found unresponsive with pinpoint pupils by the main elevator. Emergency services (911) were called, and the resident was administered Narcan (a medication to reverse opioid overdose). The resident was transported to the hospital for evaluation and the facility was notified that the resident received Narcan in the emergency room (ER) and was now stable. Interviews with staff on 7/22/25, confirmed that the resident had overdosed on illicit drugs in the facility. A review of the medical record revealed this was the resident's seventh overdose in the facility since November of 2024. The facility's failure to monitor and supervise Resident #3 who had a known history and six previous illicit drug overdoses in the facility placed Resident #3 and all other residents at risk for accidental drug overdoses. This posed the likelihood for serious harm, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 7/11/25 at 4:30 PM, when Resident #3 was found unresponsive in the main lobby and administered Narcan. The facility's Administration was notified of the IJ on 7/23/25 at 5:37 PM. An acceptable Removal Plan was received on 7/25/25 at 10:26 AM. The Removal Plan was verified on-site by the surveyor on 7/29/25. The deficient practice was evidenced by the following:A review of the facility's undated policy titled Policy on Illegal Drug Use included the facility complies with all laws, regulations, and other requirements related to substance abuse. Policy Interpretations and Implementation: 1. All residents admitted to the facility will be asked to sign a contract showing they understand that illegal drugs use (possession, taking of drugs or possession with intent to sell) is not allowed in the facility [.] 2. All residents may be subject to random room searches to ensure illegal substances are not being held within the facility. Any items found during the search will be removed, logged and locked in a designated area until the police are able to collect the items found.4. Residents identified as high risk for illegal drug use by the nursing department will be subject to be searched/have their bags searched by Security or Nursing upon return from authorized Out on Pass Visit. Security is to inform the Nurse in charge/ Director of Nursing (DON) immediately if any resident is found with illegal substances and police will be called. 5. In the event illegal drugs are found on a resident the following procedure must occur: [.] Incident report to be completed-Investigate how the resident received the illegal drugs and put interventions in place to prevent reoccurrence. The surveyor reviewed the medical record for Resident #3. According to the admission Record face sheet (admission summary), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: opioid dependence, hypertension (high blood pressure), and muscle weakness. According to the Minimum Data Set (MDS), an assessment tool dated 7/13/25, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. A review of the Progress Notes (PN) revealed the resident had overdosed from illicit drugs in the facility on 11/1/24, 11/28/24, 1/18/25, 1/28/25, 3/7/25, 3/30/25, and 7/11/25. A review of the PN dated 7/11/25 at 5:51 PM, completed by the Registered Nurse (RN), revealed that at approximately 4:30 PM, she was called to the main lobby regarding a resident's current status. Upon assessment, the resident was found unresponsive by main elevator. The resident was brought to the unit and sternal rub (rubbing the flat bone (sternum) of the chest) was performed and emergency services (911) was called. The resident's vital signs were obtained, and their pupils were pinpoint. Upon Emergency Medical Services' (EMS) arrival, the resident was placed on a non-rebreather (a mask that provides high amounts of oxygen in an emergency situation) and put on a stretcher and sent to the hospital for evaluation. A review of the PN dated 7/11/25 at 5:57 PM, indicated that a call was placed to the hospital at 5:40 PM, to obtain the resident's status. The resident was given Narcan in the emergency room (ER) and was now stable. A review of Resident #3's Care Plan (CP) included a focus area dated 10/17/24, and revised 6/12/25, that the resident had a history of opioid dependence, chronic back pain, on 5/9/25, had a history and potential risk for illicit drug abuse and overdose. The goal initiated on 10/17/24, with a target date of 7/15/25, was to verbalize relief of pain. Interventions included to encourage repositioning in bed to relieve pain; if confirmed diagnosis of overdose, facility will consider revoking out on pass and or may issue a thirty day discharge notice; reinforce facility support groups, virtual [name redacted alcohol and drug support groups] meetings can be arranged; educate the risks of overdose and/or possible death with use of illegal substances; if receiving methadone, methadone clinic also offers meetings; monitor for signs and symptoms of constipation which may be related to pain medication; and provide resident with pain medication as ordered by physician. The CP included an additional focus area dated 10/17/24 and revised 7/14/25, that the resident came from [previous facility's name redacted], has a history of opioid dependence; has a history and potential risk for illicit drug use abuse and overdose dated 7/11/25, and the resident was sent to the ER on [DATE], due to unresponsiveness and returned with diagnosis of opioid overdose. The goal initiated 10/17/24, with a target date of 7/15/25, was the resident will be safe. Interventions prior to the resident's overdose on 7/11/25, were all dated 10/17/24, and included: answer resident's questions honestly and factually to promote trust; assist in relaxation techniques, visualizations, and diversions; discuss consequences of continued substance abuse; encourage and support the resident's ability to take responsibility for their recovery; encourage resident to verbalize fears, feelings, and anxiety; increased staff supervision as needed; and Narcan as ordered. The following interventions were put in place on 7/14/25, current interventions reviewed and remain appropriate; care plan revised and updated; and Administration discussed consideration of thirty-day letter discharge. The Care Plan did not address how a resident with a history of six overdoses in the facility would be supervised and monitored to ensure their safety prior to their seventh overdose in the facility on 7/11/25. A review of the Order Summary Report dated active orders as of 7/1/25, included a physician's order (PO) dated 10/11/24, for Narcan nasal liquid 4 milligrams per 0.1 milliliter (4 mg/0.1 mL); to spray in nostril every twenty-four hours as needed for overdose. An additional PO dated 3/11/25, revealed that the resident was able to Leave the Facility independently even though the resident had multiple drug overdoses at the facility. The PO did not include an order for methadone or methadone clinic as the CP indicated if goes to methadone clinic, they hold meetings. A review of the Facility Reportable Event (FRE) for the illicit drug overdose dated 7/11/25, revealed that on 7/11/25, the resident was found unresponsive in the lobby and emergency services were called. The resident was administered Narcan and brought to the emergency room (ER). Per the ER nurse, the resident received Narcan there too. Included in the investigation and conclusion, Resident #3 indicated that they understood the reason they would be given a thirty-day discharge notice if they violated the drug policy again and the resident promised that [they] would not do this again. On 7/22/25 at 11:45 AM, the surveyor interviewed Resident #3, who stated that they did not recall the date or the exact time of their overdose but stated that they overdosed around smoke time. The resident stated they received what they assumed was a cigarette from another resident, and they smoked it. The resident further stated that after a few minutes, whatever it was took effect and they started to feel dizzy. The resident did not remember anything more except for waking up in the hospital. Resident #3 was unable to provide the surveyor with a name or a description of the resident they received the drugs from. On 7/22/25 at 12:58 PM, the surveyor interviewed the RN Supervisor, who stated that during her evening shift on 7/11/25, she observed Resident #3 went out to the smoking section on the patio to smoke around 3:00 PM. The RN Supervisor stated around 4:30 PM, she received a call from the Receptionist that Resident #3 had passed out, and when she responded to the call, Resident #3 was unresponsive. The RN Supervisor stated they brought the resident to the 3rd floor and provided oxygen and was instructed to administer a dose of Narcan by the DON, and the resident was still unresponsive. The RN Supervisor stated when EMS arrived, an additional dose of Narcan was administered, and Resident #3 remained unresponsive. The EMS placed a non-rebreather mask on the resident and transported them to the hospital. On 7/22/25 at 1:22 PM, the surveyor interviewed the DON, who stated that Resident #3 was given a thirty-day discharge notice after their overdose because they refused to tell the facility what they took or where they got it from. The DON stated the resident would only say they smoked something. The DON stated on the day of the incident, she saw the resident prior to their overdose and that the resident was fine. The DON stated that it had been a been a long time since the resident's last overdose. The DON stated the facility was not actively looking to place the resident in another facility at that time because the Licensed Nursing Home Administrator (LNHA) said the thirty-day notice could be lifted. On 7/22/25 at 1:42 PM, the surveyor interviewed the Social Worker (SW #1), who stated for residents with a history of drug use, they reviewed the drug policy with them, and that they had support groups there that the activities department could set up. SW #1 stated that the facility also posted signs about the groups. SW #1 stated if a resident violated the drug policy, she spoke to them and re-educated them on the drug policy and informed them that their out on pass could be affected or a thirty-day discharge notice could be given. On 7/22/25 at 2:00 PM, the surveyor interviewed SW #2, who stated when residents were first admitted to the facility, she went over the drug policy and had them sign it and informed the resident of the support offered. SW #2 stated if someone violated the drug policy, she met with the resident to re-educate them on the policy and reminded them that they had signed it. SW #2 stated that the DON and LNHA were responsible for revoking the resident's out on pass privileges or issuing a thirty-day discharge notice. On 7/23/25 at 3:07 PM the surveyors interviewed Assistant Director of Nursing (ADON), who stated that drug overdoses were discussed in the meetings, and they reviewed their care plans and interventions. The ADON further stated that if the current interventions in the care plan were appropriate, they add in documentation in the care plan indicating care plan was reviewed, and current interventions are appropriate. The ADON stated that all the care plans for individuals who had a history of drug overdose were reviewed and the interventions were updated. The surveyor inquired if the interventions in the care plan for Resident #3 were appropriate for Resident #3's drug abuse and overdose history. The ADON stated that she felt that Resident #3's current interventions were appropriate. The facility submitted an acceptable Removal Plan on 7/25/25 at 10:25 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice which included: the care plan for Resident #3 was reviewed and updated; daily behavioral monitoring was implemented; random room checks, room checks after going out on pass, and room checks after visitors leaved were implemented. Resident #3 was re-educated by the LNHA and the SW on the policy to prevent illicit drugs from entering the facility, which includes suspension of pass and potential 30-day discharge. The SW re-educated Resident #3 on the availability of counseling/cessation support/ and invited Resident #3 to weekly support groups to ensure safety. The care plans for Resident #3 and residents with history of having overdosed and who have overdosed at the facility were reviewed and updated to include daily behavior monitoring, random room checks, and checks made after visitors leave, in addition to reoffering of cessation support/invitation to support groups/counseling as appropriate. Signage on units to announce support group and advertise available support services. The staff caring for Resident #3 and residents with history of having overdosed and who have overdosed in the facility were re-educated on the prevention of illicit drug abuse and new care plan interventions. The surveyor verified the implementation of the Removal Plan on-site on 7/29/25. NJAC 8:39-27.1 (a)

Deficiency Text Not Available

Complaint #: NJ185458 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 5/8/25, it was determined that the facility failed to a.) update the care plan (CP) with interventions for a resident (Resident #6) who had multiple drug overdose incidents while at the facility and b.) follow the facility's policy titled Policy on Resident Care Planning. On 2/21/25 at approximately 6:30 PM, the Infection Preventionist (IP) observed Resident #6 slumped in his/her wheelchair. Resident #6's fingertips, lips, and lower half of face were cyanotic (blue), and he/she had loud breathing. The IP stated she administered Narcan to the resident. Approximately three minutes later, the resident responded to the Narcan and was sent to the hospital. On 2/22/25, Resident #6 returned to the facility from the hospital with a diagnosis of opiate overdose. On 4/1/25, the resident was found sitting in his/her wheelchair unable to be aroused. Multiple attempts were made to arouse the resident, and he/she remained unresponsive. The doctor was notified, and the resident was sent to the hospital via 911. Resident #6 returned to the facility from the hospital with a diagnosis of opiate overdose. On 5/6/25, the resident was found slumped in his/her wheelchair during rounds. The resident was noted to have twitching in his/her bilateral upper extremities. The doctor was notified, and the resident was sent to the hospital. The Registered Nurse Manager (RNM) stated that the Paramedics gave Resident #6 Narcan. According to the hospital emergency room (ER) documentation dated 5/6/25, the resident's diagnosis for the visit was opioid overdose. The facility did not update Resident #6's CPs to manage the resident's substance abuse after the resident overdosed on 2/21/25, 4/1/25, and 5/6/25. The facility's failure to update the CP with interventions for Resident #6 to prevent further drug usage and overdoses placed all residents in an Immediate Jeopardy (IJ) situation. The IJ began on 2/21/25, was identified on 5/8/25 at 6:00 PM., and was reported to the Licensed Nursing Home Administrator (LNHA). The LNHA was presented with the IJ template at that time. An acceptable removal plan was electronically mailed to the surveyor on 5/13/25 at 4:23 PM, indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. On 5/8/25, Resident #6's care plan was updated. On 5/9/25, the DON, Assistant Director of Nursing (ADON), and IP educated the administrative nursing staff and social workers (SW) were educated on updating and implementing care plans when incidents occur. The DON implemented a process to occur during daily morning clinical meeting to ensure that care plans were updated when incidents occur. The surveyor verified the removal plan on site on 5/15/25 and determined the IJ for F657 was removed as of 5/15/25. After the IJ removal plan, the non-compliance continued from 5/15/25 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for care plans and evidenced by the following: According to the admission Record (AR), Resident #6 was admitted to the facility with diagnoses which included but were not limited to: Opioid Abuse, Hypertension, and Bipolar Disorder. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 4/6/25, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. A review of Resident #6's PN dated 2/21/25 revealed the IP was called into the resident's room at 6:30 PM by staff. The resident was slumped in his/her wheelchair with loud breathing. The resident's fingertips, lips, and lower half of face were cyanotic(blue). Sternal rub was not effective. Narcan was administered at 6:43 PM with positive effect at 6:46 PM. The resident was transferred to the hospital. A review of Resident #6's Emergency Department Documentation (EDD) with a visit date of 2/21/25 revealed under Diagnosis from Today's Visit, Opiate or related narcotic overdose. A review of the PN dated 4/1/25 revealed that Resident #6 was found sitting in his/her wheelchair and unable to be aroused. Multiple attempts were done to arouse the resident, and he/she remained unresponsive. The doctor was notified, and the resident was sent out 911. The resident returned from the hospital and was treated for an overdose. A review of Resident #6's EDD with a visit date of 4/1/25 revealed under Diagnosis from Today's Visit, Opioid overdose. A review of the PN dated 5/6/25 completed by the IP revealed that during rounds Resident #6 was noted to be slumped in his/her wheelchair. Twitching was noted to the resident's bilateral upper extremities. The doctor was notified, and a new order given to send to hospital for change in mental status. 911 was called and the resident was sent to the emergency room (ER). A review of Resident #6's EDD with a visit date of 5/6/25 revealed under Diagnosis from Today's Visit, Overdose opiate. A review of Resident #6's CP revealed a Focus revised on 4/29/25, that Resident #6 had a history of opioid and fentanyl use. admitted to using fentanyl 2 days prior to ER visit to deal with his/her pain. Urine Drug screen (UDS) positive for opioids. Resident #6 had an incident here where he/she was sent to the ER due to AMS (altered mental status) possibly due to use of illegal substance. Resident #6's CP revealed no updated CP interventions after the resident overdosed on 2/21/25, 4/1/25, and 5/6/25. On 5/8/25 at 10:33 AM, the Registered Nurse Unit Manager (RN/UM) stated that the care plans were updated after an incident occurred such as falls, drug overdoses, or any unusual change occurred. The RN/UM stated that she thought that Resident #6's care plans had been updated but she would have to check into it. On 5/8/25 at 2:35 PM, the surveyor interviewed the Director of Nursing (DON) who acknowledged that Resident #6's care plan interventions were not updated after the resident's multiple drug overdoses. The DON stated that the care plan interventions that were already in place for the resident were appropriate for his/her multiple drug overdoses and did not need to be updated after the drug overdoses occurred. The DON further stated Obviously, the interventions didn't work if he/she had another overdose. The DON indicated that the care plans were updated when there is a change in condition or a significant event. The DON stated Yes, the care plan should have been updated. The DON further indicated that it was important to update the care plans because it gives an accurate picture of the resident. On 5/8/25 at 4:16 PM, the surveyor conducted a follow-up interview with the DON. The DON stated that the expectation was that the care plans should be updated the first business day after an incident occurred. The DON indicated that the Nurse Manager or Assistant Director of Nursing were responsible for updating the resident care plans. The DON further indicated I think it wasn't updated because we as a team felt he/she had everything in place. A review of the facility's policy titled Policy on Resident Care Planning dated June 2024 revealed under Purpose, The main purpose of the Care Plan is the resident's quality of life and safety and updated with any changes in diagnosis or condition. Under Procedure, 2. The care plan will be reviewed and updated by the unit manager and other departments as changes in the resident occur. 3. The Care Plan is updated as warranted by the resident's changes and preferences. NJAC 8:39-11.2 (e) (1) (2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ182907, NJ186028 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 5/7/25, 5/8/25, and 5/9/25 it was determined that the facility failed to complete thorough investigations when A) Resident #15 was observed to have bruising, swelling and a scratch to her/his face. B) when a resident reported witnessing an alleged sexual abuse between another resident (Resident #3) and the Licensed Practical Nurse (LPN #1). The facility also failed to ensure its policy titled Abuse, Resident Behavior and Facility Practice was implemented for the alleged physical abuse and alleged sexual abuse allegations. 1. On 10/12/24 at approximately 8:30 P.M, the Unit Manager (UM) was notified by LPN #6 that Resident #15 had a scratch on his/her face. LPN #6 reported that Resident #8 left the room that he/she shared with Resident #15 cursing and stating he/she had punched the resident (Resident #15). The DON failed to conduct a thorough investigation. The DON stated that Resident #15 was alert and oriented and denied being hit by their roommate (Resident #8). The DON also said, I spoke with both of them (Resident #8 and Resident #15) but they both denied that Resident #15 was hit. No follow-up investigation was conducted outside of the grievance filed for Resident #15. The facility failed to follow its policy titled, Abuse, Resident Behavior and Facility Practice and protect facility residents when the DON failed to immediately implement the abuse policy for the alleged physical abuse and to conduct a thorough investigation for the alleged physical abuse. This placed Resident #15 and all residents in an Immediate Jeopardy (IJ) situation. The IJ began on 10/12/24, was identified on 5/9/25 at 5:04 P.M. At this time, the IJ Template was presented to the DON. An acceptable removal plan was electronically emailed to the surveyor on 5/13/25 at 4:24 P.M., indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. All the facility staff were educated on the facility's policy abuse- prevention, recognition of and types of abuse, reporting urgency and reporting to the regulatory agencies. The LNHA and DON audited all incidents and accidents from 1/25 to 5/25, to assure there were no additional unresolved allegations of abuse identified. On 5/12/2025, the LNHA implemented an auditing process to assess potential abuse and ensure concerns are addressed through the policy. Auditing of all incidents/accidents will occur Monday through Friday, with weekend (Saturday and Sunday) incidents/accidents included in the Monday audit. 2. On 4/25/25, Resident #2 told LPN #1 that he/she was going to report her for raping Resident #3. LPN #1 reported this immediately to the Director of Nursing (DON) and LPN #1 was suspended. The DON stated that Resident #2 informed her on 4/25/25 that the alleged sexual abuse with LPN #1 and Resident #3 had occurred three weeks prior and then later stated the incident occurred six weeks ago. The DON stated she conducted an investigation and suspended LPN #1 immediately after the sexual abuse allegation was reported to her. The DON stated she did not conduct interviews or assessments for residents on LPN #1's assignment and did not obtain witness statements from other staff that worked on the unit when the sexual abuse allegation was made. The facility failed to follow its policies and procedures and protect the facility residents by not conducting a thorough investigation into whether other residents or staff members had any reports of abuse allegations involving LPN #1. This placed the residents being cared for by this staff member in an immediate jeopardy (IJ) situation. The IJ began on 4/25/25, was identified on 5/8/25 at 6:00 P.M., and was reported to the Licensed Nursing Home Administrator (LNHA). The LNHA was presented with the IJ template at that time. An acceptable removal plan was electronically mailed to the surveyor on 5/13/25 at 4:23PM, indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. On 5/8/25, the residents that were on LPN #1's schedule were interviewed and assessed for any complaints of inappropriate behaviors requested or witnessed by LPN #1. On 5/9/25, the DON and the LNHA educated the social workers (SW) and administrative nursing staff on the facility's policy on reporting of abuse and conducting a thorough investigation. The LNHA and the DON conducted an investigation into incidents and accidents from January 2025. On 5/12/2025, the LNHA implemented an auditing process to assess potential abuse and ensure concerns are addressed through the policy. Auditing of all incidents/accidents will occur Monday through Friday, with weekend (Saturday and Sunday) incidents/accidents included in the Monday audit. The surveyor verified the removal plan on site on 5/15/25 and determined the IJ for F610 was removed as of 5/15/25. After the IJ removal plan, the non-compliance continued from 5/15/25 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. This deficient practice was identified for 4 of 18 residents (Resident #2, Resident #3, Resident #8, and Resident #15) reviewed and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of unknown and a today's date of 4/25/2025 revealed that Resident #2 came up to LPN #1 and told her that he/she was going to report her for having sex with Resident #3. LPN #1 informed the DON and was suspended immediately pending an investigation. A review of the medical records for Resident #2 and #3 indicated the following: Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Anxiety Disorder, Persistent Mood Disorder, and Hypertension. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 4/14/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Resident #3 was admitted to the facility with diagnoses which included but were not limited to: Anoxic Brain Damage, Tracheostomy, and Epilepsy. According to the Quarterly MDS, and assessment tool dated 3/19/25, Resident #3 had a BIMS score of 99 which indicated the assessment could not be completed. The MDS further revealed the resident was non-verbal and dependent on staff with all activities of daily living (ADLs). On 5/7/25 at 10:17 AM, the surveyor interviewed Resident #2, who stated he/she went into the hallway at 3:00 AM and observed the medication cart in front of Resident #3's room. Resident #2 could not provide the surveyor with the exact date the alleged incident occurred. Resident #2 stated he/she waited about half an hour for LPN #1 to come out Resident #3's room. Resident #2 then went back to his/her room for a brief period and then returned to the hallway. Resident #2 stated he/she still observed the medication cart in front of Resident #3's room. Resident #2 stated he/she pushed the medication cart and went into Resident #3's room and observed LPN #1 pull the privacy curtain and jump off Resident #3's bed while fixing her shirt and pants. Resident #2 stated he/she observed Resident #3 with an erection. Resident #2 further indicated he/she asked LPN #1 what she was doing. The resident stated that the LPN #1 told him/her that she was giving medical attention to Resident #3. Resident #2 indicated he/she reported the alleged incident the next day to the Ombudsman and the supervisor but was unsure of the supervisor's name. On 5/7/25 at 2:30 PM, the surveyor interviewed the DON who stated that on 4/25/25, LPN #1 reported to the supervisor that Resident #2 had alleged that she raped Resident #3. The DON stated she immediately suspended LPN #1 pending an investigation. The DON stated she spoke with Resident #2, and he/she stated that LPN #1 had sex with Resident #3. She further stated she asked him/her when the incident occurred, and Resident #2 stated three weeks ago and then changed it to six weeks ago. The DON indicated she conducted a physical assessment on Resident #3 and interviewed Resident #2, LPN #1, the Assistant Director of Nursing (ADON), Infection Preventionist (IP), and the clinical manager (CM). The DON stated No, I did not speak to any residents she (LPN #1) cared for. No, I did not speak to any other staff members. I felt the people I spoke with gave me an honest report. The DON indicated that in the past she had collected resident and staff statements but denied collecting them for this incident. The DON further stated If I feel it is warranted, I would interview the residents. I did not feel it was warranted because I did not have a time frame of when the allegation occurred. I didn't interview other staff because I did not have a timeframe of when the incident happened. On 5/8/25 at 4:29 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that a thorough investigation should be conducted for all abuse allegations. The LNHA further indicated All residents on a staff member's assignment for an abuse allegation should be interviewed. The LNHA stated that the staff working when the sexual abuse allegation occurred should have been interviewed as well. On 5/8/25 at 4:42 PM, the surveyor conducted a follow-up interview with the DON. The DON stated there has never been an abuse allegation in past involving LPN #1. The surveyor left a voicemail message for LPN #1 on 5/8/2025 and LPN #1 did not return the surveyor's phone call. A review of the medical records for Resident #8 and #15 indicated the following: Resident #8 was admitted to the facility with diagnoses which included but were not limited to: Opioid Abuse, Depression, and Anemia. According to the Annual MDS, dated [DATE], Resident #8 had a BIMS score of 15 which indicated the resident's cognition was intact. Resident #15 was admitted to the facility with diagnoses which included but were not limited to: Cerebrovascular disease, Hypertension, Aphasia. According to the Quarterly MDS, an assessment tool dated 3/2/25, Resident #15 had a BIMS score of 14, which indicated the resident's cognition was intact. On 5/9/25 at 12:02 P.M, during an interview with the DON and the LNHA, the DON stated, I spoke with Resident #8 on the day I found out about the incident. I thought I wrote that on the incident report, but I guess I didn't. When the surveyor asked if an investigation was conducted, the DON said, I spoke with both of them (Resident #8 and Resident #15) but they both denied that Resident #15 was hit. No follow up investigation was conducted outside of the grievance filed for Resident #15. When the surveyor asked the DON if she spoke to witnesses, she stated, I spoke to staff but I didn't document. Nobody had witnessed any altercation. Speaking with staff I should have documented and collected witness statements. Our policy was not followed. The LNHA and DON both acknowledged a thorough investigation was not completed for the physical abuse and their policy was not followed. A review of the facility's policy titled Abuse, Resident Behavior and Facility Practice with a revised date of 5/24 revealed under Purpose, To ensure timely and thorough investigation of abuse, neglect, and/or mistreatment of residents. Under Investigation, 3. The DON/designee: a. Review the accident/incident report; b. Obtains written statements of staff assigned to the Resident for: i. the shift during which the allegation is noted; ii, a minimum of 16 hours prior to the incident if indicated or appropriate; c. Interview witnesses, in any; d. Reviews the Resident's record; e. Reviews staff assignments and staff performance; f. Corrective action is taken including but not limited to progressive counseling, education, increased supervision, up to and including termination as appropriate; g. Polices are re-evaluated and revisited if necessary to prevent recurrences; h. Reports findings to the Administrator. NJAC 8:39-9.3 (a)

Complaint #: NJ185458 Based on interviews, medical record reviews, and review of pertinent facility documentation on 5/8/25 and 5/9/25, it was determined that the facility failed to: A) ensure the residents' safety by failing to implement interventions to prevent drugs from entering the facility and overdose incidents from occurring while in the facility, B) conduct a thorough investigation into a resident's (Resident #6) drug overdoses, and C) notify the police and the New Jersey Department of Health (NJDOH) of the residents' drug overdoses. 1. On 2/21/25 at approximately 6:30 PM, the Infection Preventionist (IP) observed Resident #6 slumped in his/her wheelchair. Resident #6's fingertips, lips, and lower half of face were cyanotic (blue), and he/she had loud breathing. The IP stated she administered Narcan to the resident. Approximately three minutes later, the resident responded to the Narcan and was sent to the hospital. On 2/22/25, Resident #6 returned to the facility from the hospital with a diagnosis of an opiate overdose. 2. On 4/1/25, Resident #6 was found sitting in his/her wheelchair unable to be aroused. Multiple attempts were made to arouse the resident, and he/she remained unresponsive. The doctor was notified, and the resident was sent to the hospital via 911. Resident #6 returned to the facility from the hospital with a diagnosis of opiate overdose. 3. On 5/6/25, Resident #6 was found slumped in his/her wheelchair during rounds. The resident was noted to have twitching in his/her bilateral upper extremities. The doctor was notified, and the resident was sent to the hospital. The Registered Nurse Unit Manager (RN/UM) stated that the Paramedics gave Resident #6 Narcan. According to the hospital emergency room (ER) documentation dated 5/6/25, the resident's diagnosis for the visit was opioid overdose. The facility had knowledge that Resident #6 had a history of opioid dependence and failed to implement interventions that ensured the residents safety and prevent illicit drugs from entering the facility. This resulted in Resident #6 having multiple drug overdoses while in the facility and being sent to the hospital for treatment of their symptoms. The facility failed to report Resident #6's multiple drug overdoses that occurred while in the facility to the NJDOH and the local police. The facility's failure to protect Resident #6 from drug overdoses placed all residents with a history of opioid dependence in an Immediate Jeopardy (IJ) situation. The IJ began on 8/24/24, was identified on 5/8/25 at 6:00 PM, and was reported to the Licensed Nursing Home Administrator (LNHA). The LNHA was presented with the IJ template at that time. An acceptable removal plan was electronically mailed to the surveyor on 5/13/25 at 4:23 PM, indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. The Social Worker (SW) provided education to all residents with a history of drug overdose on the medical risks with illegal drug use, police involvement, possible discharge from the facility, and revoking of facility leave privileges. Education was provided to the residents on cessation programs and psychiatric consultations. Signage was placed at the entrance of the facility stating that drugs and alcohol were not allowed in the facility. Facility staff were educated that any drug overdose is to be reported to the appropriate regulatory agencies immediately. The facility staff were educated on the new interventions implemented to help prevent illegal drug use. These new interventions included education to the residents on the risks of a drug overdose, room searches, police involvement, possible discharge from the facility and revoking of facility leave privileges. The LNHA and the DON implemented an audit process that occurred during the morning daily clinical meeting that will identify the residents with a new history of opioid use and any drug overdoses that occur in the facility and that the police were called, and the appropriate regulatory agencies were notified. The surveyor verified the removal plan on site on 5/15/25 and determined the IJ for F689 was removed as of 5/15/25. After the IJ removal plan, the non-compliance continued from 5/15/25 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. The deficient practice was evidenced by the following: According to the AR, Resident #6 was admitted to the facility with diagnoses which included but were not limited to: Opioid Abuse, Hypertension, and Bipolar Disorder. According to the Quarterly MDS, an assessment tool dated 4/6/25, Resident #6 had a BIMS score of 14 out of 15, which indicated the resident's cognition was intact. A review of Resident #6's PN dated 2/21/25 completed by the IP revealed the IP was called into the resident's room at 6:30 PM by staff. The resident was slumped in his/her wheelchair with loud breathing. The resident's fingertips, lips, and lower half of face were cyanotic (blue). A sternal rub was not effective (used to assess a person's level of consciousness) Narcan was administered at 6:43 PM with positive effect at 6:46 PM. The resident was transferred to the hospital. A review of Resident #6's Emergency Department Documentation (EDD) with a visit date of 2/21/25 revealed under Diagnosis from Today's Visit, Opiate or related narcotic overdose. A review of the PN dated 4/1/25 completed by the Licensed Practical Nurse (LPN) revealed that Resident #6 was found sitting in his/her wheelchair and unable to be aroused. Multiple attempts were made to arouse the resident, and he/she remained unresponsive. The doctor was notified, and the resident was sent out 911. The resident returned from the hospital and was treated for an overdose. A review of Resident #6's EDD with a visit date of 4/1/25 revealed under Diagnosis from Today's Visit, Opioid overdose. A review of the PN dated 5/6/25 completed by the IP revealed that during rounds Resident #6 was noted to be slumped in his/her wheelchair. Twitching was noted to the resident's bilateral upper extremities. The doctor was notified, and a new order given to send to hospital for change in mental status. 911 was called and the resident was sent to the emergency room (ER). A review of Resident #6's EDD with a visit date of 5/6/25 revealed under Diagnosis from Today's Visit, Overdose opiate. A review of Resident #6's CP revealed a Focus revised on 4/29/25, that Resident #6 had a history of opioid and fentanyl use. admitted to using fentanyl 2 days prior to ER visit to deal with his/her pain. Urine Drug screen (UDS) positive for opioids. Resident #6 had an incident here where he/she was sent to the ER due to AMS (altered mental status) possibly due to use of illegal substance. On 5/8/25 at 9:24 AM, the surveyors interviewed Resident #7 who stated he/she was the facility's resident council President. Resident #7 stated that he/she had seen the nurses, and the Paramedics give Narcan to Resident #6 who had overdosed on Tuesday 5/6/25. On 5/8/25 at 10:33 AM, the surveyors interviewed the RN/UM who stated, Yes, he/she went to the hospital because he/she appeared high. The RN/UM stated she was unaware if the resident had taken any illegal drugs. The RN/UM further stated Resident #6 went to the Methadone Clinic on 5/5/25 for an initial dose. The RN/UM stated Yes, he/she signs himself/herself out on pass. He/she is alert and oriented and is his/her own responsible party. On 5/8/25 at 11:55 AM, the surveyors interviewed Resident #6 who stated that he/she was at the end of the facility's driveway on 5/6/25, when the staff reported that he/she was nodding out. The resident stated that he/she received Narcan. Resident #6 further stated I refused to go to the hospital, and they said I had to go. Resident #6 stated I smoked some weed that day. I bought it from a friend of mine. My friend was coming by, and I asked him to get it for me. Resident #6 further stated Between the blunt and the other meds, I nod out. Resident #6 indicated that he/she had received Narcan in the facility before. The resident stated Last time, it was a couple months. I didn't take anything, but they said I did and they Narcan me. On 5/8/25 at 1:21 PM, the surveyors interviewed the IP who stated Resident #6 was hypertensive, lethargic, and had twitching while sitting outside of his/her room on 5/6/25. The IP stated she immediately called 911. The IP indicated I am not sure if he/she received Narcan. The IP stated that on 2/21/25 she administered Narcan to Resident #6. The IP further stated the resident's fingers were cyanotic (blue) and was noted to had snored breathing. The resident wasn't completely unresponsive, but he/she was moaning. Resident #6 responded to the Narcan. I had my stopwatch on and literally three minutes later, he/she woke up. The IP stated she completed an incident report for the overdose that occurred on 2/21/25. The IP further indicated that she did not complete an incident report for the drug overdose that occurred on 5/6/25 because she wasn't sure if Resident #6 had overdosed at that time. On 5/8/25 at 1:44 PM, the surveyors interviewed the DON in the presence of the LNHA. The DON stated that Resident #6 went to the hospital on 5/6/25 because the resident had high blood pressure and twitching. The DON further stated she would have to review Resident #6's medical record to find out further information. The DON stated, Any resident with a BIMs score 12 or above can go out of the facility to drink and do drugs. She further stated, This was made clear to me by the Ombudsman. The DON stated that the facility worked with Resident #6 to get him/her to go to the Methadone Clinic and that the resident agreed to go within the last week. On 5/8/25 at 1:44 PM, the surveyors interviewed the LNHA in the presence of the DON. The LNHA stated I can't say for a fact that the residents are bringing in drugs. We can't search them. The LNHA further stated We understand we are in a drug infested neighborhood. We are doing the best we can to prevent the drug problem, but we can't infringe on the resident's rights. On 5/8/25 at 2:35 PM, the surveyors conducted a follow-up interview with the DON who reviewed Resident #6's PNs in the presence of the surveyors. The DON stated she did not investigate Resident #6's multiple drug overdoses that occurred at the facility. The DON stated that she thought that drug overdose that occurred on 4/1/25 was from the resident's prescribed medication and that was why an investigation was not conducted. The DON indicated that at that time, the facility changed the resident's plan of care by discontinuing his/her prescribed opioid medications. The DON stated that after the drug overdose that occurred in February, she had a discussion with the resident about his/her actions. The DON indicated No, I did not do an investigation. He/she was allowed outside and was not forthcoming about using drugs. The DON stated I have not reported drug overdoses to the DOH because I have not seen that in the regulations. The DON further indicated I would call the police if I suspected someone was selling drugs. The DON stated that she was made aware by staff but could not remember who Resident #6 visited at the end of the facility's property recently and were suspicious that the resident was getting drugs. The DON further stated, I have not investigated this matter so far because I didn't have proof it happened. A review of the facility's policy titled Illegal Drug Use dated 6/2024 revealed The facility recognizes that we have an increase in admission of residents with a history or recent active drug use. If drug use is suspected, resident assessment and follow up treatment, if warranted is provided. A review of the facility's policy titled Policy and Protocol for Incident Reporting with a revised date of 9/2024 revealed The Administrator and/or Director of Nursing will process all Reportable Events to the advocacy agencies required by state and federal regulations. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint Intake #NJ162088 Based on observations, interviews, record reviews, document review, and facility policy review, it was determined the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #1) of 5 sampled residents reviewed for elopement. The lack of an effective audible alarm on an exit door and lack of adequate supervision resulted in Resident #1 eloping from the facility and being found deceased on a local highway on [DATE]. The facility door alarmed when the resident exited; however, facility staff did not hear the alarm, allowing the resident to exit the facility without staff's knowledge. At the time of the survey, there were 3 residents identified as at risk for elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25(d)(2) Accidents/Supervision at a scope and severity of J. The IJ was determined to have existed on [DATE], when Resident #1 exited the building without staff knowledge and was found by law enforcement outside the facility, deceased . The facility developed and implemented a corrective action plan, and the IJ was determined to have been removed and the noncompliance corrected on [DATE], prior to the survey entrance date. On [DATE] at 5:38 PM, the Administrator, Director of Nursing (DON), Corporate Consultant #2, Administration Consultant, and Social Service Consultant were informed of the Past Noncompliance Immediate Jeopardy situation. Findings included: Review of a facility policy titled, Door Check, revised 10/2022, revealed, Purpose: To ensure the security of facility residents and personnel and door closure integrity. Policy: Facility exit stairwell doors will be monitored monthly with door code changes by the Maintenance Department. Procedure: A. Maintenance personnel shall perform rounds of facility to evaluate the integrity/security of exit doors and stairwells on a monthly basis, or more often as necessary. B. Monthly rounds shall be documented on a log form with date and result. Comments will be added as necessary. Any problems must be reported on the log form and immediately reported to the Director of Maintenance and Administrator. Review of an admission Record revealed the facility admitted Resident #1 on [DATE] with diagnoses that included dementia without behavioral disturbance and Alzheimer's disease. Review of an Elopement Assessment, dated [DATE], revealed Resident #1 could follow instructions, was ambulatory, could communicate, had a history of wandering, and had a diagnosis of dementia/cognitive impairment. Review of the Standard Assessments screen in the resident's electronic medical record indicated Resident #1 scored 8 on this elopement assessment. The scoring tool on the assessment indicated a score of 0 to 8 indicated a low risk for elopement. Review of Progress Notes, dated [DATE] at 4:58 PM, revealed Resident #1 was oriented to person, extremely confused, wandered, and walked frequently inside and outside of their room. Review of a Care Plan, dated as initiated [DATE], revealed Resident #1 had memory loss. Interventions directed staff to cue, reorient, and supervise or assist the resident as needed and to continue to anticipate Resident #1's needs. Review of Progress Notes, dated [DATE] at 4:14 PM, revealed Resident #1 was alert with some confusion and wandered around the floor at times. Review of Progress Notes, dated [DATE] at 4:33 PM, revealed Resident #1 was alert and able to make their needs known. The resident was in their room most of day watching television, and would sometimes go into a relative's room. Review of Progress Notes, dated [DATE] at 3:19 PM, revealed Resident #1 was alert with some confusion, walked around for a while, and stayed in their own room most of the shift. Review of Progress Notes, dated [DATE] at 2:30 PM, revealed Resident #1 was alert, confused, and visited a relative's room often. Review of a facility-reported incident report, dated [DATE], revealed Resident #1 eloped from the facility on [DATE] and was hit by a car and expired. Review of Progress Notes, dated [DATE] at 11:00 PM, revealed an entry written by Registered Nurse (RN) #1 that indicated Resident #1 was received in the resident's room watching television. The resident was oriented to self and confused. Resident #1 walked back and forth from their room and a relative's room. Around 8:00 PM, Resident #1 was sitting in a chair watching television with a relative. RN #1's note indicated the medication nurse provided information that Resident #1 was sitting in a chair watching television with their relative when the medication nurse provided a supplement to the resident's relative around 9:00 PM, and Resident #1 had shown pictures to a nursing assistant around the same time. The note revealed two law enforcement officers arrived at around 9:45 PM and informed RN #1 of Resident #1's unfortunate passing. Review of the evening shift staffing schedule, dated [DATE], revealed Licensed Practical Nurse (LPN) #8, LPN #9, Certified Nurse Aide (CNA) #11, CNA #12, and RN #1 were on duty during the shift when Resident #1 eloped from the facility. During an interview on [DATE] at 3:16 PM, LPN #8 stated Resident #1 was confused at times. The resident stayed in their room or their relative's room and watched television. LPN #8 stated there had been no issues with Resident #1 attempting to leave the floor or go out the exit doors to the stairwells. When asked the last time the LPN had observed Resident #1, she stated it was between 9:00 PM and 9:15 PM, and the resident was in a recliner in their relative's room. The LPN stated she then went to another floor to get some medication and did not hear an alarm when she returned to the floor. LPN #8 stated she was shocked when RN #1 told her what happened. During an interview on [DATE] at 4:00 PM, RN #1 stated she was the supervising nurse the night Resident #1 left the floor by going down the stairs. The RN stated the resident suffered from dementia and stayed in the resident's room or their relative's room, and on occasion would come as far as the nurses' station. The RN stated she supervised all floors and was not on the floor when the resident left the facility. RN #1 stated the guard at the front did not see anyone go out the front door. The RN stated the alarm worked but she could not hear it from the nurses' station when she came back onto the floor. During an interview on [DATE] at 4:22 PM, LPN #9 stated she was the charge nurse the night Resident #1 got out of the building. The LPN stated Resident #1 would wander from the resident's room to their relative's room, and to the nurses' station. The LPN stated Resident #1 was at the nurses' station between 9:00 and 9:15 PM before the incident. LPN #9 stated Resident #1 was in their relative's room when medications were provided to the relative about 9:30 PM by LPN #8. LPN #9 stated she could not hear the alarm when Resident #1 opened the door. LPN #9 indicated she talked with the two aides working on the hall, and they were providing care in other resident' rooms and did not hear the alarm. LPN #9 revealed she could not hear the door alarm from the nurses' station because the doors were too far away. During an interview on [DATE] at 9:36 AM, CNA #11 stated she was working the night Resident #1 left the building. The CNA stated she last saw Resident #1 between 9:00 PM and 9:15 PM watching television in their relative's room. CNA #11 stated she and CNA #12 were in another resident's room providing care and did not hear the alarm on the door sounding. The CNA stated they were in the other room [ROOM NUMBER] to 15 minutes and did not hear the alarm sound. CNA #11 stated she received training on elopement and residents who wandered upon being hired. The CNA stated when asked by the Administrator, she did let him know the CNAs could not hear the alarm sounding. During an interview on [DATE] at 9:55 AM, CNA #12 stated she worked on the 3:00 PM to 11:00 PM shift with Resident #1 on [DATE]. The CNA stated the last time she saw Resident #1 was between 8:00 PM and 8:30 PM in the resident's relative's room watching television. CNA #12 stated she was in another resident's room providing care with CNA #11 between 9:30 PM and 10:00 PM. CNA #12 stated when they had completed care, LPN #8 was crying and told them what happened. The CNA stated she never heard the alarm sounding on [DATE]. On [DATE] at 3:40 PM, the egress doors where Resident #1 exited the facility were observed with the Administrator present. The Administrator stated the resident had gone down the stairwell, out the egress doors, and through the unlocked gate. The Administrator stated the resident went along the building and through another fenced area where the dumpster and compactor were located. The Administrator pointed to the street to indicate the area where the incident with Resident #1 happened. During an interview on [DATE] at 4:40 PM, the Maintenance Director stated before the incident involving Resident #1, he would check the doors but did not document those checks anywhere. He stated the alarms were not loud enough to be heard at the end of the hallways with all the noise in the facility. During an interview on [DATE] at 4:55 PM, the Administrator stated he arrived at the facility at approximately 10:30 PM on [DATE], and the alarm was still sounding. The Administrator stated he entered the floor near the nurses' station and could not hear the alarm until he was right next to the door. He stated the staff could not hear the alarm when going into and out of rooms to provide resident care. During an interview on [DATE] at 7:05 PM, the Administrator stated the back patio was for barbecues and activities during the warm months. The Administrator stated he did not know if a lock had been in place on the gate in the past or if it was ever checked. On [DATE] at 8:45 AM, the area outside the compactor was observed. The area was approximately 50 feet from Highway 29. There was a sidewalk from the compactor area that led to the street. During an interview on [DATE] at 9:25 AM, the Assistant Director of Nursing (ADON) stated the interdisciplinary team discussed the elopement risk for Resident #1 on admission and determined the resident wandered to and from their relative's room and had no exit-seeking behaviors. On [DATE] at 10:24 AM, the Maintenance Director clarified the facility's old policy for checking alarm doors. He stated the old policy was to check the doors once a month to make sure they sounded and change the code to open the door. The Maintenance Director stated the alarms all sounded the same, but he never went down the hall to see if it could be heard. On [DATE] at 11:00 AM, the compactor area was observed with the Administrator and the Maintenance Director. The Administrator stated the gate must have been ajar because the approximate six-inch gap the gate had when closed would not be wide enough for the resident to get through. The Administrator confirmed the speed limit on Highway 29 where the incident occurred was 40 miles per hour. On [DATE] at 2:40 PM, the video surveillance footage from [DATE] was viewed with Corporate Consultant #2. The video showed Resident #1 walking across the concrete patio located on the south side of the building at 9:28 PM and 38 seconds. The resident left the camera view at 9:29 and 16 seconds. At 9:33 PM, the resident was observed on the inside of the gated area where the dumpster and compactor were located. Resident #1 stepped sideways and was outside the gated area. The resident turned left and walked toward Highway 29. Resident #1 was observed walking down the sidewalk towards Highway 29, reaching the road, and crossing the road at 9:34 PM. Resident #1 turned right, headed north on the median, and went out of camera view. Resident #1 entered the camera view heading south on the median at 9:44 PM, attempted to cross the street again at 9:46 PM, and was struck by an oncoming car. Resident #1 was pushed approximately thirty feet, landing on the road. Resident #1 was then struck by two additional cars. On [DATE] at 6:20 PM, the facility provided a copy of a corrective action plan that was developed and implemented beginning on [DATE] after Resident #1 got out of the facility. Review of the plan revealed the following: Trenton police notified facility in person at approximately 9:50 p.m. [PM] to speak with nursing supervisor [RN #1]- [DATE] [[DATE]]. Nursing supervisor, [RN #1] contacted DON. DON notified Administrator. [DATE] Full house resident census head count completed on all units. [DATE] DON on site to commence investigation and conducted resident unit check, interview staff and obtain statements. [DATE] DON met with [local] Police Office answering questions related to demographics. [DATE] DON rounds with staff on all units. [DATE] Increased supervision and monitoring of second floor unit by nursing staff and supervisors until door checks completed. started [DATE] Administrator on site [DATE] around 10:30 pm [PM]. Third party door alarm vendor contacted at 11:45 p.m. on [DATE]. NJDOH [New Jersey Department of Health] notified approximately 11:50 p.m. on [DATE] via phone call. Family notification by administrator approximately 12:15 a.m. on [DATE] [[DATE]]. Voice message notification left for MD [medical doctor] approximately between 12-1am [12:00 - 1:00 AM] on [DATE]. Maintenance Director called in to facility to perform door checks 12:18 am [AM] [DATE], arrived at facility around 12:30 am. Third party alarm company arrived to facility around 3:30 am on [DATE] conducts full house audit of all unit, stairwell and door alarms and found all other door alarms to be sufficient volume. Maintenance Director conducted full house audit/check of all unit stairwell, door alarms and locking mechanism on [DATE]. Secondary alarm installed on second floor unit north and south unit stairwell at around 4 am on [DATE]. Initiation of exit door, stairwell alarm and door lock checks twice daily by maintenance started on [DATE]. Nurse practitioner contacted by DON approximately 6-7 am on [DATE]. DON contacted medical director at approximately 7:30 am on [DATE]. [DATE] starting at 6 am: Review of the following policies and procedures: elopement policy and procedure, exit door egress alarm policy and procedure, elopement risk assessment policy and procedure, elopement risk assessment on all in house residents, facility education on response to alarms policy and procedures for elopement, purposeful rounding, dementia, wandering behaviors. Whole house elopement risk assessment completed on [DATE]. Ad hoc QAPI [Quality Assurance and Performance Improvement] meeting completed on [DATE]. Care plans for those residents deemed at risk for elopement reviewed and revised as necessary on [DATE]. Reportable event form submitted to NJDOH via email at 3:47 pm on [DATE]. Outdoor rounds completed on [DATE] and [DATE]. Lock installed on patio gate on [DATE]. Audits to commence: New Admissions Elopement Risk Audit commenced on [DATE]. Additional audits to be started included: Staff Knowledge of Elopement Prevention and Management, Staff Knowledge to response to egress door alarms, Audit to monitor proper function for all egress doors and alarms. Care plan agenda checklist reviewed and revised to include the quarterly elopement risk assessment. One elopement drill per shift per month. The surveyor conducted onsite verification on [DATE] to confirm the facility had implemented all components of the corrective action plan. After conducting the following interviews and record/document reviews, it was determined the facility implemented all components of the action plan and the deficient practice was corrected on [DATE] prior to the survey entrance. Review of statements from RN #1, LPN #9, CNA #11, CNA #12, LPN #8, dated [DATE] and [DATE], revealed each staff member working on Resident #1's floor on the evening of [DATE] provided a witness statement and signed it. The DON signed each statement. Review of a third-party alarm company invoice dated [DATE], indicated the company made an emergency service call at the facility and tested all the doors to ensure they were functioning properly. Review of an email to the Administrator, dated [DATE] at 6:47 AM, indicated a third-party alarm company arrived at the facility at 3:30 AM and performed a site inspection to make sure all the doors were working properly with the delayed egress and alarms. Further review of the email indicated all doors were tested and working as they should with proper equipment on them as of 6:45 AM. Review of a document titled, Simulated Elopement drill done on [DATE] with Nursing staff revealed between 1:30 AM and 5:00 AM, the facility reviewed the elopement policy with staff present in the facility, and the staff gave verbal feedback on what to do when a resident was missing and the importance of alarm response and rounding. Review of in-service documents titled, Elopement Risk Prevention: Dementia, wandering restless behaviors, and purposeful rounding, dated 03/2023, revealed staff received education on identifying elopement, wandering, and unsafe wandering. Staff members were given examples of elopement and elopement prevention interventions and educated on practices that would promote resident safety and prevent elopement. Facility staff members signed attendance forms indicating they attended the in-service. During an interview on [DATE] at 3:16 PM, LPN #8 stated after the incident with Resident #1, the facility provided in-services on elopement and knowing where the at-risk residents were located. The LPN further stated they were to go and check on an alarming door and go into the stairwell to check and make sure no residents had exited. On [DATE] from 3:24 PM through 3:31 PM, egress doors were observed with LPN #13. All three stairwell alarms were activated on the second floor, resulting in a loud audible alert. A red light also flashed when the doors were opened. Staff came to the door promptly to check the alarm. On [DATE] at 3:40 PM, the egress doors where Resident #1 exited the facility were observed with the Administrator present. Outside the doors, there was a fence around a concrete platform. There was a locked gate on the left side of the patio. During an interview on [DATE] at 4:00 PM, RN #1 stated there had been training on elopement and checking the doors when they alarmed since the incident with Resident #1. The RN stated a louder alarm was added to the doors so it could be heard throughout the unit. During an interview on [DATE] at 4:22 PM, LPN #9 stated the facility provided training on elopement after the incident and what to do if the alarm went off. The LPN stated they must not only check the door but go into the stairway to check for residents. LPN #9 stated the alarms on the doors were now very loud. During an interview on [DATE] at 4:40 PM, the Maintenance Director stated louder alarms were installed on Monday, [DATE], so the alarms could be heard throughout the unit. During an interview on [DATE] at 7:05 PM, the Administrator stated a new lock was put on the patio gate. During an interview on [DATE] at 9:25 AM, the Assistant Director of Nursing (ADON) stated new elopement assessments were completed on all residents on [DATE] because of the incident with Resident #1. During an interview on [DATE] at 9:36 AM, CNA #11 stated she received training on elopement and residents who wandered after the incident with Resident #1. During an interview on [DATE] at 9:55 AM, CNA #12 stated she had received training on elopement and door alarms sounding since the incident. On [DATE] at 10:24 AM, the Maintenance Director stated since the incident occurred with Resident #1, the facility's new policy for checking doors alarms was to check the alarms twice a day, document the findings, and make sure the alarms could be heard down the hall. The Maintenance Director stated the doors had booster alarms put in, so they were a lot louder. When asked about the open gate, he stated the gate had never been locked in the past, and they had placed a lock on it after the incident with Resident #1. Review of the facility's new policy titled, Exit Doors, Stairwell, and Egress Passageway Checks, dated 03/2023, indicated, Policy: Facility exit and stairwell doors and egress passageways will be monitored on a daily basis by maintenance personnel to ensure that the doors are effectively secured and locking mechanisms and/or alarms in place and active. The policy also indicated, Maintenance will document their findings on a daily log and any discrepancies, corrections, needed remediation will be documented in the comment section. Procedure: A. Maintenance personnel shall perform rounds of the facility to evaluate the security of the exit doors and stairwells daily and document their findings on the attached log. B. Rounds shall be documented daily to ensure that all door alarms and locks are in proper function, proper door locking release signage is present, and stairwell doors are secure on the forms entitled 'Exit Doors, Stairwells, Egress Passageways - Daily Log' & 'Door Alarm Daily Log/Egress Passageway Check'. The date and time of rounds will be entered by Maintenance Personnel, and a check mark placed in each box to indicate the door is secure and the door alarm/electronic maglock is in proper function. Any problems must be reported to the Director of Maintenance immediately for immediate follow up and repair/resolution and forwarded it to the administrator. Additionally, the policy indicated, C. Any unsecured or obstructed egress area shall immediately be reported to the Director of Facilities for immediate resolution and the surrounding area searched for Residents or any potential unauthorized persons (i.e. [that is] if a door is found to be breached and or [an] alarm is sounding). The Nursing Supervisor must be notified to account for all residents in the event of any discrepancies. Review of the Door Alarm Daily Log/Egress Passageway Check, forms indicated all floors were checked on each shift on [DATE] through [DATE] to ensure doors were armed, the alarms modules were secure, the alarms would go off when the doors were opened, and the alarms would reset. Review of the forms indicated all problems were immediately addressed. Review of the facility's QA [Quality Assurance] Minutes, dated [DATE] revealed a QA meeting was held and the committee examined the elopement and conducted a root cause analysis. New Jersey Administrative Code § 8:39-27.1(a)