Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined the facility failed to ensure that Resident #2 was free from physical abuse from a staff Licensed Practical Nurse. On 7/30/22 during the evening shift, Resident #2 was a victim of physical abuse by a Licensed Practical Nurse #1 (LPN#1) when LPN #1 punched Resident #2 on the left side of the face with a closed fist causing the resident to fall to the ground. This incident was witnessed by two facility staff, a Certified Nursing Aide (CNA #1) and a second Licensed Practical Nurse (LPN #2). The resident exhibited pain after the incident. LPN#1's failure to prevent physical abuse by punching Resident #2 with a closed fist causing the resident to fall posed a likelihood of serious harm, impairment or death to that resident on 7/30/22, resulting in an immediate jeopardy (IJ) situation that began on 7/30/22. The facility immediately suspended and terminated LPN #1 and notified all necessary parties and governing agencies and implemented additional measures to protect other residents on the same day 7/30/22. The facility was notified of the past non-compliance IJ on 10/26/22. The immediacy was lifted on 7/30/22. This deficient practice was identified for 1 of 11 residents reviewed for abuse (Resident #2). The evidence was as follows: On 10/13/22 at 9:40 AM, the surveyor observed Resident #2 in bed with his/her eyes closed. The surveyor reviewed the medical record for Resident #2 which revealed the following: A review of the admission Record face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included: metabolic encephalopathy (a condition caused by a chemical imbalance in the blood and can affect one's mental state.), bipolar disorder (a psychiatric diagnosis that causes changes in a person's mood, energy, and ability to function), anxiety disorder, and chronic pain syndrome. A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, dated 7/01/22 reflected a Brief Interview for Mental Status (BIMS) score of 9 out of 12, indicating that the resident's cognition was moderately impaired. A review of the Resident #2's comprehensive individualized care plan included that the resident had a Behavioral Care Plan with an initiation date of 7/26/16 and revised on 8/02/22 with a focus area that Resident #2 had episodes of lashing out, threatening, verbally/physically aggressive to staff/co-residents if the resident did not get what the resident wants instantly. The interventions included allowing the resident to verbalize feelings, anticipate and meet the resident's needs, and caregivers to provide an opportunity for positive interaction, attention, approach/speak in a calm manner, and divert attention. Further review of the resident's care plan revealed another focus area for behavioral if the resident's meals are not delivered to their room prior to the food truck being pulled down the hallway and staff delivering food trays. The interventions included that the staff will deliver the resident's meals to their room before passing trays out in the wing so the resident's food will be delivered hot, two staff members to assist the resident and deliver the food tray; and when the resident gets agitated, to intervene before agitation escalates; if aggressive, staff to walk calmly away, and approach later. A review of the Progress Notes (PN) revealed a health status note dated 7/30/22 at 9:35 PM which indicated, Call received from nurse on duty that there was an incident between this resident and a nurse that resulted in a fall of this resident. The nurse and the resident were arguing over orange juice, food, and medication when the resident hit the nurse with an open hand. The nurse, in turn hit the resident with a closed fist causing the resident to lose balance and fall. Resident was able to move all extremities. Resident denied pain and discomfort. Noted no obvious injury. The facility's investigation report titled, Allegation of Physical Abuse for Resident #2 dated 7/30/22, revealed that LPN#2 was a witness to the incident and heard a loud argument over an orange juice (OJ) and LPN#2 attempted to intervene by providing the OJ to the resident. The investigation report showed that LPN#1 (the perpetrator) and the resident were in each other's personal space (less than an arm's reach) and LPN#2 attempted to place herself in between the resident and LPN#1 to create a physical separation and de-escalate the situation, at the same time Certified Nursing Aide#1 (CNA#1) who was also a witness to the incident overheard the loud argument also went to the hallway where the incident was happening and attempted to help by separating the resident and LPN#1. When the ongoing verbal argument and the proximity of the resident and LPN#1 escalated to a physical altercation when the resident was able to hit LPN#1 in his chest and in response, LPN#1 hit the resident in their face with a closed fist. The hit caused the resident to fall backward, the resident landed on floor hitting his/her head even though CNA#1 was behind the resident on the floor. The facility interviews that were conducted post-incident revealed that LPN#2 and CNA#1 confirmed the above investigational report affirming their statements dated 7/30/22. A written statement dated 7/30/22 from the perpetrator/LPN #1 revealed the following: .Resident #2 asked me for OJ, we were both in the hallway. I told the resident to grab the juice on the cart. The resident was unable to hear me, I said to go in the cart and grab it. The resident starts yelling, as resident started yelling my co-workers came and grab the resident as the resident is starting to approach me, yelling at me, as my coworkers trying to help the resident back to their room he/she hit me in the chest, and I hit him/her back. When the resident starts going to their room, Resident #2 tried to spit on me, and the resident said he/she is going to kill me. The incident narrative of the investigation report dated 7/30/22 showed that the witnessing LPN #2 called the Assistant Director of Nursing (ADON) to report the staff-to-resident physical abuse at about 9:43 PM. The ADON instructed LPN#2 to assess the resident while the ADON was en route to the facility. The ADON reported the incident to the LNHA. When the ADON reported to the facility around 10:26 PM, the ADON re-assessed the resident and initiated an immediate investigation. In addition, before the ADON reported to the facility, the resident and perpetrator/LPN#1 were already separated, then the local police department were notified and arrived to the facility to conduct an investigation, and the responsible party and physician of the resident were notified of the incident. The resident declined medical treatment and transfer to the emergency room at that time, the resident was monitored for any negative outcomes. A review of the local Police Department Incident Report dated 7/30/22 at 10:38 PM revealed: On the above date and time, police officer responded to the facility on the report of an assault. Upon, arrival, .the [ADON] explained a nurse and patient of the facility were involved in an altercation which led to the nurse striking the elderly patient .[LPN #1] stated he was trying to help the resident when he was pushed in the chest by [Resident #2]. [LPN #1] explained, in defense he then struck [Resident#2] in the head with a closed fist. [Resident #2] explained that [LPN #1] was refusing to help [him/her] with [his/her] basic needs. [Resident #2] stated [he/she] asked [LPN #1] for food but was provided food [he/she] can not eat and was told to get something [him/her-self]. [Resident #2] stated that [LPN #1] also gave [him/her] [his/her] medicine late and would not help [him/her] take them. [Resident #2] further stated when [he/she] requested different pills from [LPN #1] he refused to give them to the resident. [Resident #2] stated [he/she] then stood up out of bed and pushed [LPN#1] out of the way. [Resident #2] stated at this time, [LPN #1] struck [him/her] on the left side of the face, with a closed fist. It should be noted, I did not observe any bruising, redness, swelling etc. on [Resident #2's] face and [he/she] only complained of pain. [Resident #2] stated [he/she] did not need medical attention beyond what the nurses provided at the time of the incident . On 10/20/22 at 1:00 PM, the surveyor interviewed the Director of Nursing (DON), who used to be the ADON on the 7/30/22 incident. The DON stated that she suspended LPN#1 after the police left on 7/30/22. She further stated that the 7/30/22 incident was reported to the Department of Health, the Ombudsman office, and the New Jersey Board of Nursing. She indicated that all staff was re-educated regarding the facility's abuse policy right away. The DON provided documented evidence of the same. On 10/24/22 at 10:25 AM, the surveyor interviewed the Director of Social Worker (DSW) who stated that the resident was alert and oriented. The DSW stated that the resident likes female staff who are soft-spoken and the resident doesn't like it when staff say no without an explanation. She further stated that the resident could get agitated if the resident feels that the staff was coming across as rude. The SW stated that these behaviors have been evident and it is in the care plan. She also stated that when you talk calmly with the resident and explained why something can not be done, the resident will understand. On 10/24/22 at 12:20 PM, the surveyor interviewed the DSW regarding any grievances that were filed by the resident. The DSW stated that the resident had filed no grievances. On 10/25/22 at 9:45 AM, the surveyor interviewed Resident #2 who was observed having difficulty with hearing. The resident agreed to be interviewed regarding the incident that occurred on 7/30/22. The surveyor asked the resident if he/she recalled the physical abuse on 7/30/22. The resident stated that he/she was still experiencing headaches after the incident. The resident told the surveyor that he/she had no negative interaction with the nurse before the incident. The resident stated that they interacted with the nurse earlier in the day with no issue but somehow the nurse snapped. On that same date and time, the resident stated that he/she was asking the nurse for orange juice and a snack. The food that was offered was a food that he/she was not allowed to consume. The resident further stated that he/she did not hit the nurse and that the resident put their hand on the nurse's shoulder. The nurse then punched him/her in the face. The resident further stated that he/she had no issues with the facility. In addition, the resident stated that the facility immediately fired the nurse, made sure that he/she was safe, and they assessed the resident for any injuries. The surveyor reviewed the facility provided documents of full staff education on abuse, the immediate notification of all parties and governing agencies and the New Jersey Board of Nursing letter dated 8/1/22 to confirm the immediacy had been lifted. The surveyor reviewed the personnel file for the perpetrator/LPN #1. LPN #1 was hired on 11/15/21 and had a clear background check upon hire, license verification, and reference checks done that were also clear. The LPN #1 had been educated for abuse prevention on 11/18/21 prior to the 7/30/22 incident. On 10/26/22 at 3:52 PM, the survey team met with the facility which included the Licensed Nursing Home Administrator (LNHA), Regional Registered Nurse (RRN), DON, and Regional LNHA#1. The LNHA acknowledged the staff-to-resident physical abuse occurred and that it was witnessed by CNA #1 and LPN #2. The surveyor team notified the facility that the failure to ensure Resident #2 was free from staff-to-resident physical abuse. LPN#1's failure to prevent physical abuse by punching Resident #2 with a closed fist causing the resident to fall posed a likelihood of serious harm, impairment or death to that resident on 7/30/22, resulting in an immediate jeopardy (IJ) situation that began on 7/30/22. The LNHA and facility administrative team were made aware that a review of the facility documentation regarding this incident indicated that the immediacy was lifted on the same day 7/30/22. A review of the facility's policy for Abuse, Neglect and Exploitation that was 9/21 and was provided by the RRN indicated the following: by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Under Training topics will include: 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions of residents. b. Wandering or elopement-type behaviors. c. Resistance to care. d. Outbursts or yelling out; and e. Difficulty in adjusting to new routines or staff. N.J.A.C. 4.1 (a) (3) (5) (12) (15)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** PART A Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to ensure that Resident #47 who was at risk for falls and with a diagnosis of Dementia was supervised, assessed, evaluated, and monitored to determine the cause of each fall and to prevent future falls, including a fall that resulted in serious injury. This deficient practice was identified for 1 of the 3 residents reviewed for falls. Resident #47 sustained 11 falls from 5/26/22 through 10/10/22 over a six month period of time. Seven (7) of the 11 of the falls were unwitnessed falls with most of the falls reoccurring in common areas (hallways and dining room). A review of the Investigation reports for the 11 falls revealed that they were incomplete and did not conclude possible causes/root cause of the falls. Further the investigations did not evaluate what interventions were in place at the time of the falls, nor did it address interventions or appropriate interventions to be put in place as a result of each fall, and the resident's care plan was not appropriate or specific to the resident's individualized needs to prevent falls. After multiple falls, the resident had another fall and suffered nasal fracture, rib fracture, intracranial hemorrhage with subdural hematoma, head trauma and was hospitalized for approximately two weeks. After having the fall with serious injury and returning from the hospital, the facility still did not update the resident's care plan to prevent future falls. Interviews with staff (CNA's, Nurses, Therapy) revealed inconsistent theories on what they believed close observation meant to prevent falls for Resident #47. They confirmed it was unclear and was not measurable or resident-specific. The CNA, Unit Manager, and DON were aware of the resident's cognitive impairment and reported that supervision of residents was very challenging because they were so short staffed. There was no Interdisciplinary Team (IDT) meeting or quarterly review note to review the resident's falls and evaluate interventions. The physician progress notes or Physician orders did not address the frequency of the falls or a plan to address the falls. There was no neurology/other physician consults or other medical work up to rule out if the falls were occurring due to a medical change in condition. The facility's failure to reassess after each fall, thoroughly investigate each fall to determine possible root causes, evaluate interventions and update the care plan with new, resident-centered/specific inventions after each fall in an effort to mitigate future falls, or rule out a medical change in condition, and the failure of staff to verbalize or provide evidence of what they are actively doing to prevent falls for Resident #47, when this resident already had a fall with serious injury. This places this resident and all other residents at risk for the likelihood of serious harm, impairment or death as a result of recurring falls if this practice was not immediately corrected. The Immediate Jeopardy (IJ) situation began on 5/26/22. The facility was notified of the IJ on 10/21/22 at 3:21 PM. An Acceptable Removal Plan was received on 10/24/22 at 3:53 PM. The immediacy continued through 10/26/22. The survey team verified the implementation of the Removal Plan on 10/27/22. The evidence was as follows: On 10/13/22 at 10:39 AM, the surveyor observed Resident #47 seated in a wheelchair, awake and alert. The resident was able to maintain eye contact and smiled at the surveyor; however, he/she did not respond to the surveyor's inquiry. The surveyor reviewed Resident #47's medical records. The admission Record (an admission summary) reflected that Resident #47 was admitted to the facility with diagnoses that included Unspecified dementia with behavioral disturbance, generalized anxiety disorder, and major depressive disorder. The Annual Minimum Data Set (AMDS), an assessment tool with an assessment reference date (ARD) of 8/11/22 and Quarterly MDS (QMDS) with an ARD of 5/11/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which reflected a severely impaired cognition. Both MDS assessments revealed that the resident required staff supervision for transfer, walk-in room and corridor, locomotion on the unit, and limited assistance of one-person physical assist for locomotion off the unit. The Fall Risk Evaluation (an assessment tool) reflected that anytime there was a total score of 10 or greater, the resident should be considered at HIGH RISK for potential falls. It also indicated that a prevention practice should be initiated immediately and recorded on the resident's care plan. A review of Resident #47's medical records reflected that the resident sustained 11 falls from 5/26/22 through 10/10/22, specifically on the following dates: 5/26/22, 6/2/22, 6/7/22, 6/26/22, 7/12/22, 7/17/22, 8/17/22, 8/23/22, 8/29/22, 10/3/22, and 10/10/22. The following were the reported and documented fall incidents: 1.) The 5/26/22 at 11:07 AM fall incident revealed unwitnessed fall without injuries. Documentation reflected that a nurse that passed by observed the resident lying with the back of his/her head at the base of the scale. The printed form Change in Condition Evaluation (an evaluation tool for a resident change in condition) dated 5/26/22 included that the resident wanders alone. The Fall Risk Evaluation dated after the fall on 5/27/22 revealed a score of 10 which classified the resident at high risk for falls. 2.) The 6/2/22 at 11:07 AM fall incident reflected that another resident witnessed that #47 ambulated and tripped over a buffing machine's electrical cord which was laying across the floor while Housekeeping (HK) was conducting a room cleaning. The resident sustained injuries related to the fall: an abrasion to the back right hand, a bruise to the back left hand, a laceration to the face, and a pain level of 5 as shown in the Pain Assessment Advanced Dementia (PAINAD) tool. The Advanced Practice Nurse (APN) Physician Progress Note dated 6/02/22 at 9:29 PM, authored by the Advanced Practical Nurse (APN) included Accidental fall in her assessment and included a plan to implement fall prevention and neuro monitoring. The fall incident report indicated that the witness was a resident, but it did not specify that this resident was a reliable source. In addition, the incident report did not include documented statements from the witness and HK staff. The Fall Risk Evaluation dated 6/02/22 revealed a score of 11 which classified the resident at high risk for falls. 3.)The 6/7/22 at 9:26 PM fall incident revealed that the resident had an unwitnessed fall and was found on the floor in the short hallway without injuries. The fall report did not specify who found the resident on the floor nor include documented evidence of witness statements that surrounded the occurrence of the fall. In addition, the incident report included Notes dated 6/16/22 which indicated that the staff continues to observe and redirect the resident. It did not reflect specific interventions on what to observe or when and how to redirect the resident. The Fall Risk Evaluation dated 6/07/22 revealed a score of 17 which classified the resident at high risk for falls. 4.) The 6/26/22 at 10:45 AM fall incident reflected that the resident had an unwitnessed fall in which it was indicated that the resident hit their head, was bleeding, and had a 5 numerical level of pain at the time of the incident. The electronic Health Status Note (HSN) dated 6/26/2022 at 11:39 PM, indicated that the resident was sent to the hospital and returned to the facility the same day with no recommendations received. The Change in Condition Evaluation dated 6/26/22 under the Evaluations tab in the resident's electronic medical record (EMR) reflected an In Progress status, which was initiated but incomplete. It was included in the Employee Statement report authored by the Nursing Supervisor that a CNA found the resident lying on the floor by the hallway towards the dining room door. However, there was no documented evidence of statements from this CNA. 4.) The 7/12/22 at 5:55 PM fall incident revealed that the resident had a witnessed fall in which the resident tripped and landed on his/her knees and faced forward down to the floor while ambulating in the short hallway. The resident sustained a small laceration on the nose and a scratch mark on the right knee from the fall. The Change in Condition Evaluation dated 7/12/22 in the resident's EMR reflected an In Progress status, which was initiated but incomplete. There was no documented evidence that a Fall Risk Evaluation related to the 7/12/22 fall incident was completed. The Physical Therapy (PT) Discharge Summary indicated the date of service started on 6/03/22 and the discharge on [DATE]. It indicated that the resident had poor safety awareness and poor ability to navigate obstacles and busy hallways. It also included recommendations to provide the resident with close supervision for ambulation without assistive devices to reduce the risk of falls. The care plan was not updated related to the 7/12/22 fall incident to implement interventions to ensure resident safety and reduce the risk of further falls. It also did not include or address the PT's discharge recommendations. 5.) The 7/17/22 at 02:33 PM fall incident revealed that the HK staff reported that the resident was found lying flat on the floor in the hallway. The report included that the resident cried out and was holding on to his/her right knee and hip, at the time of the incident. It also indicated that the resident sustained a bruise on the right knee from the fall. The APN Physician Progress Note dated 7/18/22 at 04:23 PM reflected that she included Accidental fall in her assessment and included a plan to implement fall prevention and neuro monitoring. The facility Neurological Evaluation Flow Sheet form (used to assess the neurological status of the resident) was initiated on 7/17/22 but was incomplete. There was no documented evidence that a Fall Risk Evaluation related to the 7/17/22 fall incident was conducted. 6.) The 8/17/22 at 8:29 PM fall incident reflected that the resident had an unwitnessed fall in which Resident #47 sustained a laceration on the left eyebrow. It included that the staff were at the nursing station, heard a sound, looked up, and found the resident on the floor in the long hallway near room [ROOM NUMBER]. There was no documented evidence that a Fall Risk Evaluation related to the 8/17/22 fall incident was conducted. The electronic HSN dated 8/17/2022 at 23:43 (11:43 PM) indicated that the resident was transferred and admitted to the hospital within the same day with a diagnosis of Intracranial Hemorrhage (brain bleed). The hospital records dated 8/17/22 revealed a Problem List for the current admission to the hospital that included a diagnosis of Acute on Chronic Intracranial Subdural Hematoma (a serious condition where blood collects between the skull and the surface of the brain). It also included those diagnostic tests that were performed on the resident during hospitalization and showed results of posterior left third rib fracture and bilateral nasal bone fractures. The electronic HSN dated 8/22/22 at 7:12 PM was readmitted to the facility from the hospital via ambulance via stretcher. The readmission Fall Risk Evaluation dated 8/22/22 revealed a score of 12 which classified the resident at high risk for falls. 7.) The 8/23/22 at 5:20 PM fall incident revealed that Licensed Practical Nurse#1 (LPN#1) was called by another resident from room [ROOM NUMBER]W to see Resident#47 on the dining room floor. It did not indicate that the resident who reported the fall was a reliable source nor include a documented statement from this resident. Furthermore, the incident report indicated that LPN#1 was accompanied by Physician#1 who assessed Resident#47 with an order to send him/her to the hospital for evaluation following a fall with head trauma. The fall report did not reflect the identification of the causal factor that influenced the resident's fall. CNA#1's statement dated 8/23/22 reflected that she did not witness the resident's fall. She indicated that another resident notified her of Resident #47's fall in the dining room. The 8/23/22 incident report did not identify the resident who reported the fall to CNA#1 nor indicate whether this resident was a reliable source. There was no documented evidence of a statement from the resident who reported the fall to CNA#1. Additionally, CNA#2's statement dated 8/23/22 reflected that she did not witness the resident's fall in the dining room. She indicated that an activity staff was also in the dining room serving dinner to the residents. There was no documented evidence of a statement from the activity staff that was in the dining room, which was mentioned in CNA#2's statement. CNA#1 and #2's statements did not reflect whether the resident was supervised by staff in the dining room when the fall occurred. The Fall Risk Evaluation dated 8/23/22 revealed a score of 17 which classified the resident at high risk for falls. The facility-provided hospital records dated 8/23/22, After Visit Summary, reflected Fall for Reason for Visit and Diagnosis of Fall, initial encounter. The hospital records indicated the list of imaging tests conducted during the resident's visit. However, there was no documented evidence of the results that were included in the hospital records. The HSN dated 8/24/22 at 6:06 AM, reflected that the resident returned to the facility from the hospital at around 12:40 AM. The APN Physician Progress Note dated 8/24/22 at 13:06 (01:06 PM), reflected that the resident was readmitted to the facility from the hospital where he/she was diagnosed with Acute on Chronic Subdural Hematoma and Nasal Fracture. In the same notes, the APN included in the Plan for neurological monitoring and closed monitoring. However, there was no documented evidence of accountability in the resident's medical records that the neuro monitoring was conducted. Close monitoring was not defined. 8.) The 8/29/22 at 12:40 PM fall incident revealed that the resident had a witnessed fall in which the resident was sitting in a chair at the nursing station and attempted to rise from the chair which caused Resident #47 to fall on the floor. It was indicated that the resident had a pain level of 5 at the time of the incident. It also reflected that the resident's mobility assessment was ambulatory without assistance. In the incident report, LPN#2's statement dated 8/29/22 reflected that she was in the short hall where she witnessed the resident fall to the floor. She indicated that the resident had poor balance and attempted to ambulate which caused him/her to land on the buttocks and then hit his/her head possibly on the floor. The Fall Risk Evaluation dated 8/29/22 revealed a score of 16 which classified the resident at high risk for falls. The APN Physician Progress Note dated 8/29/22 at 01:32 PM, indicated that the APN was notified of the resident's fall. She included that the resident had no apparent injury on examination other than minor bruising on the forehead. She included in the Plan that for neuro monitoring should be conducted. However, there was no documented evidence of accountability in the resident's hybrid medical records that the neuro monitoring was completed. 9.) The 10/3/22 at 5:28 PM fall incident indicated that the resident had an unwitnessed fall in which the resident was heard screaming, crying, and laying on the dining room floor. The incident report included Notes dated 10/07/22 which indicated that the resident had a history of falls, no safety awareness, and being very spontaneous. It also included that the staff distantly observes the resident and anticipates his/her needs. A written statement from the Licensed Practical Nurse/Unit Manager#1 (LPN/UM#1) dated 10/03/22, reflected that she was called to the dining room where she observed the resident sitting on the floor in front of the wheelchair, crying, grimacing, and holding his/her head. The printed form Change in Condition Evaluation dated 10/03/22 under interventions specified Frequent monitoring. It was also indicated that the primary care clinician was notified on 10/03/22 at 17:16 (2:16 PM) with recommendations for Neuro checks and Monitoring. The PT Discharge Summary indicated the date of service started on 8/23/22 and the discharge on [DATE]. It included that the resident was discharged on a Supervision or touching assistance level for sit-to-stand transfer and gait with rehab recommendations for use of a wheelchair for mobility due to impaired safety and HHA/CGA (handheld assist/contact guard assistance) for all ambulation with staff as tolerated. There was no documented evidence that the PT discharge recommendations mentioned above were updated in the resident's care plan interventions during the surveyor's record reviews. The fall care plan was inappropriately updated on 10/5/22 related to the 10/3/22 fall, which included non-resident-centered interventions. Furthermore, there was no documented evidence that the intervention indicated in the 10/3/22 incident report which included that the staff distantly observed the resident, was recorded in the fall care plan interventions. The Fall Risk assessment dated [DATE] revealed a score of 16 which classified the resident at high risk for falls. 10.) The 10/10/22 at 02:19 PM fall incident revealed that the resident had a witnessed fall in which he/she was in the day room, stood up from the wheelchair, and took a few steps before falling and hitting his/her head on the foot of the table and the resident had a pain level of 5 at the time of the incident. The printed form Change in Condition Evaluation dated 10/10/22 indicated that the primary care clinician was notified on 10/10/22 at 14:00 with recommendations to continue to monitor and initiate neuro checks (an assessment that detects brain, spinal cord, and nerve injuries or disorders). Furthermore, the fall care plan intervention that was created on 10/10/22 included Staff to provide close observation. It did not identify what close observation meant for Resident #47, when or how often it close observation occurs, nor did it specify if it meant the proximity between the observing staff and the resident to be considered close observation. The Fall Risk assessment dated [DATE] revealed a score of 14 which classified the resident at high risk for falls. The above fall investigations showed the following: On 5/26/22, 6/26/22, 7/12/22, 7/17/22, and 8/17/22 fall incidents, there was no documentation of a root cause analysis written in the summary and conclusion of the fall investigation reports to evaluate what interventions were in place at the time of the fall and whether they were effective or not. There was no determination as to whether the falls were avoidable or unavoidable. There was no documentation in the resident's medical record that the neurological check orders were implemented or immediate actions were taken on 5/26/22, 6/02/22, 7/17/22, 8/23/22, 8/29/22, 10/03/22, and 10/10/22 in accordance with the fall incidents that were initiated. There was no documented evidence in the resident's hybrid medical records that the resident was seen and evaluated by a clinician following the falls that occurred on 5/26/22, 6/7/22, 6/26/22, and 10/03/22. There was no documented evidence that the Interdisciplinary team met to discuss the resident's falls that occurred on 5/26/22, 6/02/22, 6/07/22, 6/26/22, 7/12/22, 7/17/22, 8/17/22, 8/23/22, 8/29/22, and 10/10/22. In addition, there was no evidence that these fall occurrences, including those with major injury, were updated on the resident's care plan related to the incident and interventions to prevent further falls. There was no documentation that the resident was screened by the Rehabilitation Department following the 5/26/22, 7/17/22, and 10/10/22 fall incidents to determine if the resident could benefit from rehabilitation services or screen for the use of other durable medical equipment. There was no documentation that the staff received education, training or in services on the residents' safety and prevention of further falls following the 11 fall incidents. On 10/18/22 at 11:35 AM, the surveyor asked the DON to provide all the supporting documentation related to the resident's fall incidents from 5/26/22 through 10/10/22. The DON acknowledged to the surveyor that she provided the surveyor with all the documentation related to the resident's fall investigations except the hospital records. The DON stated that the neurological checks were completed on a paper form titled Neurological Evaluation Flow Sheet, which was attached to the fall reports that were given to the surveyor. On the same day at 12:07 PM, the RDON and DON met with the survey team. The RDON informed the surveyors that the staff and resident statements for fall investigations were paper documentation. He also stated that the statements were part of the fall investigation and should be attached to the fall incident report. Furthermore, he stated that after obtaining statements, the UM, DON, and LNHA would do a full investigation which included a fall summary and conclusion. During the interview, the RDON stated that the interim fall investigation report should be electronically entered immediately and completely by the nurse within the shift. He stated that the printed interim fall report should go to the UM to be reviewed for completion, then the DON and LNHA would be made aware of the investigation. The RDON acknowledged that the fall incident investigations and reports were not being completed. The DON also agreed and stated that the completion of the investigation process was not being done. On 10/18/22 at 01:33 PM, the surveyor had a follow-up interview with the DON in the presence of the survey team. The DON stated that the fall care plan should be updated by the UM within 24-72 hours of the fall occurrence, depending on when the fall occurred. She further stated that the fall care plan should have included appropriate interventions related to each fall. On that same date and time, the DON reviewed the resident's care plan and acknowledged that Resident #47's fall care plan was not appropriately updated and stated, You probably won't find the care plan updated. At that same time, during the interview with the DON, the DON informed the surveyors that the LPN/UM#1 did not update the fall care plan because she was not aware that she was supposed to update the resident's care plan to include appropriate interventions for each fall occurrence. On 10/19/22 at 11:32 AM, two surveyors interviewed LPN/UM#1. LPN/UM#1 informed the surveyors that she was responsible for care plan initiation and revision. She stated that with each fall, there should be new intervention. She acknowledged that the resident had multiple falls and his/her fall care plan was not updated for each fall. She stated that the resident's fall care plan interventions should have been adjusted accordingly on each fall to prevent the resident from future falls. The LPN/UM#1 stated that the resident had no safety awareness and needed continuous 1 on 1 observation only when they can due to short staffing. She also acknowledged that the resident's fall investigation reports were incomplete. On 10/20/22 at 10:41 AM, the surveyor interviewed the Director of Rehabilitation (Rehab) (DOR). The DOR informed the surveyor that the Rehab Department conducted Rehab screenings for residents every quarter, annually, for each new admission and readmission, and with a change in status. She stated that Rehab screenings were also initiated by staff or family referrals as needed, which included residents who had fallen to determine any decline in mobility, cognition, and communication that warrant rehab evaluation, treatment, and services. She informed the surveyor that the resident was referred for Rehab due to her multiple falls. On that same date and time, the surveyor asked the DOR if the resident was screened and evaluated after each fall incident. The DOR stated that she was not sure and would verify after reviewing the rehab notes. She also stated that she would provide the surveyor with a copy of the resident's rehab notes. In addition, she stated that the communication with the nursing department would be documented in the rehab daily notes. On 10/20/22 at 12:09 PM, the DOR met with the survey team. She stated that the nursing department would send a referral to the rehab department for each fall occurrence. The DOR further stated that the resident had a decline since his/her readmission from a hospitalization after a fall incident. She stated that the resident was discharged from PT on 10/3/22 with recommendations for use of a wheelchair for mobility and Handheld Assist (HHA) or Contact Guard Assist (CGA) for all ambulation with staff as tolerated due to his/her impaired safety awareness. During the interview, the surveyor also reviewed the PT Discharge summary dated [DATE] in the presence of the DOR. It was documented by Rehab staff a recommendation that the resident required close supervision for ambulation without an assistive device to reduce the risk of falls. Furthermore, the DOR stated that she expected that the rehab recommendations be included in the resident's care plan. The surveyor asked the DOR for documented evidence of accountability that the rehab recommendations were relayed to the nursing department. The DOR stated that the rehab recommendations were discussed in the weekly Utilization Review (UR) meeting with the nursing department. The surveyor asked the DOR to provide a copy of the accountability of the rehab discharge recommendations dated 7/15/22 and 10/3/22 in the UR meeting. The DOR did not provide further information at this time. On 10/21/22 at 10:30 AM, LPN/UM#1 acknowledged that Resident #47 had frequent falls. She also stated that the resident could ambulate when the resident wants to and that the resident required staff supervision to prevent further falls because of poor balance and safety awareness. She further explained that the staff should be close enough to the resident to intervene as needed. On the same day at 10:35 AM, the surveyor interviewed CNA#3. She acknowledged that the resident had frequent falls. She stated that the resident always needed to be closely supervised by staff due to the resident's confusion and safety unawareness to prevent him/her from future falls. At that same time, CNA#3 further stated that due to staffing issues, they could not closely supervise the resident. She informed the surveyor that they were short staff and they needed more staffing to monitor the resident due to her impaired cognition and agitated behavior, and to provide for the resident's needs. The surveyor asked the CNA what close supervision meant. She stated that she sat by the resident so she can prevent her from falling. The surveyor reviewed the staffing assignment sheets associated with the dates and shifts of each fall for the unit. The assignment sheets revealed insufficient staff during the times of the falls in accordance with New Jersey State minimum staffing requirement. Review of the staffing patterns for the days and shifts that Resident #47 falls occurred were as follows: 5/26/22: Census: 44, 4 CNAs, 2 Nurses 6/2/22: Census: 45, 3 CNAs, 2 Nurses 6/7/22: Census: 45, 3 CNAs, 2 Nurses 6/26/22: Census: 53, 4 CNAs, 2 Nurses 7/12/22: Census: 54, 5 CNAs, 2 Nurses 7/17/22: Census: 54, 4 CNAs, 2 Nurses 8/17/22: Census: 57, 4 CNAs, 2 Nurses 8/23/22: Census: 55, 4 CNAs, 2 Nurses 8/29/22: Census: 55, 3 CNAs, 2 Nurses 10/3/22: Census: 51, 3 CNAs, 2 Nurses 10/10/22: Census: 51, 3 CNAs, 2 Nurses On 10/21/22 03:14 PM, the survey team met with the LNHA, DON, and RDON. The surveyor informed the facility's management that the facility's failure to ensure that Resident #47 who is at risk for falls and with diagnosis of dementia prevent the serious injury by failing to ensure that the resident was supervised, assessed, evaluated, and monitored to determine the cause of falls and to prevent future falls placing all residents at risk for serious injury, harm or death. From 5/26/22 through 10/10/22, for a period of six months, the facility failed to ensure Resident #47's safety who is at risk for falls and cognitively impaired by preventing falls, and including falls with major injuries (resident had lacerations, subdural hematoma with intracranial hemorrhage, fractures in the nose, and rib, and head trauma). This resulted in an IJ situations. The surveyor notified the facility management that the facility had to provide an acceptable removal plan, and an IJ template was provided to the facility. On 10/21/22 at 3:22 PM, the surveyor interviewed the Regional RN (RRN) in the presence of the survey team. The surveyor asked the RRN to define close supervision and close observation. The RRN responded that they both meant the same. She further explained that when the resident was in the staff's line of sight they would be able to see the resident and attend to his/her as needed. The surveyor asked the RRN to interpret the line of sight and what was the expected distance between the resident and the staff providing observation. The RRN could not provide further information. On 10/24/22 at 11:01 AM, the surveyor interviewed the resident's primary attending Physician#2. Physician#2 acknowledged that Resident # 47 was his resident. He stated that the resident had a decline and was frail due to Dementia. He informed the surveyor that he or his NP were notified and made aware of the resident's falls. However, he stated that he did not see and evaluate the resident after every fall. At that same time, the surveyor asked Physician#2 if he had meetings with the IDCP team that discussed the resident's falls. Physician#2 stated that he did not have a formal actual meeting with the IDCP team and stated, I wouldn't go to the meeting and that he went directly to the UM. The surveyor asked the physician about what he had done when he kept getting notified of the resident's falls. He stated that he included recommendations for CNA observation of the resident. He further stated, they can use the alarm if necessary to prevent the resident from future falls. He further stated, As far as I know, the facility told me we cannot use an alarm for the resident because it's against the resident's rights. On 10/24/22 at 11:54 AM, the survey team met with the RRN, DON, and LNHA. The RRN informed the survey team that 1:1 will never prevent falls. She further stated that the facility did not use a personal alarm to prevent residents from falling. She also stated that they did not try to use an alarm for Resident#47. Additionally, she stated that alarms will not deter the resident from falling. The RRN acknowledged that the resi[TRUNCATED]