Complete Care At Court House, Llc

The surveyor reviewed the responses noted in the NCA, which indicated that NS #1 recalled a conversation with a nurse from the transferring facility which described an incident that involved Resident #3 that required security to respond. NS #1 stated that she completed the elopement section based on information she received from the transferring nurse. NS #1 stated that the Elopement Assessment was not completed because they were unsure if the resident had an actual elopement attempt or if it was a behavioral incident.On 12/19/25 at 2:16 PM, the surveyor attempted to conduct an interview with CNA #1, who did not answer.During a telephone interview on 12/19/25 at 2:20 PM, Licensed Practical Nurse (LPN #1) stated that at approximately 2:30 AM, the assigned Certified Nursing Assistant (CNA #1) for Resident #3 approached the nursing desk and stated that the resident was not in their room. LPN #1 further stated that CNA #1 heard the resident arguing on the phone, . was loud for a while, cursing, and then [CNA #1] heard nothing and felt a draft. LPN #1 stated that when she entered Resident #3's room on the second floor, the window was wide open but the resident was not in the room. LPN #1 stated that they then initiated elopement protocol which includes search of facility grounds. LPN #1 further stated while they were searching the facility grounds, they noticed tree branch located directly under the resident's window appeared split, and footsteps were observed on the ground under the window.During a joint interview with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) on 12/19/25 at 2:55 PM, the DON stated that for a resident with a history of elopement, they would complete an assessment and based on the result of the assessment, they would develop and implement interventions based on the resident's needs.On 12/24/25 at 3:04 PM the surveyor received an email that included an Evaluation Outcome dated 12/6/25 at 11:04 PM.

This indicated that Resident #3 had an Elopement Risk Score of 99.0, which meant that no risk was identified for that category.

This information conflicted with the NCA completed by NS #1.

The document also referenced that a PN had been completed, by Licensed Practical Nurse (LPN #2), for the same date and time. A review of the corresponding PN did not reference an elopement history nor an elopement risk.

During a follow-up interview with the DON on 12/29/25 at 12:31 PM, the DON confirmed that the record contained conflicting information regarding Resident #3's elopement risk. No evidence was provided that LPN #2 completed an Elopement Assessment.During an interview on 12/29/25 at 12:31 PM, the Medical Director (MD) stated that the expectation was that when a resident was admitted to facility, staff would complete an assessment that included an elopement risk assessment.

The MD further stated that if a resident was identified to be an elopement risk, staff would develop and implement appropriate interventions to prevent elopement. A review of the facility's policy titled Elopements and Wandering Residents dated 9/1/24, included Policy: This facility ensures that residents. at risk for elopement receive adequate supervision and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk [.] Policy Explanation and Compliance Guidelines: [.] 3.

The facility shall. utilize a systemic approach to monitoring and managing residents at risk for elopement [.] 4.

Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a.

Residents will be assessed for risk of elopement and unsafe wandering. b.

The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. NJAC 8:39-11.1; 11.2(d); 27.1(a)

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