Every finding on record at Avant Rehabilitation and Care Center

Based on observation, interview, and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 143 of 145 residents who received dietary services. Findings include:Review of the facility's undated policy titled, Pot Washing revealed, Policy: Kitchen will wash, rinse, and sanitize, all pots, pans, and cook ware and small wares following each meal. Procedure. 10. Air dry all clean and sanitized pots and wares. Do not wipe dry. Review of the facility's undated policy titled, Wet Nesting dated Oct.22 revealed, Policy: When ware washing plates, cups, bowls, eating utensils, kitchen utensils, cooking ware, and equipment they must be air dried completely before being placed into storage for use. Procedure. Place items on drying rack and allow them to air-dry. Do not stack. Do not wipe dry any items; they must be allowed to air dry. Once items have dried completely, they can be properly stored. All coffee pots and air pots must be allowed to dry inverted (upside down) so that there is no standing water left inside.During an observation and interview on 08/25/25 at 10:20 AM, the Dietary Manager (DM) confirmed two pans, 12 inches by 24 inches by 4 inches deep; two pans 12 inches by 24 inches by 3 inches deep; one 12 inches by 24 inches; two pans, 10 inches by 12 inches by 4 inches had been cleaned and stacked for use, were still wet when they were stacked. The pans were found to have been stacked wet and not allowed to properly air dry prior to being stacked. Interview at this time, the DM stated, They should be dry. They shouldn't be wet. They weren't dry before they were stacked. When they are put away wet, it increases the risk of contamination. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and policy review the facility failed to ensure the code status was in easy access for one of one resident (Resident (R)15) reviewed for Advanced Directive information prominently displayed in the medical record in the sample of 33 residents. As a result of this deficient practice the residents had the potential for receiving cardiopulmonary resuscitation (CPR) when potentially against the wishes of the residents.Findings include:Review of R15's admission Record located in the electronic medical record (EMR) under the Profile tab revealed an admission date of [DATE] and readmission on [DATE] with medical diagnosis that included end stage renal disease requiring dialysis. Review of R15's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R15 was cognitively intact. Review of R15's Physician orders under the Orders tab in the EMR lacked an order for code status. Review of R15s header in Point Click Care (PCC) next to the heading for code status was blank. Review of the admission Record under the Profile tab in the EMR lacked documentation of code status. Review of R15's Advanced Directive provided by the facility, indicated R15 requested a full code dated [DATE]. Review of R15's Care Plan under the Care Plan tab in the EMR revealed a focus for Advance Directives Code Status: FULL CODE Date Initiated: [DATE], with intervention to ensure Resident has an order from Attending regarding code status Date Initiated: [DATE]. During an interview on [DATE] at 2:53AM, Unit Manager/Licensed Practical Nurse (LPN)2 explained when checking for the code status of a resident, especially in an emergent situation, looked at the header in PCC in the computer, to verify if a resident was a full code or Do Not Resuscitate (DNR) to know what action to take if a resident stops breathing/heart stops beating. If the code status was blank, the Unit Manager/LPN2 would check the hard chart for a Physician Orders for Life-Sustaining Treatment (POLST) form. Unit Manager/LPN2 confirmed the information was also communicated during the shift report. During an interview on [DATE] at 11:25 AM, Unit Manager/LPN2 confirmed the header in PCC should have the code status. The Unit Manager/LPN2 confirmed PCC was missing a physician's order for code status and the header in PCC was blank. During an interview on [DATE] at 1:38PM, the Director of Nursing (DON) confirmed the code status should be prominently displayed on the EMR in the PCC header for quick reference for staff, as needed. Review of the facility's policy titled Advanced Directives revised 12/16 revealed, Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. NJAC 8:39-4.1(a)NJAC 8:39-9.6

Based on document review, interview, and facility policy review, the facility failed to provide written quarterly statements within 30 days of the end of the quarter to residents and/or resident representatives to inform them of the residents' balance in their personal funds accounts. This failure had the potential to affect 10 residents (R)64, R153, R104, R83, R85, R96, R93, R29, R94, and R61) of 55 residents who had a personal funds account in the second quarter (April - June 2025) to be uninformed of the balance in their account. Findings include:Review of the facility's policy titled, Accounting and Records of Resident Funds dated April 2021 revealed, Policy Statement: Our facility maintains accounting records of resident funds on deposit with the facility. Policy Interpretation and Implementation: 1. The business office maintains a record of all financial transactions involving the resident's personal funds on deposit with the facility. 5. Individual accounting records are made available to the resident through quarterly statements and upon request. Quarterly statements include the following information: a. The resident's balance at the beginning and end of the statement period; b. The total deposits and withdrawals by the resident for the quarter; c. Interest earned on the resident's funds; .Review of the facility's Quarterly Statement for the period of 04/01/25 - 06/30/25 (signature sheet) revealed 10 residents (R)) of 55 residents as having not been provided a copy of their quarterly statements. Quarterly statements for the period of 04/01/25 - 06/30/25 were provided to the remaining 45 residents.During an interview on 08/28/25 at 3:45 PM, the Administrator stated, The residents sign after receiving their quarterly statements. Based on the signature sheet for the second quarter, if there is no signature on the sheet then the statement was not provided to the resident and there is no record of the statement being given to the resident representative. NJAC 8:39-4.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure a residents who self-administered medication was assessed for self-administration, had a physician's order for self-administration, and ensure the interdisciplinary care planning team was involved in the decision for the resident to self-administer for one of one residents (Resident (R) 40) reviewed in the sample of 33 residents. As a result of this deficient practice the residents had the potential for harm by self-medicating without the knowledge of the physician or nursing staff.Findings include: Review of the facility's policy titled Administering Medications revised 04/19 revealed, Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of R40's admission Record located in the electronic medical record (EMR) under the Profile tab revealed an admission date of 10/07/24 and a readmission on [DATE] with medical diagnoses that included bilateral osteoarthritis of knees, muscle weakness, and depression. Review of R40's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/15/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R40 was cognitively intact. Observation on 08/25/25 at 11:09 AM, in R40's room on the bedside table were two cans of Tinactin spray, one almost empty, the second can about half full. During an interview on 08/25/25 at 11:09 AM, R40 confirmed using the Tinactin spray on her feet when they felt itchy. R40 confirmed the Tinactin spray had been brought by her daughter. Review of R40's Physician orders under the Orders tab in the EMR lacked an order for the Tinactin foot spray. Review of R40's Progress Notes under the Prog Note tab in the EMR lacked documentation of interdisciplinary meeting concerning self-administration of medications. Review of the Assessments tab in the EMR lacked an assessment for R40's self-administration of medications. Review of R40's Care Plan under the Care Plan tab in the EMR lacked documentation that R40 had been assessed for self-administration of medications. During an interview on 08/28/25 at 11:07AM, Registered Nurse (RN) 2 confirmed the two cans of Tinactin on R40's bedside table should not be there and that they were brought in by the daughter. During an interview on 08/28/25 at 11:09 AM, the Unit Manager/Licensed Practical Nurse (LPN) 2 confirmed that R40 had not been evaluated for self-administration and there was no physician's order for Tinactin. During an interview on 08/28/25 at 1:33 PM, the Director of Nursing (DON) confirmed residents' medications were not supposed to be left at the bedside unless they were assessed for self-administration of medications and there was a physician's order for the medication. NJAC 8:39-29.2(c)6

Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to medications for one of 33 sampled residents (Resident (R)4), and a urinary catheter for one of one resident (R138) This deficient practice increased the potential for missed opportunities of care or services. Findings include: 1. Review of R4's admission Record located in the electronic medical record (EMR) under the Profile tab indicated an admission date of 01/05/24 and diagnoses of cerebral infarction, diabetes, and hypertension. Review of R4's quarterly MDS with an Assessment Reference Date (ARD) of 07/16/25 and located in the EMR under the MDS tab revealed that R4 was coded that he received an anticoagulant and an antiplatelet medication. Review of R4's July 2025 physician orders revealed R4 had a current order for Plavix (an antiplatelet medication) 75 milligrams (mg) by mouth daily. R4 does not have an order for an anticoagulated medication. 2. Review of R138's admission Record located in the EMR under the Profile tab indicated an admission date of 06/05/25 and diagnoses of diabetes, hypertension, and difficulty walking. Review of R138's admission MDS with an ARD of 06/12/25 and located in the EMR under the MDS tab revealed that R138 was coded as having an indwelling urinary catheter in place. During an interview on 08/26/25 at 1:30 PM, R138 stated he did not have a urinary catheter at present, or at the time of admission. R138 stated he was able to self-ambulate with the use of his walker to the bathroom or he used his urinal. During an interview on 08/27/25 at 4:45 PM, the Minimum Data Set Coordinator (MDSC) stated that R138 did not have an indwelling urinary catheter at the time of admission. The MDSC confirmed she .misread. hospital documentation and thought R138 had a urinary catheter. During the same interview on 08/27/25, the MDSC confirmed that R4 did not receive an anticoagulant only antiplatelet. The MDSC stated Licensed Practical Nurse (LPN) 1 had completed R4's MDS. The MDSC further stated the facility follows the RAI Manual for guidance and coding and does not have a specific policy related to MDS. NJAC 8:39-33.2(d)

Based on interview, record review, and policy review, the facility failed to ensure a resident assessed as a smoker had a care plan for smoking for one of six residents (Resident (R)7) evaluated for safety when smoking. As a result of this deficient practice the residents had the potential for harm while smoking.Findings include:Review of R7's admission Record located in the electronic medical record (EMR) under the Profile tab revealed an admission date of 07/18/24 and readmitted on [DATE] with medical diagnoses that included low white blood cell count, chronic viral hepatitis C, and anemia. Review of R7's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/01/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R7 was cognitively intact. During an interview on 08/25/2025 at 12:00 PM, R7 confirmed she was a smoker and went out on smoke breaks a couple times a day. Review of R7's Nursing Admission/readmission form under the Assessments tab in the EMR dated 06/24/25 documented R7 was a smoker. Review of R7's Smoking Safety Evaluation under the Assessments tab in the EMR dated 06/24/25 documented R7's use of cigarettes and safety questions for independent smoking. Review of R7's Care Plan under the Care Plan tab in the EMR lacked focus and interventions for smoking. During an interview on 08/27/25 at 11:44AM, Licensed Practical Nurse (LPN)4 confirmed R7 was a smoker and there was no smoking focus or interventions for smoking in R7's care plan and there should be a care plan. During an interview on 08/28/25 at 2:53PM, Behavioral Aide (BA)1 confirmed being the monitor for the residents who smoke and confirmed R7 came to the smoking area three to four times a day to smoke. During an interview on 08/28/25 at 11:30AM, the Unit Manager/Licensed Practical Nurse (LPN) 2 confirmed R7 was a smoker and verified the care plan did not have a focus for smoking and should have one. During an interview on 08/28/25 at 1:38PM, the Director of Nursing (DON) confirmed that all residents who smoke need to have a care plan for smoking in place. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised 03/22 revealed, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Review of the facility's policy titled Smoking Policy - Residents revised 07/17 revealed, Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. NJAC 8:39-11.2(e)NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of the facility's policy, the facility failed to clean respiratory equipment for one of one resident (Resident (R)56) reviewed for respiratory care in the sample of 33 residents. The failure to maintain a clean oxygen concentrator filter had the potential to increase the risk of infections for the resident. Findings include: Review of the facility's policy titled, Oxygen Administration dated October 2010 revealed the policy failed to address the need for routine cleaning and/or maintenance of oxygen concentrators, including the need to maintain a clean filter. Review of R56's undated admission Record located in R56's electronic medical record (EMR) under the Profile tab revealed R56 was admitted to the facility on [DATE], with diagnoses which included respiratory failure and emphysema. Review of R56's Physician Order dated 05/27/25 located in the EMR under the Orders tab revealed, oxygen (O2) at 4 lpm [liters per minute] via nasal cannula continuously every shift. Clean O2 concentrator filter weekly every shift every Saturday. Observation on 08/25/25 at 4:34 PM and 08/28/25 at 1:45PM, R56's concentrator filter was dirty and coated with dirt and dust. During observation and interview on 08/28/25 at 2:30 PM, the Assistant Director of Nursing (ADON) confirmed R56's oxygen concentrator filter to be dirty and coated with dirt and dust. The ADON stated, The filter should be cleaned regularly. A dirty filter can increase the risk of infections for the resident.NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure the care of a dialysis resident with a fistula was checked for the patency daily, and document in the medical record for one of five residents (Resident (R)15) reviewed for dialysis care. As a result of this deficient practice the residents had the potential for clotting of the access point for dialysis treatments.Findings include:Review of R15's admission Record located in the electronic medical record (EMR) under the Profile tab revealed an admission date of 04/21/22 and readmission on [DATE] with medical diagnosis that included end stage renal disease requiring dialysis. Review of R15's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 06/05/24 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R15 was cognitively intact. Observation on 08/25/25 at 1:53PM, R15 held out her left arm to point to the shunt used by the dialysis treatment center for dialysis treatment. Review of R15's Care Plan under the Care Plan tab in the EMR revealed the focus Resident has end stage renal disease and was on hemodialysis (HD). Date Initiated: 06/30/25, with an intervention Check for Bruit and Thrill every shift and document in Medication Administration Record (MAR). Site of the arteriovenous (AVF) shunt left arm. Date Initiated: 06/30/25. Review of R15's MAR and Treatment Administration Record (TAR) for August 2025 lacked documentation that R15's AVF was checked for bruit and thrill through the fistula on the left arm every shift. Review of the TAR revealed, document AVF site for bleeding or signs and symptoms of infection every shift, notify Medical Doctor (MD) of changes every shift -Start Date- 07/18/25. During an interview on 08/27/25 at 11:23AM, the Unit Manager/Licensed Practical Nurse (LPN) 2 confirmed that the thrill and bruit on any dialysis resident with an AVF should be checked and documented every shift and that R15 did not have an order in place to document the thrill and bruit. There should be an order to document. The site was being checked for bleeding every shift. During an interview on 08/27/25 at 11:32AM, LPN4 stated that R15's AVF was checked when resident returned from dialysis treatment and documented on the form. LPN4 stated the AVF should be checked more often, however, there was no place on the MAR or TAR to document the thrill or bruit. LPN4 confirmed there was not a physician order to check the AVF for thrill and bruit. During an interview on 08/28/25 at 1:27PM, the Director of Nursing (DON) confirmed there should be documentation on any dialysis resident receiving treatments using AVF to check for the bruit and thrill every shift and document in the EMR and not just checking when resident returned from dialysis treatment. Review of the facility's policy titled Hemodialysis Access Care revised 09/10 revealed, To prevent infection and/or clotting: . Check the patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access. NJAC 8:39-27.1(a)

Based on observation, interviews, and review of facility policy, the facility failed to ensure the daily nurse staffing information was posted in a manner that residents and visitors had access to the information. This deficient practice has the potential to affect all residents and visitors. Findings include: Upon entrance to the facility on [DATE] at 9:00 AM, the daily nurse staffing information was observed in a glassed bulletin board, behind the main reception desk at the upper left corner, approximately six feet high. The posting was current for the day, all three shifts, however, was not readable, or accessible, for residents in a wheelchair or with vision problems. Observations on the subsequent survey days of 08/26/25 at 3:30 PM, 08/27/25 at 1:00 PM and 08/28/25 at 11:15 AM revealed the daily nurse staffing information was in a glassed bulletin board, behind the main reception desk at the upper left corner, approximately six feet high. The posting was current for the day, all three shifts, however, would not be readable, or accessible, for residents in a wheelchair or with vision problems. During an interview on 08/28/25 at 12:00 PM the Staffing Coordinator (SC) stated the daily nurse staff information has .always been posted in the glass bulletin board. She also stated that residents do not come behind the receptionist desk and that the nurse staffing posting was not accessible, or visible, to residents in a wheelchair. During an interview on 08/28/25 at 12:15 PM, the Administrator stated that the daily nurse staffing information was not posted in any other location other than behind the reception desk. NJAC 8:39-41.2

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) notify a physician of a resident's multiple refusals for a sliding scale coverage insulin (Resident #68) and b.) maintain and monitor the functionality and the effectiveness of a pacemaker since admission to the facility for a resident with a pacemaker (Resident #32) in accordance with professional standards of practice. This deficient practice was identified for 2 of 5 residents reviewed for unnecessary medications (Resident #32 and Resident #68). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. This deficient practice was evidenced by the following: 1. On 3/13/24 at 10:50 AM, the surveyor observed Resident #68 seated in a wheelchair, who stated he/she had left sided weakness and used a wheelchair to get around the building. The surveyor reviewed the medical record for Resident #68. A review of the Resident Face Sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included flaccid hemiplegia (a severe or complete loss of motor function on one side of the body) affecting left dominant side, major depressive disorder, and diabetes mellitus. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/20/24, reflected a brief interview for mental status (BIMS) score of 15 out of 15; which indicated a fully intact cognition. A review of the individual comprehensive care plan included a focus area dated initiated 1/6/24, for diabetes. Interventions included my diabetes will be managed through a combination of long-acting insulin plus sliding scale coverage; and we will administer insulin via injection as ordered. A review of the March 2024 Physician's Orders report included a physician order (PO) dated 1/7/24 with a renewal date of 3/11/24, for insulin lispro; inject by subcutaneous route once daily (4:30 PM) before dinner as per sliding scale: 200-250 = 2 units; 251-300 = 4 units; 301-350 = 6 units; 351-400 = 8 units. A review of the corresponding March 2024 Medication Administration Record (MAR) reflected the following: From 3/1/24 to 3/19/24, the nurse had indicated the star symbol (*). According to the chart codes * indicated Not administered (see last section). A review of the last section of the March 2024 MAR revealed the resident had refused the insulin lispro on 3/1, 3/2, 3/3, 3/4, 3/5, 3/8, 3/11, 3/13, 3/14, 3/15, 3/16 and 3/17. A review of the corresponding Progress Notes for March 2024 did not include documentation that the resident had refused his/her insulin lispro medication, or that the resident's physician had been notified of their refusal of the insulin lispro medication. On 3/19/24 at 11:09 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated the nurse contacted a resident's physician if a resident refused medication. At that time the surveyor and the UM/LPN reviewed Resident #68's March 2024 MAR, and the UM/LPN acknowledged the resident had refused insulin on multiple occasions. The UM/LPN stated she needed to review the resident's progress notes and the 24-hour Nursing Report (a shift-to-shift communication resource for nurses regarding residents' current statuses) to see if a nurse had documented the physician had been notified of the medication refusal. On 3/19/24 at 12:02 PM, the surveyor and the UM/LPN reviewed the 24-hour Nursing Report as well as March 2024 nursing Progress Notes, which neither included any documentation that Resident #68's physician had been notified of their refusal of insulin. On 3/19/24 at 1:48 PM the surveyor interviewed the Director of Nursing (DON) who stated if a resident refused medication, the nurse educated the resident and encouraged the resident to take their medication. If a resident continued to refuse his/her medication, then the nurse contacted the physician. The DON stated the nurse documented the resident's medication refusal in the nursing Progress Notes, and once the physician was notified, they documented that as well. At this time the surveyor with the DON reviewed the resident's March 2024 MAR, and the DON acknowledged the resident refused their insulin lispro. The DON stated the nurse should have contacted the physician to see how to proceed. The DON stated she needed to review the resident's medical record for further information. On 3/20/24 at 1:49 PM, the DON stated she was still reviewing the nursing Progress Notes and had not found any documentation which indicated the physician had been notified, but she was still checking. On 3/21/24 at 11:02 AM, the survey team met with the DON and Licensed Nursing Home Administrator (LNHA), and the DON confirmed there was no documentation the physician had been made aware the resident had been refusing their insulin medication. A review of the facility's Administering Medications policy dated revised April 2019, did not include instructions for medication refusal. A review of the facility's Charting and Documentation policy dated revised July 2017, did not include instructions for medication refusal. A review of the facility's Documentation of Medication Administration policy dated revised April 2007, did not include instructions for medication refusal. 37175 2. On 3/15/24 at 9:43 AM, the surveyor observed Resident #32 lying in bed awake, and the resident stated they were comfortable. A review of the Resident Face Sheet reflected the resident was admitted to the facility with diagnoses that included a cardiac pacemaker (an implantable device in the chest that regulates a slow heart rate), hypertension (high blood pressure), and chronic ischemic heart disease (heart problems caused by narrowed heart arteries the supply blood to the heart). A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 3 out of 15, which indicated severe cognitive impairment. A review of the March 2024 Physician's Orders report included a general order dated 1/23/24, for a pacemaker at the left chest wall with no further indications to monitor the pacemaker. A review of the individualized comprehensive care plan, dated effective 1/8/24, included a focus for cardiac disease with goals that included maintaining adequate cardiac function and the pacemaker will continue to function properly. There were no interventions included for this focus. Further review revealed a focus dated 7/24/23, for a pacemaker that indicated no goals exit for this focus; no interventions exist for this focus, and no notes exist for this focus. On 3/19/24 at 1:28 PM, the surveyor interviewed the UM/LPN who stated that if a resident had a pacemaker, it would be checked for function. The UM/LPN was unable to locate any pacemaker checks performed for Resident #32. On 3/19/24 at 1:35 PM, the surveyor interviewed the DON who stated that the facility was responsible for ensuring pacemakers were checked according to the physician's orders. On 3/21/24 at 10:00 AM, the surveyor re-interviewed the DON who acknowledged that the facility did not have pacemaker checks for Resident #32, and the facility was unable to identify the type of pacemaker the resident had. The DON stated that the resident's physician and family members did not know the type of pacemaker the resident had; that the pacemaker was inserted prior to admission to the facility. On 3/21/24 at 11:02 AM, the DON in the presence of the LNHA and the surveyor team, stated there was no further information regarding the pacemaker and confirmed it was essential to know the type of pacemaker the resident had to ensure it was maintained according to manufacturer's specifications. A review of the facility's Pacemaker, Care of a Resident with procedure dated December 2021, included .monitoring the resident for pacemaker failure by monitoring for signs of bradyarrhythmia [slow heart rate] that may consist of fainting, shortness of breath, dizziness .Documentation in the medical records on the pacemaker's identification card upon admission .the name and address of the cardiologist, type of pacemaker, type of leads, manufacturer, and model, serial number, date of implant, and paced rate . NJAC 8:39-27.1(a)-29.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) consistently complete the dialysis communication form and b.) maintain a resident's dialysis communication record. This deficient practice was identified for 1 of 2 residents reviewed for dialysis (Resident # 60), and was evidenced by the following: On 3/13/24 at 9:46 AM, the surveyor observed Resident #60 in bed in their room, who stated he/she went to dialysis on Mondays, Wednesdays, and Fridays. The surveyor reviewed the medical record for Resident #60. A review of the Resident Face Sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included end stage renal disease, diabetes mellitus with diabetic neuropathy (nerve damage), anemia( a low number of red blood cells), and chronic kidney disease. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/19/24, reflected a brief interview for mental status (BIMS) score of 14 out 15, which indicated an intact cognition. A further review in Section O - Special Treatment and Procedures reflected that the resident received hemodialysis services (a process of purifying the blood due to impaired kidney function). A review of the Physician's Orders for March 2024 included a physician order (PO) dated 3/1/24, for dialysis Monday, Wednesday, Friday from 3:00 PM to 11:00 PM. A review of the individualized comprehensive care plan included a focus area dated 3/17/24, that the resident was at risk for complications related to hemodialysis services. Interventions included to ensure that you are prepared to attend dialysis as ordered; monitor you for bleeding every shift upon return from dialysis; take your vital sign pre and post dialysis on dialysis days; take your weights as ordered on dialysis days both pre and post dialysis; and notify your dialysis center of any changes in your condition via communication book or telephone as needed. On 3/15/24 at 10:58 AM, the surveyor requested from the Unit Manger/Licensed Practical Nurse (UM/LPN) the resident's dialysis communication record. The UM/LPN stated he was unsure where the resident's communication record was; he thought the record had possibly been left at dialysis or with the transport company. At this time the surveyor reviewed the resident's paper medical record which included the following incomplete Dialysis Communication forms (DCF) for the section To be completed by facility Nurse upon return which included: time returned to the facility; dialysis access site location; access site assessment post dialysis; site intact/no signs of bleeding or infection; thrill/bruit; vital signs; nurse signature and date were not completed as followed: 12/4/23,12/8/23, 12/13/23, 12/31/23, 1/17/24, 1/19/24, 1/22/24, 1/24/24, 1/26/24, 1/29/24, 2/2/24, 2/9/24, 2/12/24, 2/14/24, 2/16/24, 2/19/24, 3/4/24, 3/6/24, 3/12/24 and 3/13/24. On 3/15/24 at 11:00 AM, the surveyor interviewed the UM/LPN who stated the facility was unable to locate the resident's dialysis communication record, so the facility obtained copies of the records from dialysis and created a new book. The UM/LPN acknowledged the nurses should have completed the To be completed by the facility Nurse upon return section. On 3/20/24 at 11:15 AM, the surveyor interviewed Resident #60 who stated upon return from dialysis, the nurses sometimes assessed him/her. The resident stated the nurses sometimes checked his/her dialysis access site and their blood pressure. On 3/21/24 at 9:10 AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team acknowledged the resident's Dialysis Communication forms were not completed upon return from the facility. The DON stated the nurses needed to assess the resident upon return to the facility, and documenting on the forms. A review of the facility's End-Stage Renal Disease, Care of a Resident with policy dated 9\September 2010, included .the following residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of car .the residents comprehensive care plan will reflect the resident's needs related to ESRD/Dialysis care. The policy did not address the facility nurses responsibility to complete the DCF forms once the resident returns to facility . NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during a wound care treatment. This deficient practice was identified for 1 of 2 wound observations observed for 1 of 2 residents reviewed for pressure ulcer and injury (Resident #56), and was evidenced by the following: On 3/13/24 at 10:25 AM, the surveyor observed Resident #56 in bed with a pressure-relieving device who stated he/she had a wound on his/her bottom. The surveyor reviewed the medical record for Resident #56. A review of the Resident Face Sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement), dementia, diabetes mellitus, neuromuscular dysfunction of the bladder (lack of bladder control due to nerve damage), schizophrenia and a wound to the sacrum (lower portion of the spine near the pelvis). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/21/23, revealed a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). A review of the Physician's Orders included a physician's order (PO) dated 3/6/24, to cleanse the sacral wound with a wound cleansing solution; apply calcium alginate (used to aid in wound absorption and healing); and apply a silicone foam dressing daily. On 3/19/24 at 10:50 AM, the surveyor observed the Unit Manager/Licensed Practical Nurse (UM/LPN) perform a wound care treatment on Resident #56 and observed the following: The UM/LPN entered the resident's room and placed the wound treatment supplies directly on the resident's overbed table without first sanitizing or applying a clean barrier. The UM/LPN proceeded to date and initial the foam dressing, then left the room to retrieve the zinc oxide. At 10:58 AM, the UM/LPN reentered Resident #56's room and washed his hands with soap and water lathering under the flow of running water for thirteen seconds. The UM/LPN then put on gloves; cleaned the resident's wound and without changing his gloves or performing hand hygiene, applied calcium alginate on the clean wound and covered the wound with a silicone foam dressing. The UM/LPN then removed his gloves, washed his hands with soap and water lathering outside the flow of running water for eight seconds; then put on a new pair of gloves, and repositioned the resident. The UM/LPN then removed his gloves and performed hand hygiene lathering with soap outside the flow of running water for eleven seconds. At 1:16 PM, the surveyor interviewed the UM/LPN who confirmed he should have changed his gloves and washed his hands after cleaning the wound prior to performing the treatment. The UM/LPN also acknowledged he should have sanitized the table and put down a clean barrier prior to putting the supplies on it, and he should have washed his hands for the length of time it took to sing two Happy Birthday songs. The UM/LPN was not aware of the exact timeframe that hands should be lathered with soap outside the flow of running water. On 3/21/24 at 11:02 AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team confirmed the overbed table should have been sanitized prior to placing the wound care supplies on it, and the nurse should have lathered his hands with soap and water outside the flow of running water for twenty seconds. A review of the facility's Handwashing/Hand Hygiene, policy dated revised August 2019, included the facility considers hand hygiene the primary means to prevent the spread of infections .washing hands .wet hands first with water, then apply an amount of product recommended by the manufacturer to hands . rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, rinse hands with water and dry thoroughly with a disposable towel . A review of the facility's Wound Care policy dated revised October 2010, included the purpose of this procedure is to provide guidelines for the care of wounds to promote healing .steps in the procedure .use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during the procedure on the clean field .be sure all clean items are on the clean field .use clean field saturated with alcohol to wipe the overbed table . A review of the facility's Wound Care Clean Dressing Change Competency Skills Checklist included .wipe table clean with appropriate surface cleanser, let dry, put down protective barrier .open treatment supplies on clean barrier .apply treatment to wound as ordered .discard protective barrier and gloves and perform hand hygiene .wipe down bedside table with appropriate surface cleanser and discard in plastic bag .perform hand hygiene . NJAC 8:39-19.4(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the accuracy of a re-admission nutrition assessment for a resident with significant weight loss. This deficient practice was identified for 1 of 4 residents reviewed for nutrition (Resident #60), and was evidenced by the following: On 3/13/24 at 9:46 AM, the surveyor observed Resident #60 in bed who stated he/she just finished breakfast and was still hungry. At this time, the surveyor observed the Licensed Practical Nurse (LPN) deliver the resident a sandwich. The surveyor reviewed the medical record for Resident #60. A review of the Resident Face Sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included end stage renal disease, diabetes mellitus with diabetic neuropathy (nerve damage cause by diabetes), anemia (low red blood cells), and chronic kidney disease. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/19/24, reflected the resident had a brief interview for mental status (BIMS) score of 14 out of 15; which indicated a fully intact cognition. A review of the Resident Progress Notes included a nursing note dated 3/1/24 at 11:09 PM, that the resident was admitted to the facility from the hospital. A review of the dietary note dated 3/16/24 at 11:36 AM, that the Registered Dietitian (RD) assessed the resident for a weight loss of 7.1 pounds (.lbs) which was 6% since 2/6/24, which was a significant weight loss greater than 5% in one month. A review of the resident's weights indicated the following: 1/9/24 116.2 .lbs 2/6/24 117.5 .lbs 3/13/24 110.4 .lbs The weights did not include an admission weight on 3/1/24, when the resident was readmitted from the hospital. A review of the Dietary-Readmission/Quarterly assessment dated [DATE], included the resident's current body weight was 117.5 .lbs on 2/6/24, with a one month weight gain of 1.3 .lbs or 1.1% since 1/9/24. This assessment did not include a current weight since re-admission. On 3/21/24 at 10:13 AM, the surveyor interviewed the RD who stated he completed nutrition assessments for the residents upon admission, re-admission, quarterly, and annually. The RD stated part of the assessment was to assess if the resident lost a significant amount of weight which would be 5% in one month; 7.5% in three months, and 10% or more in six months. The RD stated weights were obtained monthly usually by the fifth of the month and reweights if concern with accuracy were obtained by the eighth of the month. If the resident was admitted or readmitted to the facility, and no weight was obtained yet, he would ask staff for the resident to be weighed. The RD stated the assessment could not be based on a hospital or previous weight; the weight needed to be current from admission. At this time, the surveyor reviewed Resident #60's Dietary-Readmission/Quarterly assessment dated [DATE], and the RD confirmed the weight used for the assessment was not the resident's current weight, but the weight from the previous month prior to hospitalization . The RD stated at the time of the assessment, the resident's weight was not obtained, and acknowledged the assessment should have been based on a current weight for accuracy. The RD stated that the resident was weighed on 3/13/24 (twelve days after admission), and had a significant weight loss so one of the interventions he added was double protein portions at all meals for the resident. The surveyor continued to review the medical record. A review of the March 2024 Progress Notes included a physician's order dated 3/16/24, for double protein at all meals. On 3/21/24 at 11:02 AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team stated that a resident's weight should be obtained upon admission, and the weight used in the nutrition assessment should be the resident's current weight. On 3/21/24 at 11:58 AM, the Lead RD in the presence of the RD informed the survey team that Resident #60 was readmitted to the facility on [DATE], and at the time of the nutrition assessment, there was no re-admission weight so the RD used the previous weight. The Lead RD continued the RD was out of the facility and upon return observed the resident had a significant weight loss, so he wrote a dietary note on 3/16/24 to address the weight loss. The Lead RD confirmed the re-admission nutrition assessment from 3/1/24 was not accurate since the weight used was prior to re-admission. A review of the facility's Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol policy dated revised September 2017, included . The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition .The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequence of weight loss/or impaired nutrition. A review of the facility's Food and Nutrition Services'', dated revised October 2017, included . Each resident is provided with a nourishing palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident: The multidisciplinary staff, including nursing staff, the attending physician and the dietician will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization . A review of the facility's Nutritional Assessment, dated revised October 2017, included .As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factor for impaired nutrition, shall be conducted for each resident .The Dietitian, in conjunction with the nursing staff and healthcare practitioner, will conduct a nutritional assessment for each resident upon admission (with current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition . NJAC 8:39-27.1(a); 27.2(a)

Based on interview, review of Nurse Staffing Report sheets, and other pertinent facility documents, it was determined that the facility failed to ensure a Registered Nurse worked seven days a week for at least eight consecutive hours a day for 4 of 21 days reviewed. This deficient practice was evidenced by the following: During entrance conference on 3/13/24 at 10:45 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's staff was, and the LNHA stated that staffing was good; that the facility primarily utilized agency staff for certified nursing aides (CNA). At this time, the surveyor requested the Nurse Staffing Report to be completed for the following weeks: 6/25/23 through 7/1/23; 7/2/23 through 7/8/23; 3/3/24 through 3/9/24. The surveyor reviewed the Nurse Staffing Reports which revealed there was no Registered Nurse (RN) to work eight consecutive hours on the following dates: 1. No RN on 6/25/23; the last RN was scheduled on the 3:00 PM to 11:00 PM (3-11) shift on 6/24/23. 2. No RN on 7/2/23; the last RN was scheduled on the 7:00 AM to 3:00 PM (7-3) shift on 7/1/23. 3. No RN on 7/8/23; the last RN was scheduled on the 3-11 shift on 7/7/23. 4. No RN on 3/4/23; the last RN was scheduled on the 11:00 PM to 7:00 AM (11-7) shift on 3/3/24. A review of the corresponding nursing staffing sheets verified the following: During the 3-11 shift on 6/24/23, there was a RN scheduled, and the next RN scheduled to work on the 7-3 shift on 6/26/23. During the 3-11 shift on 7/1/23, there was a RN scheduled, and the next RN scheduled to work was on the 3-11 shift on 7/3/23. During the 3-11 shift on 7/7/23, there was a RN scheduled, and the next RN scheduled to work was on the 3-11 shift on 7/9/23. During the 11-7 shift on 3/3/24, there was a RN scheduled, and the next RN scheduled to work was on the 7-3 shift on 3/5/24. On 3/20/24 at 10:26 AM, the surveyor interviewed the Staffing Coordinator who stated the RNs scheduled in the building during the shifts were usually the supervisors. The Staffing Coordinator confirmed there should be a RN in the building daily for eight consecutive hours. On 3/21/24 at 11:02 AM, the DON in the presence of the LNHA and survey team, confirmed there was no RN in the facility for eight consecutive hours on the dates above. A review of the facility's Staffing policy dated revised October 2017, included our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services in accordance with resident care plans and the facility assessment . NJAC 8:39-25.2(h)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident. This deficient practice was identified for 1 of 26 residents reviewed for accommodation of needs (Resident #37), and was evidenced by the following: On 3/13/24 at 10:58 AM, the surveyor observed Resident #37 in bed with their eyes open; the resident did not speak but responded to the surveyor's greeting with a smile and waved both arms. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was on the floor, not within his/her reach. On 3/15/24 at 11:43 AM, the surveyor observed Resident #37 in bed with the call bell tied to the lower aspect of the right side rail (bar positioned on the side of a bed to assist residents with mobility) not within his/her reach. On 3/19/24 at 9:47 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated the resident used their call bell to alert staff they needed assistance. At that time the surveyor accompanied by the CNA entered Resident #37's room, and they observed the call bell wrapped around the lower part of the side rail, not within his/her reach. The CNA acknowledged the call bell should have been left within the resident's reach, and proceeded to unwrap the call bell and placed it within the resident's reach. The CNA asked the resident to push the call bell, and the surveyor observed them hit the call bell with his/her arm and the light went on. On 3/19/24 at 9:52 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who acknowledged the call bell should be within the resident's reach at all times. The surveyor reviewed the medical record for Resident #37. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included respiratory failure, diabetes mellitus, contractures of the right and left hands, tracheostomy status (a surgical opening in the neck to the windpipe to allow air to fill the lungs) and gastrostomy status (a surgical opening into the stomach used for feeding). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/20/24, reflected the resident had no speech, could understand others, was sometimes able to make himself/herself understood, and was dependent on staff for all Activities of Daily Living (ADLs). On 3/20/24 at 1:43 PM, the surveyor informed the above observations with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The DON acknowledged that all residents should have their call bells within reach. A review of the facility's Answering the Call Light policy dated revised March 2021, included when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . NJAC 8:39- 31.8 (c)(9)(10)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined the facility failed to ensure vulnerable residents were: a.) free from sexual abuse, and b.) protected from verbal abuse from staff. This deficient practice occurred for 3 of 6 residents reviewed for abuse (Resident #10, Resident #56, and Resident #63) and was evidenced by the following: Part A On 08/10/22, multiple staff members observed on the locked nursing unit, Resident #63, a registered sex offender, exit Resident #10's room. Resident #10 had intellectual disabilities and was dependent completely on staff for Activities of Daily Living (ADLs). Resident #63 was reported to be happy, bobbing their head side to side while smiling with feces on both of their hands. Certified Nursing Aide (CNA #1) reported this observation was alarming and reported it to a Licensed Practical Nurse (LPN #1). CNA #1, LPN #1, and Behavioral Aide (BA #1) entered Resident #10's room and observed the bed curtain was open, the resident was lying in bed with the blanket pulled down, their hospital type gown was pulled up, and their incontinence brief was twisted and opened to one side with feces coming outside of the brief. Resident #10 was reported to be shaking and appeared nervous while saying, mommy, rape, and doctor. LPN #1 reported the incident to the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) who both failed to investigate and report the situation. Resident #10 remained on the locked nursing unit for two weeks with Resident #63, until Resident #10's room was changed on 8/25/22 by the DON, since the resident reportedly did not need to be on a locked unit. Resident #63 remained on the locked unit with no additional monitoring and was free to roam around the unit and into other resident rooms. An interview with the LNHA revealed that the facility observed Resident #63 exit Resident #10's room on video surveillance footage, that was unable to be provided to the survey team. The LNHA stated that Resident #63 was only in Resident #10's room for six to seven minutes, and upon interview, Resident #63 stated he/she was in Resident #10's bathroom by mistake, the LNHA stated that was determined as plausible since LPN #1 was at some point inside Resident #10's room while administering medication and did not observe Resident #63. The LNHA concluded that no abuse had occurred, therefore, no investigation was required. The facility's failure to ensure all residents were free from abuse including sexual, verbal, and physical by failing to investigate the abuse, reporting to the appropriate authorities, and implementing interventions regarding an allegation of sexual abuse to Resident #10 by Resident #63, after staff and administration confirmed Resident #63, who was a registered sex offender was observed exiting Resident #10's room, posed a serious and immediate threat for abuse which can cause serious physical and emotional harm, impairment, or death that resulted in an Immediate Jeopardy (IJ) situation that began on 08/10/22, after Resident #63 was observed exiting Resident #10's room, and Resident #63 continued to remain on the locked unit for 15 days with no monitoring. The facility administration was notified of the IJ on 09/28/22 at 2:55 PM. The facility submitted an acceptable Removal Plan (RP) on 09/29/22 at 2:25 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 10/03/22. During an interview on 09/26/22 at 1:43 PM, Temporary Nursing Aide (TNA #1) informed the surveyor (#1) that she had concerns about an event that occurred on the third-floor locked nursing unit involving Resident #10 who had intellectual disabilities. TNA #1 stated she observed Resident #63 exit Resident #10's room with their hands soiled in feces. When TNA #1 went to check Resident #10, the resident was observed in bed with their incontinent brief twisted and opened on one side with feces all over. The resident was reportedly saying mommy and rape. TNA #1 stated Resident #10's assigned aide, CNA #1 was not at the facility today, but she could corroborate the incident as well as BA #1. TNA #1 stated LPN #1 was informed of the incident. On 09/27/22 at 8:38 AM, the surveyor re-interviewed TNA #1 who stated Resident #63 was independent and did not need assistance from staff for Activities of Daily Living (ADLs), while Resident #10 had the mindset of a five-or six-year-old and required total assistance from staff for ADLs. When Resident #63 was observed leaving Resident #10's room with feces on their hands and staff observed Resident #10 in bed with their incontinent brief twisted and feces coming out, LPN #1 told staff not to touch the resident. The DON had come to the floor and asked questions but she did not take a formal statement from TNA #1 or have TNA #1 sign a formal statement. TNA #1 reported the DON informed staff she would move Resident #10's room, but the resident was not moved until two weeks later. There was no monitoring of Resident #63 who still had access to all the residents in the locked unit. TNA #1 stated the LNHA was aware of this incident, and the police never came to the facility and Resident #10 was never sent to the hospital to be examined for possible rape. TNA #1 stated she had the date of when the incident occurred with a photo of the nursing staff sheet from that day. On 09/27/22 at 9:00 AM, the surveyor interviewed CNA #1 who confirmed she was Resident #10's aide on the date in question, and stated she had clearly recalled observing Resident #10 in bed in their hospital type gown with a blanket covering them, watching television with their bed curtain in the open position prior to her taking a morning break. CNA #1 stated that upon her return from her break, around 9:00 AM or 10:00 AM, she stated she observed Resident #63 exiting Resident #10's room and he/she appeared happy and was bobbing their head side to side with a smile which alarmed me and seemed weird. CNA #1 went into Resident #10's room and observed their roommate (Resident #56) who was lying in the first bed, and was alert but in their own world and was unable to be interviewed. CNA #1 stated she then observed Resident #10's curtain was now drawn closed as if someone was in there with them, and she knew the resident was unable to close the curtain themselves. When CNA #1 opened the curtain, Resident #10's sheet was pulled off of them, their legs were spread open, their incontinent brief was opened on one side, and their face looked disoriented. When CNA #1 asked Resident #10 what Resident #63 did to them, they were crying asking for their mother and said [he/she] raped [him/her]. CNA #1 reported the incident to LPN #1 who was an Agency nurse and LPN #1 assessed the resident in the presence of multiple aides. CNA #1 stated after that, she went to see Resident #63 to ask what they did, but she observed feces under their fingernails and that was all she needed to see since there was feces in Resident #10's brief. CNA #1 stated LPN #1 called downstairs, and it took twenty minutes for the DON and LNHA to come to the floor. The DON and LNHA were back and forth between Resident #10 and #63's rooms. Resident #10 was assessed by LPN #1 but never sent to the hospital for an evaluation and the police were not called, and LPN #1 told me to clean [Resident #10] up which I was not comfortable doing. CNA #1 stated she asked LNHA what the facility was doing and if they needed her to write a statement and the LNHA responded to CNA #1 to let him handle it. CNA #1 stated Resident #63 was a registered sex offender and did not receive special monitoring. CNA #1 stated that Resident #63 usually stayed in his/her room, which was another reason that seeing them exiting out of Resident #10's room was weird. CNA #1 stated Resident #63 was able to self-propel in their wheelchair as well as get out of their wheelchair. CNA #1 stated I still haven't written a statement and confirmed that no one has asked her to write one. On 09/27/22 at 9:22 AM, the surveyor accessed the United States Department of Justice National Sex Offender Public registry and confirmed Resident #63 was a registered sex offender for aggravated criminal sexual abuse for a victim under thirteen years old. The surveyor reviewed the medical record for Resident #63 which revealed the following: Resident #63's Face Sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included, but were not limited to; bipolar disorder, current episode manic without psychotic features (mental condition with extreme mood swings), and Diabetes Mellitus. The most recent quarterly Minimum Data Set (MDS), an assessment tool dated 07/08/22, reflected a brief interview for mental status (BIMS) score of 7 out of 15, which indicated a severely impaired cognition. The resident's Comprehensive Care Plan (CP) included a focus area dated effective 04/28/22, for at risk for loneliness, boredom and isolation due to the Pandemic (Coronavirus). Interventions included to bring to activities that you enjoy; to arrange phone calls or video chats with your family; to ensure you have activities of your choosing available; and to provide you with tools you need to do your favorite activity if applicable. The care plan failed to include the resident's history of sexual offense. A review of the all Progress Notes did not include the incident with Resident #10. The surveyor reviewed the medical record for Resident #10 which revealed the following: A review of the Admission Record face sheet reflected the resident was admitted to the facility with diagnoses which included; cerebral palsy (a congenital disorder of movement, muscle tone, or posture), history of seizure, developmental delay, and [intellectual disabilities]. A review of the most recent annual MDS, dated [DATE], reflected a BIMS score unable to be determined with a long and short-term memory problem with severely impaired cognitive skills. A review of the resident's CP included a focus area dated effective 07/07/22, for ADL Function/ [Rehabilitation] Potential. Interventions included to provide total dependence of staff for bathing, bed mobility, dressing, eating, personal hygiene, toilet use, transfer with a mechanical lift of two people from bed to chair and chair to bed, and turn and reposition. The care plan did not include the incident with Resident #63. A review of the Progress Notes did not include documentation regarding the incident with Resident #63. On 09/27/22 at 9:57 AM, the surveyor interviewed TNA #2 who stated about two months ago, she observed Resident #63 exit Resident #10's room and was told he/she touched Resident #10. TNA #2 stated that Resident #63 should not have been in Resident #10's room. TNA #2 stated LPN #1 was informed of the incident which occurred either the end of July or August; it was two months ago. TNA #2 confirmed that there was no monitoring completed for Resident #63. On 09/27/22 at 10:30 AM, the surveyor interviewed TNA #3 who stated Resident #63 could be aggressive with other residents such as trying to lure a wandering resident of the opposite sex into his/her room. TNA #3 stated she only witnessed it happen one time, and that the wandering resident had only made it to Resident #63's door before the aide then redirected the resident, and told Resident #63 that they were not allowed into the other resident's room. TNA #3 stated that she felt it was not safe for any resident in general to be alone in the room of resident of the opposite sex and that Resident #63 had not done anything in particular that she had been aware of to make her feel extra concerned about it. TNA #3 when asked, stated she was unaware of Resident #63 ever being inside another resident's room. On 09/27/22 at 10:38 AM, TNA #1 informed the surveyor that her cell phone battery was dead and she needed to charge the phone first to provide the surveyor with the information regarding the date of the incident. On 09/27/22 at 10:46 AM, the surveyor interviewed the DON who stated she had worked at the facility since 08/01/22, and was in charge of investigations. The DON stated the facility investigated falls, anything unwitnessed, bruises, skin tears, any kind of abuse including physical, verbal, and misappropriation of property. The DON stated the process for an investigation was to collect statements from all staff who saw the resident or took care of the resident; interview the resident if able to, even if the resident was confused. Then the facility notified the family or representative and the physician. The DON stated that abuse and/or neglect was investigated with the LNHA, and abuse was reported to the New Jersey Department of Health (NJDOH). At that time, the DON provided the surveyor with all investigations and incidents, which totaled five, that the facility conducted from 08/01/22 through the present. The DON stated the facility was searching for additional investigations, and if they could find any, they would give them to the surveyor. On 09/27/22 at 11:02 AM, the surveyor reviewed the five investigations provided by the DON. None of which did included the incident alleged by staff that occurred between Resident #10 and Resident #63. On 09/27/22 at 11:09 AM, the LNHA stated and confirmed that the surveyor had all of the facility investigations. The LNHA, upon inquiry, stated that he did not keep any soft files, but then stated there may be one or two reportables (mandatory facility reporting) and he would check. On 09/27/22 at 11:23 AM, the surveyor attempted to interview Resident #10's Power of Attorney (POA) via telephone, however, the POA did not answer. The surveyor left a message to call back. On 09/27/22 at 11:25 AM, the surveyor attempted to interview Resident #10's Emergency Contact via telephone, but the number was not in working service. On 09/27/22 at 12:10 PM, the LNHA confirmed that the surveyor had been provided with all investigations, incidents, and grievances from the past three months. This did not include any investigation regarding the alleged incident between Resident #10 and Resident #63. On 09/27/22 at 12:12 PM, the surveyor attempted to interview LPN #1 via telephone, but there was no answer. The surveyor left a message to call back. On 09/27/22 at 12:14 PM, the surveyor called the POA again on the telephone, and there was no answer. On 09/27/22 at 12:34 PM, the surveyor attempted to interview Resident #63 who spoke minimal English and stated that he/she was in pain, and mostly stayed in bed. On 09/27/22 at 12:35 PM, the surveyor interviewed the Director of Social Services (DSS) who stated she was the only social worker at the facility. The DSS stated she was involved in the grievance process as well as room changes. If a resident wanted a room change she would speak to the LNHA or DON and change their room if one was available. The DSS stated she would document in the electronic medical record (eMR) under Progress Notes as to why a room change was occurring. When asked why Resident #10 changed their room on 08/25/22, the DSS responded she was not involved in that room change but thought it was because Resident #10 was not appropriately placed on a locked unit. The DSS stated Resident #10 was a younger resident who had cerebral palsy and was wheelchair bound. The DSS stated the resident spent time in the dayroom, had stuffed animals and toys, and had minimal speech with the communication skills of a child. The DSS confirmed the room change was not documented in the eMR. On 09/27/22 at 1:31 PM, the surveyor attempted to interview Resident #10 in the presence of CNA #1, but was unable to tell the surveyor their name or how long they lived in their room. The resident was watching cartoons on the television, and holding a stuffed animal and kept pointing to the surveyor's manilla folder saying book and book yellow. On 09/27/22 at 1:34 PM, the surveyor attempted to interview Resident #10's previous roommate, Resident #56. When asked about Resident #10, Resident #56 stated he/she really liked that roommate who was young and did not talk. The surveyor asked if Resident #10 ever had visitors, and Resident #56 stated that Resident #10 left something here and he/she wanted it returned to them. At that time, Resident #56 went to the empty bed that Resident #10 had previously occupied and provided the surveyor with a Christmas card. When the surveyor opened the card, the card was written to Resident #63's name from [name redacted], an unknown person. On 09/27/22 at 1:41 PM, the surveyor showed LPN #2 the Christmas card, and she could not speak to why Resident #63's card would have been inside Resident #10's previous room. LPN #2 confirmed that was not Resident #63's room, and could not speak to if Resident #63 had ever been inside Resident #10's room. On 09/27/22 at 1:49 PM, the surveyor accompanied by a Laundry Aide interviewed Resident #63 in their native language. Resident #63 looked at the Christmas card, and confirmed it was theirs. Resident #63 did not speak to why the Christmas card was in Resident #10's former room, and told the surveyor that they could keep the Christmas card. On 09/27/22 at 2:23 PM, TNA #1 informed the surveyor that she was able to retrieve the nurse staffing reports and reviewed the nursing staff reports from 08/10/22 through 08/24/22. TNA #1 confirmed the incident had occurred on 08/10/22. On 09/27/22 at 2:23 PM, the LNHA presented the surveyor team with an undated document entitled Summary of Events. The document included the following On [no date] I received a call from unit [unnamed unit] a staff member [unnamed] was yelling in the hall. When I arrived I saw staff outside [Resident #63's] room and when asked the nurse [unnamed] what was going on that a patient had just come out of [Resident #10's] room who was [an opposite sex] patient. The report continued that the nurse [unnamed] and I immediately went into both Resident A [Resident #63] and Resident B's [Resident #10] rooms. Resident #10 was observed playing with his/her stuffed animal and we spoke with the resident for a few minutes, then spoke to Resident #63 who stated that he/she was confused and went into Resident #10's room to use the bathroom and when realized it was the wrong bathroom he/she was embarrassed. There were a couple of staff members [unnamed] expressing themselves about the resident's [Resident #63's] history, and I pulled staff aside and educated them on the importance of HIPAA (HIPAA; Heath Insurance Portability and Accountability Act; a law created to protect patient health information) and staff [unnamed] were concerned [Resident #63] was in [Resident #10's] room. We reviewed the camera footage [no date or time] and observed Resident #63 was in Resident #10's room for 6-7 minutes. The report continued that Resident #63 entered Resident #10's room at 9:43 AM after [LPN #1] walked away from her medication cart and we could see LPN #1 came back to her cart 1.5 minutes later that was outside of Resident #10's room and she went into the room [unnamed room] and gave medications to the patients [unnamed] and left the room. Then [He/she] moved on from that room towards Resident room [ROOM NUMBER] and as she was walking away, Resident #63 came out of Resident #10's room. Since LPN #1 was in the room and Resident #63 was in the bathroom, that was why we did not see [Resident #63 in the room]. The timeline and event details supported [Resident #63] went into the bathroom and left as suggested. Met with all staff on sensitivity, behavior, and HIPAA. State Agency [name redacted] came to the facility after an anonymous call, and she had nothing further to share because wrong date and wrong time [date and time not included], furthermore no detail on anything. We went over the situation from that day, shared our video footage/pictures from video and timeline. She spoke with some staff [unnamed] and suggested she was closing the case and left. In addition to the statement, there were three dark grainy pictures of surveillance video on an unidentifiable nursing unit. The first picture revealed a nursing unit hallway with a medication cart, a grainy picture of an unidentifiable resident self-propelling in a wheelchair into a resident room, and another person possibly in a wheelchair behind the medication cart. Viewing the picture, the sex of the people or the room could not be determined. The picture was undated and the time stamp was Tue 09:43:51 (S). The second picture was a grainy picture of a nursing unit hallway with the only identifiable object being a medication cart, and an unidentifiable person. There was no date and the timestamp only included 48:08 (S). The third grainy picture showed a nursing unit hallway with an unidentifiable nurse at a medication cart, a possible staff member walking up the hallway towards the nurse and the rest of the picture was unidentifiable. There picture was undated, and the timestamp indicated 9:53:12 (S). The packet also contained Resident #10's admission record Face Sheet dated generated by the LNHA on 09/27/22 at 1:11 PM, and Resident #63's admission record Face Sheet dated generated by the LNHA on 09/27/22 at 2:04 PM. On 09/27/22 at 2:23 PM, the surveyor interviewed the LNHA who stated he found the undated Summary of Events, stuck in a drawer in his desk even though he previously informed the surveyors earlier that he kept no soft files, and he confirmed that the surveyors had been provided all the investigations since he had been at the facility. The LNHA stated this event was immediately dismissed, there was no concern. When asked why there was no concern, the LNHA stated it was no concern because Resident #63 immediately came out of the room. According to the undated Summary of Events Resident #63 was in Resident #10's room for 6-7 minutes. The LNHA stated that the event could have occurred on 8/23/22 because that was my statement to self not provided to the surveyors. The LNHA continued, there were staff a CNA, maybe an activity aide, do not recall the names saying Resident #63 was a sexual predator who came to this facility from our sister facility. The LNHA stated he did not know if Resident #63 was a sexual predator, but has a history of their background as a sexual predator. The LNHA confirmed staff was upset, but he never followed up on it. The LNHA also stated that the sexual predator status was not followed up on. The LNHA stated that staff members refused to write statements and he did not memorialize that. The LNHA stated the first picture was Resident #63 entering Resident #10's room, the second picture was the nurse in Resident #10's room, and the third picture was Resident #63 exiting Resident #10's room (that could not be corroborated by the photos provided by the LNHA ). On 09/27/22 at 2:37 PM, the surveyor asked the DSS if she was aware of any allegations of sexual abuse at the facility. The DSS responded she was out of the office on 08/23/22, and was informed by the DON and LNHA on 08/24/22, that Resident #63 went into Resident #10's room, and based on video surveillance footage, there was no need to take it any further. The DSS continued she was under the impression everything had been taken care of. When asked if the incident would be a concern, the DSS responded, definitely a huge concern no resident should be discussed regarding, HIPAA. At this time, the surveyor reviewed the facility's abuse policy with the DSS who confirmed she was familiar with policy. When asked what she would have done if there was an allegation of sexual abuse, the DSS stated I am an advocate and that the police would be called, the resident would be interviewed, and interview the residents and staff. When inquired to the DSS if the staff were interviewed, she stated no. The DSS stated the LNHA closed this investigation after viewing the video surveillance footage, and speaking with the residents, and she confirmed there was no documentation to ensure the residents were okay. On 09/27/22 at 3:03 PM, the surveyor interviewed LPN #3, who stated she was unaware why Resident #10's room was changed on 8/25/22, when she arrived for shift, the resident was in a new room. LPN #3 stated that she changed the resident's room number in the eMR only. On 9/27/22 at 3:16 PM, the surveyor interviewed the DON who stated she was not at the facility on the morning the incident occurred when Resident #63 was observed exiting Resident #10's room by a behavioral aide. When the DON went upstairs, two behavioral aides that she cannot recall their names said Resident #63 came out of Resident #10's room and they reported they did not see what occurred in the room, just Resident #63 exited quickly. The DON stated that Resident #63 had a history of sexual abuse and discussed this with the LNHA. The DON stated she asked staff for statements, but none were provided, and she had no documentation to corroborate that. The DON stated she checked Resident #10, and their incontinent brief and clothing was in place and believed the incident occurred on 8/23/22. The DON stated she did not feel this situation was an allegation of abuse because no one saw anything. Resident #63 stated he/she went to use the bathroom and there was no evidence on the resident. The DON acknowledged there was no documented assessment of either resident as well as there were no documented statements from the residents, staff, or herself. The DON stated she changed Resident #10's room maybe, a day or two later since Resident #10 was not appropriately placed on the locked nursing unit. The DON stated that since Resident #63 was a sex offender, she should have interviewed other residents and looked into another facility placement for Resident #63. The DON stated if the facility policy was followed, the police should have been called, and Resident #10 should have been sent to the hospital for an assessment, as well as a thorough investigation conducted, and Resident #63 should have been monitored. The DON then confirmed none of that was completed. On 09/27/22 at 5:27 PM, the surveyor conducted a telephone interview with LPN #1. LPN #1's first asked if she would lose her job due to speaking with the surveyor. When asked if there had been any incident/s that occurred with Resident #10, LPN #1 stated yes, but the incident was resolved. LPN #1 stated that another resident (Resident #63) was in their bathroom, and she could not recall the date, maybe occurred sometime in August. LPN #1 stated that she had administered Resident #10's medication and then was down the hall with her medication cart when she heard CNA #1 hollering in the hallway saying get out of the room, this was not your room. The resident who CNA #1 hollered at, was Resident #63. The LPN #1 then called downstairs to the LNHA and DON to let them know what occurred. LPN #1 stated she was down a ways in the hallway and when CNA #1 was heard hollering, she then observed Resident #63 exit Resident #10's room. LPN #1 stated she went into Resident #10's room with the LNHA and DON, and at that time observed Resident #10 in bed partially covered with their legs bent. The LPN #1 could not recall if they were bent and open or bent and closed. LPN #1 stated the resident had on a cloth diaper that was soaked, and she could not recall if the resident had a bowel movement since she did not check, but the diaper was fastened at one side but could not recall the other side. LPN #1 could not recall if this was how the resident looked when she administered his/her medications. When asked what the resident's demeanor was, LPN #1 first responded the resident's usual demeanor. When asked what that was, LPN #1 stated laughing. When asked if Resident #10 was laughing, LPN #1 stated no, the resident was saying doctor. When asked why the resident would say doctor, LPN #1 responded she was unsure, maybe the resident thought she was a doctor. LPN #1 stated that she asked Resident #63 why they were in Resident #10's room, and the resident stated he/she was in the bathroom. LPN#1 stated she did not see Resident #63 in Resident #10's room when she was in there, he/she could have been in the bathroom since the bathroom door was closed. When asked if the door opened into the room or into the bathroom, LPN #1 stated the door opened into the room and she confirmed the door could be closed to move towards the exit. LPN #1 stated she assessed Resident #10, but did not complete documented assessment, or provide any information to the surveyor regarding the type of assessment completed. The LPN #1 stated the DON also entered Resident #10's room, but then stated she was not present for that. LPN #1 stated she was unsure how long Resident #63 was in the room, but believed there was camera footage, but the footage would not have shown inside the room. On 09/28/22 at 10:38 AM, the surveyor re-interviewed TNA #3, who stated she only saw Resident #63 try to lure a resident once into his/her room. TNA #3 stated she just did not think it was safe for two residents of the opposite sex to be in the same resident room so had a behavioral aide take that resident to the dayroom. TNA #3 stated she was aware she had to report incidents to the nurse, but she did not feel Resident #63 luring another resident into their room was a concern. On 09/28/22 at 11:42 AM, the surveyor re-interviewed CNA #1 via telephone who stated she was informed by multiple staff on the day of the incident that Resident #63 was a registered sex offender. On 09/28/22 at 11:50 AM, the surveyor re-interviewed the DSS who stated the LNHA was the head abuse officer, but she was trained on abuse during orientation including investigating and reporting. On 09/28/22 at 12:02 PM, the surveyor interviewed the Unit Clerk/Medical Records who stated Resident #63 was transferred to this facility from their sister facility who was contracted with the [redacted] Department of Corrections. The Unit Clerk/Medical Records stated Resident #63's admitting Face Sheet indicated they were admitted from the [redacted] Department of Corrections, and at this time she looked at Resident #63's thinned chart and stated someone removed that Face Sheet from the chart. The Unit Clerk/Medical Records continued on 8/10/22, there was commotion that Resident #63 was witnessed coming out of another resident's room by multiple staff including BA #1 and CNA #1 who were all upset. The Unit Clerk/Medical records stated that the DON was not present at the time of the commotion, but she knew staff made her aware of their concerns. On 09/28/22 at 1:12 PM, two surveyors requested the LNHA to show the video surveillance footage associated with the pictures provided. The LNHA stated he did not have access to the video footage, but the Interim Licensed Practical Nurse/Infection Preventionist (LPN/IP) who was regional, emailed him the video footage. The LNHA produced an email from the a Licensed Practical Nurse, Infection Preventionist, dated 08/23/22 at 3:33 PM, that did not include details of the video footage. The LNHA was unable to play the video footage. for the surveyors, and stated that he, recorded the video footage using his cell phone, and while watching the video surveillance footage on the computer monitor. At that time the surveyors requested the original video surveillance, not the cell phone footage. The footage was never provided. On 09/28/22 at 1:41 PM, the Unit Clerk/Medical Records confirmed Resident #63's admitting Face Sheet with the [redacted] Department of Corrections could not be located. On 09/29/22 at 11:14 AM, the surveyor asked BA #1 if she had ever witnessed Resident #63 touch another resident, and she responded that once Resident #63 pinned a resident of the opposite sex against a wall. The resident was ambulating in the hallway with a walker, when Resident #63 wheeled themselves towards the resident and they tried to grab their legs, but I stopped them. BA #1 stated she reported it to the nurse, but cannot recall which nurse because there was inconsistent nurses in the facility. BA #1 stated the day of the incident, [TRUNCATED]

Based on interview, record review and document review it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure policies, procedures and systems were developed and implemented to ensure immediate action was taken to make certain that the facility operated in a manner to ensure residents' attained or maintained the highest practicable physical, mental and psychosocial well-being of each resident by ensuring that a resident was free of sexual abuse, and the facility maintained an effective infection control program that limited the spread of COVID-19 an infectious deadly virus as was identified during an on-site survey that began on 09/21/22 and was evidenced by the following: Refer to 600L, 880L, 886L This IJ situation began on 9/28/22 and the facility administration was notified of the IJ on 9/28/22 at 2:55 PM. The facility submitted an acceptable removal plan on 09/27/22 at 3:46 PM. The IJ removal plan was verified as implemented during an onsite visit on 10/04/22 at 12:02 PM. Two Immediate Jeopardy (IJ) situations were identified on 09/23/22 at 1:04 PM for 880L and 886L, which began on 09/21/22 at 1:09 PM, when the Licensed Nursing Home Administrator (LNHA) was unable to provide the survey team with requested policies, procedures and documentation required to conduct the survey, and on 10/11/22 at 2:03 PM, the 880L and 886L were revised to incorporate additional IJ findings of deficient practice. A subsequent IJ situation was identified on 09/28/22 at 2:55 PM for 600K, and on 09/30/22 at 1:31 PM was revised to incorporate additional findings which elevated the deficient practice to widespread finding of abuse at 600L. An additional finding of IJ was identified on 10/11/22 at 2:03 PM for 888L. Refer to 880L Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure that Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance was implemented to limit the spread of COVID-19, infectious disease by failing to ensure: 1.) a process was in place to conduct comprehensive contact tracing upon the identification of a single new case of COVID-19 for 3 of 3 resident care units, and 2.) a process was in place to ensure all required staff were appropriately fit tested for an N-95 respirator for 3 of 3 resident care units which placed all residents and staff at risk for contracting a contagious infectious and potentially deadly virus. Refer to 886L Based on interview, record review and document review it was determined that the facility failed to: 1.) conduct immediate resident and staff testing upon the identification of a single COVID-19 positive staff or resident result, and 2.) ensure a system was in place, and the facility Infection Preventionist followed the facility policy to ensure that all staff who required weekly or bi-weekly COVID-19 testing was completed and documented during a COVID-19 outbreak. The facility's failure to take immediate action, follow Centers for Medicare and Medicaid Services (CMS) guidance, Centers for Disease Control and Prevention (CDC) and facility policies to limit exposure risks placed all residents and staff at risk for contracting COVID-19, a contagious potentially deadly virus. Refer to 600L Based on observation, interview, record review, and other pertinent facility documentation, it was determined the facility failed to ensure a.) residents were free from sexual abuse after an allegation of sexual abuse involving (Resident #10), and b.) protect vulnerable residents from being verbally abused by staff (Resident #56). Refer to 888L Based on interview, record review and document review it was determined that the facility failed to: 1.) ensure the facility policy, Centers for Disease Control and Prevention (CDC), and Centers for Medicare and Medicaid Services (CMS) for COVID-19 vaccinations was implemented to ensure that all staff were up to date with COVID-19 vaccinations, or have been granted a qualifying exemption during a COVID-19 outbreak that began on 06/24/22 and 2.) ensure all staff that were not up to date with vaccinations, or had been granted a qualifying exemption were not permitted to work in the facility. The facility's failure to take immediate action, follow Centers for Medicare and Medicaid Services (CMS) guidance, Centers for Disease Control and Prevention (CDC) and facility policies to limit exposure risks placed all residents and staff at risk for contracting COVID-19, a contagious potentially deadly virus. The non-compliance remained on 10/12/22 for no actual harm with the potential for more than minimal harm that is not IJ based on the following: 1. Based on interview and document review during the on-site survey conducted on 10/12/22, multiple Immediate Jeopardy situations were identified, in addition to a subsequent IJ identified on 10/11/22 at 2:03 PM for 888L, multiple deficient practices that were identified that had the potential to affect the health, safety and welfare of all residents who resided at the facility on 3 of 3 resident units. Refer to 609F, 610F, 689H, 865F, 725F, 812F, 843F, 865F, 867F, 882F On 09/21/22 at 9:05 AM, the LNHA informed the survey team that the facility was presently experiencing a COVID-19 outbreak and he would provide the facility line listing. The surveyor requested all of the infection control information, including staff vaccination policies and matrix, information on residents who smoked and times, and Quality Assurance and Performance Improvement (QAPI) information. On 09/21/22 at 1:09 PM, the surveyor conducted a follow-up interview with the LNHA who stated the Infection Preventionist, who had not completed an infection control certification, was responsible for all of the vaccination effort and would be able to provide all the information. On 09/22/22 at 10:06 AM, the Director of Nursing (DON) provided the survey team with a list of smokers, without the corresponding policy. On 09/22/22 at 2:14 PM, the DON and LNHA were unable to provide the survey team with all of the requested entrance conference documents including all infection control policies and procedures, vaccination matrix (document with the vaccination status of all staff) and a current facility line listing. On 09/22/22 at 2:26 PM, the LNHA confirmed that the facility infection control policies and procedures were not available. On 09/23/22 at 10:00 AM, the facility uncertified Infection Preventionist provided the survey team with a copy of the facility line listing two days after the initial request. On 09/23/22 at 11:32 AM, the LNHA informed the survey team that he was unable to provide the QAPI policies and procedures. On 09/23/22 at 11:34 AM, the survey team conducted an interview with the LNHA and DON regarding the National Health and Safety Network information that is required to be submitted regarding the staff vaccination status. The LNHA confirmed he inputted the information and confirmed there was no current employee vaccination list since not all employees were on it. The DON stated I am not making up what I don't have. On 10/06/22 at 2:43 PM, the survey team presented findings to the LNHA, DON, Regional Interim Infection Preventionist Licensed Practical Nurse (RIIPLPN), Regional Administrator and Regional Nurse. On 10/12/22 at 12:41 PM, the survey team met with the Regional Administrator and Regional Nurse who confirmed there was no rebuttal for the findings presented by the survey team and the facility had not additional information to provide. A review of the Administrator Job Description, signed by the LNHA on 06/22/2022, revealed the Purpose of Your Job Position; The primary purpose of your position is to direct the day-to day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times., Delegation of Authority; As Administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties., Administrative Functions; Plan, develop, organize, implement, evaluate, and direct the Facility's programs and activities in accordance with guidelines issues by management, Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility, Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice, Review the Facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations, Interpret the Facility's policies and procedures to employees, residents, family members, visitors, government agencies, etc., as necessary, Ensure that all employees, residents, visitors, and the general public follow the Facility's established policies and procedures, Assist the Medical Director in the development and implementation of medical and nursing services policies and procedures and professional standards of practice, Inform the Medical Director of all suspected or known incidents of resident abuse ., Resident Rights; .Review resident complaints and grievances and make written reports of action taken. Discuss such actions with resident and family as appropriate, Ensure that all policies governing the timely notice for resident discharges and/or room or roommate changes are strictly followed by all personnel .; Administrator; .Report all allegations of resident abuse and/or misappropriation of resident property, The Acknowledgement section of the jog description, dated 06/22/2022 and signed by the LNHA revealed I have read this job description and fully understand that the requirements set forth therein have be determined to be essential to this position. I hereby accept the position of Administrator and agree to perform the tasks outlined in this job description in a safe manner and in accordance with the Facility's established procedures. N.J.A.C. 8:39-9.2(a)

Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure that Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance was implemented to limit the spread of infectious disease by failing to ensure: 1.) a process was in place to conduct comprehensive contact tracing upon the identification of a single new case of COVID-19 for 3 of 3 resident care units, and 2.) a process was in place to ensure all required staff were appropriately fit tested for an N-95 respirator and documentation was completed for 3 of 3 resident care units. This deficient practice placed all residents and staff at risk for contracting a contagious infectious and potentially deadly virus and was evidenced by the following: Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, revised 03/10/22, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements. Reference: Centers for Disease Control and Prevention, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 23, 2022 Part 1 The facility's failure to ensure a process was in place to conduct comprehensive contact tracing upon the identification of a single new case of COVID-19 for 3 of 3 resident care units resulted in an Immediate Jeopardy (IJ) situation that began on 09/20/22, when two symptomatic residents (Resident #44 and Resident #52) were not immediately tested for COVID-19 and tested on e day later, on 9/21/22, and both residents were positive for COVID-19. The facility uncertified Registered Nurse Infection Preventionist (URNIP) confirmed contact tracing was not completed to identify any close contacts for Resident #44 and Resident #52, and the URNIP was unable to provide documented evidence of contact tracing that was completed to identify close contacts for both residents. The facility administration was notified of the IJ on 9/23/22 at 1:04 PM. The facility submitted an acceptable removal plan via electronic mail (email) on 09/27/22 at 3:46 PM. The IJ removal plan was verified as implemented during an on-site visit on 10/03/22 at 1:49 PM. The evidence was as follows: On 09/21/22 at 9:18 AM, upon entrance to the building, Surveyor #1 requested information from the Corporate Nurse (CN) regarding any COVID-19 positive residents currently residing in the building. The CN stated there were no COVID-19 positive residents in the building, and there were two persons under investigation (PUI- a person who had been in contact with a person who had an infection, or was awaiting testing for a suspected infection) who resided on the first floor. The Licensed Nursing Home Administrator (LNHA) informed the survey team that the facility was currently in an outbreak of COVID-19 and would provide the survey team with a copy of the current line listing. On 09/21/22 at 1:09 PM, surveyor #1 conducted an entrance conference with the LNHA and Director of Nursing (DON). The LNHA stated the URNIP was the facility Infection Preventionist and confirmed that she did not have an infection control certification since she had not completed infection control training. The LNHA stated that the URNIP was responsible for all of the facility COVID-19 vaccination effort. Surveyor #1 inquired to the number of COVID positive residents and symptomatic residents who currently residend in the facility, and the LNHA confirmed there were currently no COVID-19 positive residents who resided in the facility, and there were two PUI residents. Surveyor #1 requested all the information related to the COVID-19 vaccination status of all residents and staff and all related testing for COVID-19. The LNHA and DON stated that residents and staff were tested twice per week, however, they were unable to provide the documentation, and stated that the URNIP would provide it. On 09/22/22 at 9:55 AM, the DON and LNHA informed the survey team that two residents (Resident #44 and Resident #52) had tested positive for COVID-19 and had been moved to the first floor for isolation. The LNHA stated the positive results were identified during routine COVID-19 testing. On 09/22/22 at 1:46 PM and 2:14 PM, during interviews, the DON and LNHA failed to provide the survey team with the requested documents related to infection control, which included the staff vaccination documentation and staff and resident testing documentation. The LNHA stated the documents were now with the corporate people and he was unable to produce the documents. On 09/22/22 at 3:42 PM, the URNIP was interviewed by Surveyor #1, #2 and #3 regarding the facility COVID-19 testing process. The URNIP stated that not all staff and residents were tested twice weekly. She stated if the resident had not yet received a COVID-19 booster vaccine, they would be tested twice weekly. The survey team inquired as to what was the criteria that was used to determine which staff were tested for COVID-19. The URNIP then proceeded to review her COVID-19 testing log with the surveyors. The URNIP stated if some staff felt like they had a cold, they could be tested , and stated there are no staff members that need to be tested at present. The URNIP presented a log with handwritten COVID retesting employees, Binax Now Test Sign Off and had a handwritten date of 09/20/22, which contained three staff names, each dated 09/20/22, with a negative result. The three staff included a Licenced Practical Nurse (LPN #1), Unidentified Staff, (Staff #1), and the Maintenance Director (MD). The URNIP stated only residents were on her list to receive COVID-19 testing twice per week. A second document provided by the URNIP, revealed a handwritten COVID [sic.] res [NAME], 09/20/22, pt's The handwritten document contained eleven names and had a handwritten date of 09/20/22 with a negative result, and seven names were listed and dated 09/21/22. The URNIP stated the eleven names listed were not tested related to the COVID-19 positive residents, (Resident #44 and Resident #52, that were tested on [DATE]). Resident #52 and Resident #44, were listed with a positive result, and the remaining five names were negative. The survey team inquired to the URNIP regarding why the other names listed received a test, and the URNIP stated three staff requested a test, one resident requested a test, one resident was the Unsampled Resident roommate of Resident #44 who also requested to be tested after the resident had found out that the room mate tested positive. At 3:45 PM, the URNIP confirmed she was responsible for COVID-19 testing, and the two pages that she had provided to the survey team, and reviewed with the survey team was the only facility COVID-19 testing log that was used for residents and staff on 09/20/22 and 09/21/22. On 09/23/22 from 9:42 AM to 10:00 AM, Surveyor #2, #3 and #4 conducted a subsequent interview with the URNIP. The URNIP stated Resident #44 was tested for COVID-19 on 09/21/21, and she confirmed the resident had been symptomatic on 09/20/22. The URNIP stated that Resident #52 was tested for COVID-19 due to also having symptoms on 09/20/22, and she confirmed the resident also had tested positive on 09/21/22. The URNIP stated she had not been made aware until the 09/21/22 that Resident #44 and #52 were symptomatic. When asked if she should have been informed of the symptomatic residents she stated yes, I would think so. When asked who was responsible for completing any contact tracing related to the COVID-19 positive cases, the URNIP stated that is a good question and stated it would be under her jurisdiction. The URNIP stated that she had just found out from the survey team that Resident #52 had attended a funeral, otherwise, she stated she would have tested the resident for COVID-19 before and after attending a funeral outside of the facility. The URNIP stated that she had tried to obtain information from staff and made rounds daily on the resident units. When inquired to the URNIP when the current outbreak began and what the status was, the URNIP stated she did not know when the outbreak started, not the specific date, and as far as she knew the facility had always been in an outbreak. The Regional Administrator Registered Nurse (RARN) provided the survey team with a copy of the facility Outbreak Plan/Covid-19 Response, revised 03/10/22 which was reviewed in the presence of the URNIP. The document revealed Higher -risk exposure- referred to exposure of an individual's eyes, nose, or mouth to material potentially containing SARS-CoV-2, particularly if present in the room for an aerosol-generating procedure. This can occur when staff does not wear adequate personal protective equipment during care or interaction with an individual. The document also revealed Upon identification of a single new case of COVID-19 in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing though two approaches, contact tracing or broad-based (e.g., facility-wide) testing. Surveyor #1 inquired to the URNIP regarding what staff were considered exposed to Resident #44 and Resident #52, and were any of the staff tested for COVID-19 in response to the exposure. The URNIP stated everyone could be going into the room, anyone can answer a light [call bell], and stated, I will be honest with you, I didn't test anyone, and stated I tested the two [Resident #44 and #52] that were positive and the immediate roommate. The URNIP then confirmed, in the presence of the survey team, that she did not complete any contact tracing, and stated the book of testing that she had provided to the survey team was the entirety of the facility COVID-19 testing documentation, and confirmed there was no facility wide testing completed in response to the Residents #44 and #52 positive COVID-19 status. She stated any other staff member could have completed a COVID-19 test if they were trained. When inquired if any other staff had been trained to complete COVID-19 testing she stated, not off the top of my head. The survey team inquired to the URNIP regarding what should have been completed at the time a resident was experiencing symptoms of COVID-19. The URNIP stated that the facility has a DON, and testing supplies could be obtained as needed, and the residents should be tested if they were symptomatic. The URNIP stated that unvaccinated and symptomatic residents should be transferred to a COVID-19 isolation room with isolation signs placed outside. The URNIP stated if residents were symptomatic and then tested negative for COVID-19, they should be moved to an isolation room for PUI in the event they became symptomatic. The URNIP stated if there was a room mate to the COVID-19 positive resident, that person would be tested , and Resident #52 did not have a roommate. The URNIP stated that the roommate of Resident #44 was tested for COVID-19 on 09/21/22, and tested negative but was not restricted to the PUI section at this point. The URNIP stated both Resident #44 and Resident #52 had been coughing on 09/20/21 and were very alert. The surveyor inquired to the URNIP if she was aware that Resident #52 had attended a funeral on 09/16/22 outside of the facility, as documented in Resident #52's progress notes. The URNIP stated no, she was not aware. The URNIP was asked if she completed the facility line listing (the spreadsheet of all COVID-19 infections that is transmitted to the Department of Health) and communicated with the local Department of Health (DOH) regarding new COVID-19 cases. The URNIP stated the LNHA was responsible for completing the line listing and contacting the DOH. The URNIP provided the survey team with a copy of the facility line listing which revealed that the symptoms for Residents #44 and #52 had an onset date of 09/21/22. The survey team inquired if that date was correct and the URNIP stated that date should be changed to 09/20/22, when both residents became symptomatic. The surveyors inquired to the URNIP if she had reviewed the staff assignment sheets for Resident #44 and Resident #52 to determine who provided care for the residents. The URNIP confirmed that she had not looked at the assignment sheets to determine who had cared for Resident #44 and Resident #52. When asked how far back would it be reviewed to determine close contacts for the purpose of contact tracing, the URNIP did not specify and stated that she would have to get clarification. The survey inquired if the URNIP received a job description, and she stated, not as of yet. The survey team inquired to the URNIP regarding a list of all staff vaccination status and the percent vaccinated staff. The URNIP stated she could get that information from the employee files, however, she was not provided with that information for any new hires, and confirmed that she did not enter the information into the National Healthcare Safety Network (NHSN). On 09/23/22 at 11:34 AM, the survey team interviewed the DON regarding who was responsible for completing the NHSN information. The DON stated the LNHA completed it, however, she was unable to provide a staff vaccination list to the survey team, and she did not know what the percent COVID-19 vaccination status was for the staff. The DON stated she did not have a completed vaccination list and I am not making up what I don't have. The survey team inquired to the DON regarding what was the process when a resident became symptomatic for COVID-19. The DON stated as soon as symptoms developed the symptomatic person should be tested for COVID-19, and the Assistant Director of Nursing could complete the testing on the 11:00 PM-7:00 AM shift. The DON stated there was no reason that testing should not be completed. On 09/23/22 at 11:49 AM, Surveyor #1 interviewed the DON and LNHA in the presence of the survey team regarding if contact tracing was completed after Residents #44 and #52 tested COVID-19 positive. Both confirmed that contact tracing was not completed. A review of the facility provided document, Contact Tracing Policy Covid 19 Pandemic undated and provided on 09/26/22, included but was not limited to Purpose: committed to following all state and federal guidance and regulations to prevent the spread of Covid 19 .As per the CDC, contact tracing and close contacts are critical to help slow transmission of COVID-19. Procedure: maintain a continuous log of every person, including staff and visitors, who may have close contact with individuals at the facility. The Administrator or his/her designee will maintain the contact tracing log. If a staff member, resident, or consultant that visited the facility reports testing positive for COVID-19, the facility will immediately notify the local health officials and follow directives. For a new onset of a positive Covid case in a resident or staff member, the Infection Preventionist will document all contacts and conduct contact tracing utilizing Contact Tracing Form. Part 2 The facility's failure to ensure a process was in place to ensure all staff were appropriately fit tested for an N-95 respirator and documentation was complete for 3 of 3 resident care units, resulted in an Immediate Jeopardy situation that began on 09/23/22 at 8:53 AM, when a Licensed Practical Nurse (LPN #2) was observed at a medication cart on the 2nd floor wearing a surgical mask. LPN #2 informed the surveyor that she had not been fit tested for an N-95 mask, she worked on multiple resident units, and that she had not received a COVID-19 booster. The IJ was identified on 10/11/22 at 2:03 PM, when the facility IIPLPN was unable to confirm, and provide documented evidence that all staff who required fit-testing for an N-95 mask (a close facial fitting respiratory protection device for filtration of airborne particles) had been appropriately fit-tested . The facility submitted an acceptable removal plan via email on 10/12/22 at 1:42 PM. The IJ removal plan was verified as implemented on 10/12/22 at 2:35 PM. On 09/23/22 at 9:06 AM, Surveyor #1 interviewed the URNIP, in the presence of the survey team, regarding if staff were currently fit tested for N-95 masks, the URNIP stated that she did not have a test mask to complete the fit testing process. The URNIP stated everybody is not fit tested . When asked if all staff that worked on the COVID-19 unit were required to be fit tested and wear an N-95 mask. The URNIP stated no they can wear either [N-95 or surgical mask], and stated they should wear the N-95 mask. The URNIP stated I did not get to everybody, and I still have to get around to doing the new people. On 09/23/22 at 8:53 AM Surveyor #1 observed LPN #2 on the 2nd floor medication cart wearing a surgical mask. Surveyor #1 interviewed LPN #2 at that time who stated she was a new hire. The surveyor asked LPN #2 if she was vaccinated for COVID-19 and if she had been fit tested for an N-95 mask. LPN #2 stated not fit tested , not boosted, and she stated she was vaccinated for COVID-19 and confirmed that the facility was aware that she was not boosted. LPN #2 stated that she signed a waiver form that was provided by the facility since she did not want a COVID-19 booster. Surveyor #1 inquired to LPN #2 if she had received COVID-19 testing and she stated that the facility would let her know if she needed to take a test, and she could also let the URNIP know if she needed to take a COVID-19 test. Surveyor #1 asked if LPN #2 if she was assigned to a particular unit, and she stated that she floated to different units. Surveyor #1 inquired to LPN #2 if she was responsible for completing any COVID-19 symptom monitoring for her assigned residents. She stated, vitals are taken on everyone usually, if there were new symptoms then she would check vital signs (clinical measurements, specifically pulse rate, temperature respiration rate and blood pressure that indicate essential body functions), and that she would do vital signs if she had to, and stated she had not seen any formal resident monitoring for vital signs. On 10/06/22 at 12:30 PM, Surveyor #1 observed LPN #2 on the 1st floor COVID-19 unit at the nursing station. LPN #2 was observed wearing a NIOSH tc N-95 mask. Surveyor #1 inquired what N-95 mask was she required to wear, the LPN #2 removed two different masks from the bins outside of a resident room, and stated that she could wear either one. LPN #2 stated the mask Surveyor #1 was wearing (N95 # 8210) was very tight, and she stated that she was fit tested for both masks by the IIPLPN. Surveyor #1 inquired if LPN #2 had a medical or religious exemption for the COVID-19 booster. LPN #2 again stated that she had signed a paper waiver provided by the facility that indicated she does not want the booster, and stated no, it was not a medical exemption or a religious exemption and stated it was a document that offered risks and benefits. Surveyor #1 asked LPN #2 if she was fit tested for the mask she was wearing and she stated she could wear both and chose the N-95 that did not hurt her face which was the NIOSH tc N-95. LPN #2 stated if the masks were in the bins that they were okay to wear. On 10/06/22 at 4:03 PM, Surveyor #1 in the presence of the survey team, interviewed the Interim Infection Preventionist Licensed Practical Nurse (IIPLPN) regarding the N-95 fit testing process. The IIPLPN stated the N-95 fit testing should be done upon hire and annually. Surveyor #1 asked if the IIPLPN had received training or a certification for fit testing. The IIPLPN stated she watched videos and stated that a hood was used over a person's head and there was a solution that would be used to test the person to see if the mask fit. The IIPLPN provided the surveyor with a book of N-95 Respirator Training and Fit Testing Verification Forms (FTVF) for employees, and she stated the papers proved that a person had been fit tested for an N-95 mask. The IIPLPN stated there were certain brands and they fit differently. She stated that the fit testing was completed with the masks that were most prevalent and stated, no there was no shortage of N-95 masks. The IIPLPN stated if the employee needed a special mask, we would order it and some employees medically cannot use the N-95 masks. The IIPLPN stated the staff that were not up to date with their COVID-19 vaccinations were required to wear the N-95 masks, and staff who worked with the COVID-19 positive residents. On 10/06/22 at 4:10 PM, Surveyor #1 reviewed the FTVF form for LPN #2. The document revealed the Training and Fit Date was 09/23/22 for the 8210 N95 model. The IIPLPN was the trainer's name and signature. The Respirator Fit Test Record had a blank in the Respirator Selected and Manufacturer section was blank. The Fit Checks section with Negative Pressure, Positive Pressure, Pass, Fail and Not Done was blank. The Fit Testing section with Fit Factor for Quantitative and Qualitative, Isoamyl Acetate, Sweet, Bitter and Smoke and pass/fail for each was completely blank. The employee acknowledgement of test results was signed on 09/23/22 by LPN #2 and the Test Conducted by section was blank. Surveyor #1 inquired to the IIPLPN if the 8210 N-95 was available at the facility and she stated yes, it is a common mask. Surveyor #1 inquired about the FTVF document and was it completed since there were blanks and stated I don't have an answer for that and confirmed that she was unable to tell if LPN #2 passed or failed her fit test because the form was incomplete. The IIPLPN stated that it was important for all staff to know their results and stated although the document was incomplete that LPN #2 had been fit tested . Surveyor #1 inquired about a waiver that was completed by LPN #2 that stated she could waive the booster and the IIPLPN stated she was unaware of such a document. On 10/06/22 at 4:22 PM, Surveyor #1 asked the Regional Licenced Nursing Home Administrator (RLNHA) if there was a certification needed to conduct fit testing and if the facility allowed staff to waive the COVID-19 vaccine. The RLNHA stated yes a certification was required to provide fit testing and staff were required to be up to date all three were needed (two vaccines and one booster). On 10/07/22 at 10:49 AM, Surveyor #1 asked the IIPLPN if there was any staff that were currently not fit-tested for an N-95 mask. She confirmed that she did not know because she was not doing fit testing prior and was currently putting a list together and stated, it has been started. The IIPLPN stated, I watched the O.S.H.A. [Occupational Safety and Health Administration] video and did the competency back in the pandemic. The IIPLPN was not sure how long the certification was good for. The IIPLPN provided the survey team with a document on 09/28/22, in a packet with document related to an Occupational Therapy Assistant's (OTA) COVID-19 information. The document revealed the OTA's name handwritten on the document. The document was titled ACCEPTANCE/DECLINATION FORM/VACCINATION RECORD with three areas that can be checked off. The first area revealed a Covid-19 Vaccine Administration Consent, I wish to receive the Covid-19 Vaccine. I read or had explained to me the Covid-19 Vaccine Information. I was given the opportunity to ask questions that were answered to my satisfaction. I understand the health benefits and risks of Covid-19 and the Covid-19 Vaccine. The second area revealed Covid-19 Vaccine Declination, I decline to be vaccinated at this time. I have been given the opportunity to be vaccinated with the Covid-19 Vaccine. I understand that by declining this vaccine, I continue to be at increased risk of acquiring Covid-19, a serious disease, and a risk to others. I understand I can request the COVID 19 vaccine at any time during my employment with this facility, and the third section revealed, and was checked off by the Occupational Therapy Assistant, I have already received the COVID 19 vaccination. Please provide a copy of your COVID 19 vaccination card. (This document reflected what LPN #2 stated she had been offered and signed, however was not provided by the facility) The non-compliance remained on 10/12/22 for no actual harm with the potential for more than minimal harm that is not IJ based on the following: Based on observations, interview, record review and document review it was determined that the facility failed to ensure that CDC and CMS infection control guidance was followed to limit the spread of infections and ensure: a.) staff donned (put-on) the appropriate Personal Protective Equipment (PPE) upon entry into the room of residents who were on transmission-based precautions (TBP) for PUI, a new admission and un-vaccinated for COVID-19, and COVID-19 positive residents (Resident #245 and #249) and one unsampled resident on 1 of 3 units reviewed for TBP, b.) COVID-19 surveillance was conducted and documented for any signs and symptoms of COVID-19 during a COVID-19 outbreak for all facility residents who resided on 3 of 3 units, c.) a resident with a multidrug-resistant organism (an organism resistant to multiple antibiotics) was placed on TBP to prevent the spread of a multi drug resistant organism (MRDO) for 1 of 1 resident (Resident #86) reviewed for urinary catheter/UTI (urinary tract infection), d.) staff disinfected a blood pressure cuff prior to use on multiple residents, on 1 of 3 units observed for nursing care, e.) all staff completed the required COVID-19 entrance screening prior to providing resident care on 1 of 3 units, f.) to maintain a clean and sanitary environment in double occupancy resident room (Resident #7 and an unsampled resident) on 1 of 3 units (third floor unit), and g.) the facility annually reviewed Infection Control Policies and Procedures (ICPC) for 1 of 1 ICPC manuals provided and reviewed. The deficient practice was evidenced by the following: 38079 a.) On 09/21/22 at 11:07 AM, Surveyor #4 observed the COVID-19 PUI unit on the first floor. Surveyor #4 observed room [ROOM NUMBER] with a Stop sign affixed to the door and a plastic bin located next to the door. The plastic bin contained PPE gowns, surgical masks, N95 masks, gloves, hand sanitizer, and eye protection. Surveyor #4 observed another sign on the door Stop Observation-Quarantine Precautions, in addition to standard precautions; only essential personnel should enter this room; everyone MUST: hand hygiene before gloving and after glove removal, wear Mask N95 if fit tested and available or surgical mask if not fit tested or failed fit test, and eye protection; gown and gloves required prior to entering if you anticipate contact with resident or potentially contaminated surfaces in close proximity to resident. Quarantine Precautions: for use during COVID-19 pandemic - newly admitted residents during observation period (14 days); unvaccinated residents with frequent visits outside the facility .personal protective equipment with illustration how to don (put on) and doff (take off). Surveyor #4 then observed a staff member inside of the room without wearing eye protection, or a PPE gown, and the staff was wearing a cloth mask, and gloves. The staff member was handing Resident #245 a bar to exercise with. The staff member was identified as an Occupational Therapy Aide (OTA), and the OTA proceeded to exit the room wearing the same cloth mask and gloves. The OTA stated that PPE was not part of her training when she began at the facility about two weeks prior, and stated she had not been fit tested for the N95 mask. She stated she did see the signage on the door but did not wear any PPE because she had seen the resident before and she did not think it was a problem. The OTA then stated to Surveyor #4 that by not wearing her PPE, she could become contaminated, and possibly spread the COVID-19 infection. The OTA stated she had been trained about a year ago on PPE, but that was with a different company. Surveyor #4 asked the OTA if she was aware why the resident was on isolation. The OTA stated she believed something for COVID-19, but the resident did not have any symptoms that she was aware of. The OTA acknowledged the Stop sign affixed to the door and stated that she had not checked with the nurse prior to entering the room. A review of Resident #245's medical records revealed the resident had been recently admitted with diagnoses which included, but was not limited to; Multiple Sclerosis and pain. A review of the Admission Minimum Data Set (MDS), an assessment tool dated 09/16/22, revealed a Brief Interview of Mental Status (BIMS) of 15/15 indicating the resident was cognitively intact. A review of the Physician's Orders (PO) revealed an order dated 09/13/22, for Occupational Therapy Screen, Evaluate and Treat. A review of the facility provided immunizations for the resident revealed Resident #245 had not been vaccinated for COVID-19. During an interview with Surveyor #4 on 09/21/22 at 11:19 AM, and in the presence of the OTA, the DON stated the therapy department was not new to the facility. The DON stated there would be signs on the doors of isolation rooms to alert the staff of what PPE should be worn inside the rooms, and the DON confirmed there was a sufficient supply of PPE in the bins next to the doors. The DON then informed the OTA that she should not be wearing a cloth mask, and could not wear gloves in the hallway. The OTA at that time placed her gloved hands into her scrub top pockets. The DON stated if staff did not wear the appropriate PPE, they could spread infection (COVID-19). The DON further stated she was not sure who would be responsible for training new therapy staff on PPE. The DON then acknowledged the OTA had not been fit tested and stated the OTA should not be in the COVID-19 isolation room without first being fit tested . At that time, the DON again instructed the OTA to remove her gloves and wash her hands. On 09/23/22 at 9:06 AM, during an interview with Surveyor #4, the acting URNIP stated she had not fit tested everyone working on the PUI/COVID-19 unit with the residents. The RN #1 stated the staff should be wearing N95 masks and that she had not gotten around to check, or work with staffing to see who should be working with the PUI/COVID-19 positive residents. On 09/28/22 at 8:39 AM, Surveyor #4 observed a staff member on the first floor PUI/COVID-19 unit. The staff member was wearing an N95 mask that was not secured around her head and both straps of the N95 mask were sticking out of the sides of a surgical mask she was wearing. The staff member was stepping into the COVID-19 isolation room of Resident #249 with signage on the door. The signage, Stop Observation-Quarantine Precautions, in addition to standard precautions, only essential personnel should enter this room, everyone MUST: hand hygiene before gloving and after glove removal, wear Mask N95 if fit tested and available or surgical mask if not fit tested or failed fit test, and eye protection; gown and gloves required prior to entering if you anticipate contact with resident or potentially contaminated surfaces in close proximity to resident. Quarantine Precautions: for use during COVID-19 pandemic .personal protective equipment with illustration how to don (put on) and doff (take off). At that time Surveyor #4 interviewed the staff member who identified herself as an LPN who worked with a contracted wound care company. The wound care LPN stated she had been in-serviced on PPE before, but not at the facility. She further stated she was not sure if the resident was positive for COVID-19. The wound care LPN stated she had been fit tested for the N95 mask and knew that the straps should be around her head, but my nose is sore, so I anchored the N95 with a surgical mask. Surveyor #4 asked how the N95 should fit. The wound care LPN stated the N95 should be a tight fit and acknowledged that hers was not really a tight seal. She further stated that by wearing the N95 incorrectly, she could become exposed to COVID-19. A review of Resident #249's medical records revealed the reside [TRUNCATED]

Based on interview, record review and document review it was determined that the facility failed to: 1.) conduct immediate resident and staff testing upon the identification of a single COVID-19 positive staff or resident result, and 2.) ensure a system was in place, and the facility Infection Preventionist followed the facility policy to ensure that all staff who required weekly or bi-weekly COVID-19 testing was completed and documented during a COVID-19 outbreak. The facility's failure to take immediate action, follow Centers for Disease Control and Prevention (CDC) , Centers for Medicare and Medicaid Services (CMS) guidance, and facility policies to limit exposure risks placed all residents and staff at risk for contracting COVID-19, a contagious deadly virus. Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, revised 03/10/22, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements. Reference: Centers for Disease Control and Prevention, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 23, 2022 Refer to 880L, 888L Part 1 The failure to conduct immediate resident and staff testing upon the identification of a single COVID-19 positive staff or resident result. This resulted in an Immediate Jeopardy (IJ) situation which began on 09/20/22 and was identified on 09/23/22 at 1:04 PM. The facility's COVID-19 outbreak began on 06/24/22. Two residents (Resident #44 & #52) were symptomatic, coughing and sneezing on 09/20/22, and the facility's uncertified Infection Preventionist Registered Nurse (UIPRN) confirmed testing was not immediately performed on 09/20/22. The facility administration was notified of the IJ on 9/23/22 at 1:04 PM. The facility submitted an acceptable removal plan on 09/27/22 at 3:46 PM. The IJ removal plan was verified as implemented during an onsite visit on 10/03/22 at 1:49 PM. The evidence was as follows: On 09/21/22 at 9:18 AM, upon entrance to the building, Surveyor #1 requested information from the Corporate Nurse regarding if there were any COVID-19 positive residents in the building. The Corporate Nurse stated there was no COVID-19 positive resident in the building, and there were two persons under investigation (PUI- a person who had been in contact with a person with an infection or awaiting testing for a suspected infection) who resided on the first floor. At 9:05 AM, the Licensed Nursing Home Administrator (LNHA) informed the survey team that the facility was currently in an outbreak of COVID-19 and would provide the survey team with a copy of the current line listing. On 09/21/22 at 1:09 PM, Surveyor #1 held an entrance conference with the LNHA and Director of Nursing (DON). The LNHA stated the UIPRN was not certified since she had not yet completed the infection control training. The LNHA stated that the UIPRN was responsible for all of the facility vaccination effort. Surveyor #1 inquired to the number of COVID-19 positive residents and symptomatic residents who were currently residing in the facility and the LNHA stated there were currently no COVID-19 positive residents who resided at the facility, and there were two residents who were considered persons under investigation. Surveyor #1 requested all the information related to the current COVID-19 vaccination status of all residents and staff and all related testing for COVID-19. The LNHA and DON stated that residents and staff were tested twice per week, however, they were unable to provide the documentation and stated that the UIPRN would be able to provide the testing information. On 09/22/22 at 9:43 AM, the DON and LNHA informed the survey team that two residents (Resident #44 & Resident #52) had tested positive for COVID-19 and now resided on the first floor after being transferred from the third floor due to testing COVID-19 positive. The LNHA stated the positive results were identified during routine COVID-19 testing. On 09/22/22 at 9:55 AM, the DON and LNHA failed to provide the survey team with the requested documents related to infection control, which included staff vaccination and staff and resident testing documentation. The LNHA stated the documents were with the corporate people and he was unable to produce the documents. On 09/22/22 at 3:42 PM, the UIPRN was interviewed by Surveyor #1, #2, and #3, regarding the facility testing process. The URNIP stated that not all staff and residents were tested twice weekly. She stated if the resident had not yet received a COVID-19 booster vaccine, they would be tested twice weekly. Surveyor #1 inquired as to what was the criteria that was used to determine what staff were tested for COVID-19. The UIPRN reviewed her COVID-19 testing log with the surveyors and stated if some staff felt like they had a cold, they could be tested . The URNIP then stated there is no staff members that need to be tested at present. The UIPRN presented a log with handwritten COVID retesting employees, [brand name rapid COVID-19 test] Test Sign Off dated 09/20/22, and contained three staff names, dated 09/20/22, with a negative result documented for a Licence Practical Nurse (LPN #1), Maintenance Director (MD) and Staff #1. The UIPRN stated only residents were on her list to receive COVID-19 testing twice per week. A second document provided by the UIPRN, revealed a handwritten COVID testing, 09/20/22, pt's The handwritten document contained eleven names, dated 09/20/22, with a negative result and seven names were listed and dated 09/21/22. The UIPRN stated the eleven names that were listed did not receive a COVID-19 test due to the COVID-19 Positive residents identified on 09/21/22. Resident #52 and Resident #44 were also listed on the document, with a positive result, and the remaining five names were listed with a negative result. Surveyor #1 inquired to the UIPRN regarding why the other names listed had received a COVID-19 test. The UIPRN stated three staff requested a test, one resident requested a test, one resident was the Unsampled Resident roommate of Resident #44 who also requested to be tested . At 3:45 PM, the UIPRN confirmed the two pages that were provided to the surveyors, and reviewed with the surveyors, was the only COVID-19 testing log for employees or staff on 09/20/22 and 09/21/22, with no other testing dates provided. A review of the Electronic Nursing Progress Notes (EPN) for Resident #44 revealed on 09/21/22 at 10:51 PM a nurse documented that Resident has been coughing and sneezing since yesterday. MD [doctor] made aware and ordered COVID test. Resident tested positive for COVID 19 .Resident Transferred to the 1st floor room . The Care Plan Activity Report for Resident #44 revealed, The COVID-19 Actual or suspected Care Plan, As Evidenced By: Confirmed positive for COVID 19 09/21/22, Effective: 09/21/22, Goals revealed, I will recover from COVID 19, Effective 09/21/22, Interventions included; We will place you in isolation form droplet and contact precautions until the virus is resolved. Effective:09/21/22, We will confine you to your room during your illness to prevent the spread of the virus, Effective:09/21/22, We will monitor your temp [temperature], vital signs, pulse ox [blood oxygen level] and symptoms to see if you are responding to treatment, Effective 09/21/22. A review of the EPN for Resident #52 revealed on 09/21/22 at 3:50 PM, Licence Practical Nurse #1 (LPN #1) documented covid swab requested., and at 10:50 PM, another nurse documented Resident has been coughing since yesterday. MD made aware and ordered COVID test. Resident tested positive for COVID 19 .Resident Transferred to the 1st floor . (This represented a seven hour delay from the documented request for the Covid swab at 3:50 PM) On 09/23/22 from 9:42 AM to 10:00 AM, Surveyor #1 again interviewed the UIPRN in the presence of Surveyor #2, #3, and #4. The URNIP stated Resident #44 was tested on [DATE], and confirmed the resident was symptomatic on 09/20/22. The UIPRN stated that Resident #52 was tested due to also having symptoms on 09/20/22, and the resident tested positive on 09/21/22. The UIPRN stated she was not made aware until 09/21/22, that Resident #44 and #52 were symptomatic on 09/20/22. When asked if she should have been informed of the symptomatic residents she stated yes, I would think so. When asked who is responsible for completing any contact tracing related to the COVID-19 positive cases, the UIPRN stated that is a good question and stated it would be under her jurisdiction. The surveyor inquired to the UIPRN if she was aware that Resident #52 had attended a funeral on 09/16/22, as documented in Resident #52's progress notes. The URNIP stated no, she was not aware. The UIPRN stated that she had just found out from the survey team that Resident #52 had left the facility out on pass, otherwise, she stated she would have tested the resident for COVID-19 before and after having left the facility out on pass. The UIPRN stated that she tried to get information from staff and made rounds daily. When inquired to the URNIP when the current outbreak started and what the status was, the UIPRN stated she did not know when the outbreak started, not the specific date, and as far as she knew they were always in an outbreak. The Regional Licensed Nursing Home Administrator (RLNA) provided the survey team with a copy of the facility Outbreak Plan/Covid-19 Response, revised 03/10/22, which was reviewed in the presence of the UIPRN . The document revealed a Higher -risk exposure- refers to exposure of an individual's eyes, nose, or mouth to material potentially containing SARS-CoV-2, particularly if present in the room for an aerosol-generating procedure. This can occur when staff does not wear adequate personal protective equipment during care or interaction with an individual. The document also revealed Upon identification of a single new case of COVID-19 in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing though two approaches, contact tracing or broad-based (e.g., facility-wide) testing. Surveyor #1 inquired to the UIPRN regarding what staff were considered exposed to Resident #44 and Resident #52 and were any of the staff tested for COVID-19 in response to the exposure. The UIPRN stated everyone could be going into the room, anyone can answer a light, and stated, I will be honest with you, I didn't test anyone and stated I tested the two [Resident #44 and #52] that were positive and the immediate roommate. The UIPRN then confirmed, in the presence of the survey team, that she did not complete any contact tracing and the book of testing that she had provided to the survey team was in it;s entirety, no other COVID-19 testing documentation was available and confirmed there was no facility wide testing completed in response to the Residents #44 and #52 positive COVID-19 status. The UIPRN stated any other staff member could complete a COVID-19 test if they were trained. When inquired if any other staff had been trained to do COVID-19 testing she stated, not off the top of my head. Surveyor #3 inquired to the UIPRN regarding what should be done when a resident was experiencing symptoms of COVID-19. The UIPRN stated that the facility had a DON and testing supplies can be obtained as needed and the residents should be tested if they are symptomatic and unvaccinated, the resident should be transferred to a COVID-19 isolation room with isolation signs placed. The UIPRN stated if residents were symptomatic and then tested negative for COVID-19, they should be moved to an isolation room for PUI in the event they became COVID-19 positive. The UIPRN stated if there was a room mate to the COVID-19 positive resident, that person would be tested , and Resident #52 did not have a roommate. The UIPRN stated that the roommate of Resident #44 was tested for COVID-19 on 09/21/22, and tested negative, but was not restricted to the PUI section at this point. The URNIP stated both Resident #44 and #52 were both coughing on 09/20/21, and were very alert. The URNIP was asked if she completed the facility line listing (the spreadsheet of all COVID-19 infections that is transmitted to the Department of Health) and communicated with the local Department of Health (DOH) regarding new COVID-19 cases. The URNIP stated the LNHA was responsible for the line listing and contacting the DOH. The UIPRN provided the survey team with a copy of the facility line listing which revealed that the symptoms for Residents #44 and #52 had an onset date of 09/21/22, and the survey team inquired if that date was correct, and the UIPRN stated that date should be changed to 09/20/22. On 09/24/22 at 9:30 AM, Surveyor #1 toured the third floor unit and observed a Certified Nursing Aide (CNA #1), who was wearing a black surgical mask and was making the bed in Resident #44's room. The surveyor inquired to CNA #1 where Resident #44 was at present and CNA #1 stated that the Resident #44 was in physical therapy. Surveyor #1 interviewed Licensed Practical Nurse #1 regarding where Resident #44 was at present. The nurse stated that Resident #44 had tested COVID-19 positive and had been transferred to the 1st floor COVID-19 unit and CNA #1 was not made aware. CNA #1 was not tested for COVID-19 on 09/21/22, when she had been assigned to provide care for Resident #44 while the resident was symptomatic for COVID-19 on 09/20/22, and had tested COVID-19 positive on 09/21/22. Part 2 The facility infection preventionist failed to ensure a system was in place, and was followed to ensure the all staff who required weekly, or bi-weekly COVID-19 testing was implemented and documented during a COVID-19 outbreak. This resulted in an IJ situation that was identified on 10/11/22 at 2:03 PM, when the facility failed to complete required COVID-19 testing which placed all residents and staff at risk for contracting a contagious and potentially deadly virus. The facility submitted an acceptable removal plan on 10/12/22 at 1:42 PM. The survey team verified the removal plan as implemented during an onsite survey on 10/12/22 at 2:35 PM. The deficient practice was evidenced by the following: On 09/23/22 at 9:42 AM, Surveyor #2 conducted an interview with LPN #1 who stated she was not vaccinated, had a medical exemption, and was not fit tested . On 09/26/22 at 12:02 PM and 2:18 PM, the Director of Nursing (DON) and Interim Infection Preventionist Licence Practical Nurse (IIPLPN), respectively provided the staff vaccination matrix and both did not include LPN #1. The DON confirmed at 12:05 PM, that the facility vaccination matrix had not been completed until the past weekend. On 10/04/22 at 11:19 AM, Surveyor #1 conducted an interview with the IIPLPN, in the presence of the survey team regarding what the frequency was for testing staff that were not up to date with COVID-19 vaccines. She stated it depended on the county rate and the staff should be tested on ce or twice per week, and we are low, so we are testing everyone every three to five days because of the outbreak. The IIPLPN stated that staff that was not up to date with COVID vaccinations should also have been wearing N-95 respirator masks when they provided care. At that time, Surveyor #1 requested that the IIPLPN review the facility Outbreak Response Plan regarding any guidance for facility testing for information regarding testing. The IIPLPN stated testing was once or twice per week, she did not write the facility policy, and she had reviewed it. On 10/06/22 at 1:46 PM, Surveyor #1 interviewed the IIPLPN in the presence of the team regarding the staff COVID-19 vaccination requirements. The facility had been informing staff that they must receive a COVID-19 booster. The surveyor inquired regarding if the staff that are not fully vaccinated are being tested for COVID-19. The IIPLPN stated I am going to say no, and stated the facility was in an outbreak and they were tested for that. Surveyor #3 inquired to what testing frequency should have been completed. The IIPLPN stated that everyone should have been tested twice per week due to the current COVID-19 outbreak, and confirmed the facility testing lists were not consistent and were not updated. On 10/06/22 at 2:09 PM, Surveyor #3 conducted an interview with the IIPLPN in the presence of the survey team. The IIPLPN acknowledged that all staff were currently not up to date with their COVID-19 vaccinations, and the vaccination staff tracking was not current. The IIPLPN stated this was not known until she assumed the role of IIPLPN. The IIPLPN was unable to provide any documentation and confirmed staff that were currently not up to date or exempted from receiving the COVID-19 vaccination, were not being tested for COVID-19 the way they should be tested , which was twice per week during an outbreak which began on 06/24/22. On 10/07/22 at 11:52 AM, Surveyor #2 observed LPN #1 providing care on 09/21/22, 09/22/22, 09/24/22, 09/26/22, 09/28/22, 09/29/22, 09/30/22, 10/03/22, 10/04/22 and 10/06/22. During all observations, LPN #1 was observed wearing a black surgical mask. The LPN #1 stated she had cared for the Unsampled third floor Resident who was symptomatic, and then tested COVID-19 positive on 10/06/22. LPN #1 stated she had been working at the facility for four months, and confirmed to the survey team that she had not been fit tested for an N95 respirator mask. On 10/11/22 10:51 AM, the IIPLPN, in the presence of the LNHA, provided an updated vaccination list to the survey team. Surveyor #1 inquired to the LNHA and IIPLPN why the list was provided today and the IIPLPN stated I did it yesterday and I don't have an answer why it was not done earlier. The IILPN stated there are a lot of components to this program and I cannot fix it in a week or two. The LNHA stated I was aware, when asked if he knew the vaccination list was incomplete, and the IILPN stated she was not aware that the vaccination list was incomplete. A review of the facility's policy, Update to COVID Vaccination and Testing dated 04/06/22 and facility reviewed on 9/2/2022, revealed Policy: It is the policy of [redacted] Rehabilitation and Care Center to offer COVID-19 vaccination and testing as per CDC and DOH guidance as a preventative health measure to reduce the risk of infection from COVID 19. Based on the above definitions, CMS has set the requirement that if staff have not received a COVID booster they are not considered up to date and will require routine testing in accordance with CDC community transmission rates. A review of the facility's policy, COVID 19 Management (All Policies), revised on 5/31/2022, revealed; Staff COVID 19 Vaccination and Testing Requirements, Procedure: Employee Vaccinations for COVID 19 (per DOH order summary action). This facility will track and securely document the COVID 19 vaccination and/or testing status of all staff including vaccination booster doses. 3. All employees of this facility must be fully vaccinated including booster vaccinations as they are mandated or have an approved medical exemption. 4. For Staff whom are partially vaccinated (one dose for multi-dose vaccine schedule or those who are eligible for the booster vaccines as it is mandated): at minimum perform weekly testing and use of NIOSH N95 or equivalent for source control, 12. All employees, contract staff and medical staff will be tested for COVID-19 as per the most current guidelines. A review of the facility's policy, Outbreak Plan/COVID-19 Response, revised 3/10/22, revealed Guidelines: Testing of Nursing Home Staff and Residents to enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set for the the HHS Secretary. 41858 The non-compliance remained on 10/12/22, for no actual harm with the potential for more than minimal harm that was not IJ evidenced by the following: 1. Based on interview and review of facility documentation, it was determined that the facility failed to test unvaccinated staff for Coronavirus Disease 2019 (COVID-19) at a frequency based on the facility's policy, COVID 19 Management (All Policies). This deficient practice was identified for 3 of 3 staff members reviewed for COVID-19 testing and was evidenced by the following: On 09/26/22 at 12:02 PM, the DON provided the Staff Vaccination Matrix (SVM) to the survey team, she confirmed it was completed over the weekend because they did not have staff vaccination cards prior to that time. On 09/26/22 at 2:18 PM, the IIPLPN provided an updated SVM to the survey team. On 10/05/22 at 9:37 AM, after a review of the SVM in the presence of the survey team, the RLNHA, the LNHA, the Regional Nurse (RN) and the DON, Surveyor #3 requested 9 weeks of testing from August 1, 2022 for the two staff members identified by the facility as having COVID-19 vaccination exemptions, and one partially vaccinated staff member as listed on the SVM. A review of the testing from August 1,2022 provided by the Regional Administrator (RA) on 10/5/22 at 10:53 AM, revealed the following: A. The Staffing Coordinator tested negative on 9/28/22 and 10/4/22. B. LPN # 3 tested negative 8/17/22. C. Temporary Nurses Aide (TNA) #1 tested negative on 8/17/22 and 9/28/22. On 10/05/22 at 1:18 PM, in the presence of the survey team, the RLNHA confirmed that the above provided testing was the only COVID-19 testing that could be located for the prior nine weeks beginning August 1, 2022 and confirmed that the facility's Outbreak started 06/24/22. On 10/06/22 at 1:50 PM, in the presence of the survey team, Surveyor #3 interviewed the IIPLPN. The IIPLPN reviewed the facility's policy COVID 19 Management (All Policies), and confirmed that all staff who are exempt or not up to date with the COVID-19 vaccine should be tested for COVID-19 at least once a week but they are not. Surveyor #3 reviewed the testing for the above listed staff members with the IIPLPN. She then stated that staff with an exemption or partially vaccinated should be tested twice a week during an outbreak. She stated LPN #3 works per diem (as needed). Surveyor #1 confirmed LPN #3 worked on 9/16/22, the IIPLPN confirmed that there was not testing provided for 9/16/22, but she should have been tested that day. She further stated, if staff with an exemption work per diem they should test when they come to work. She stated that the Staffing Coordinator was here every day so she should have been tested twice a week and TNA #1 is not fully vaccinated and should have been tested twice a week. The IIPLPN acknowledged that staff that are exempt and/or not up to date were not being tested the way that they should be during an outbreak, which was twice a week and according to the facility's policy, which was once a week. On 10/06/22 at 02:45 PM, in the presence of the survey team, Surveyor #3 made the IIPLPN, the LNHA, the DON, and the RA aware of the above concerns with testing of employees that were not up to date with their vaccination. A review of the facility's policy, COVID 19 Management (All Policies) revised on 5/31/2022, revealed; Staff COVID 19 Vaccination and Testing Requirements, Procedure: 3. All employees of this facility must be fully vaccinated including booster vaccinations as they are mandated or have an approved medical exemption. 4. For Staff whom are partially vaccinated (one dose for multi-dose vaccine schedule or those who are eligible for the booster vaccines as it is mandated): at minimum perform weekly testing, 12. All employees, contract staff and medical staff will be tested for COVID-19 as per the most current guidelines. N.J.A.C. 8:39-5.1(a)

Based on interview, record review and document review, it was determined that the facility failed to: a.) ensure the facility policy, Centers for Disease Control and Prevention (CDC), and Centers for Medicare and Medicaid Services (CMS) for COVID-19 vaccinations was implemented to ensure that all staff were up to date with COVID-19 vaccinations, or have been granted a qualifying exemption during a COVID-19 outbreak that began on 06/24/22; and, b.) ensure all staff that were not up to date with vaccinations, or had been granted a qualifying exemption were not permitted to work in the facility. The facility's failure to take immediate action, follow Centers for Medicare and Medicaid Services (CMS) guidance, Centers for Disease Control and Prevention (CDC), and facility policies to limit exposure risks placed all residents and staff at risk for contracting COVID-19, a deadly contagious virus. Reference: Centers for Disease Control and Prevention, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated September 23, 2022 Refer to F880 and F886 The failure to ensure all staff were up to date with COVID-19 vaccinations or granted a qualifying exemption during a COVID-19 outbreak were not permitted to work in the facility placed all residents and staff at risk for contracting a contagious, potentially deadly virus. This situation resulted in an Immediate Jeopardy (IJ), which began on 06/24/22 when a Licensed Practical Nurse (LPN #1), who was unvaccinated for COVID-19, without having a qualifying exemption, proceeded to work forty-seven shifts from the start of the facility outbreak on 06/24/22 until 10/10/22. The IJ was identified on 10/11/22 at 2:03 PM. The facility administration was notified of the IJ on 10/11/22 at 2:03 PM. The facility submitted an acceptable removal plan on 10/12/22 at 01:42 PM. The IJ removal plan was verified as implemented during an onsite visit on 10/12/22 at 02:35 PM. The evidence was as follows: On 09/21/22 at 9:09 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) stated that the facility was currently in outbreak status for COVID-19, and the outbreak was three days from ending. On 09/21/22 at 1:09 PM, Surveyor #1 conducted an entrance conference with the LNHA and the Director of Nursing (DON). During the entrance conference, Surveyor #1 requested the facility infection control policies related to COVID-19 and the COVID-19 Staff Vaccination Matrix. The LNHA and DON confirmed the Uncertified Registered Nurse Infection Preventist (URNIP) did not have an infection control certification and that she was responsible for all of the COVID-19 vaccination efforts. The LNHA stated that the URNIP has all of the documents and noted that there was currently no symptomatic resident in the facility. On 09/22/22 at 3:42 PM, in the presence of the survey team, the URNIP stated that not everyone was tested twice weekly. When the survey team asked the criteria for the staff to be tested , she said, if some people feel like they have a cold, they would be tested and that currently, there were no staff members that needed to be tested . The URNIP confirmed that her log was the only facility testing document at that time. The survey team inquired to the URNIP regarding the staff vaccination list, and the URNIP stated that she did not have a completed list for the staff's COVID-19 vaccination status. On 09/23/22 at 11:34 AM, the survey team interviewed the LNHA and DON regarding the National Health and Safety Network information that is required to be submitted. The LNHA confirmed that he inputted the data and that there was no current employee vaccination list since not all employees were on it. The DON stated, I am not making up what I don't have. On 09/22/22 at 9:43 AM, the DON and LNHA informed the survey team that two residents (Resident #44 & Resident #52) had tested COVID-19 positive and had been moved to the first floor for isolation. The LNHA stated the positive results were identified during routine COVID-19 testing. On 09/22/22 at 9:55 AM, the DON and LNHA failed to provide the survey team with the requested infection control documents, which included the staff vaccination and staff and resident testing documentation. The LNHA stated the documents were now with the corporate people, and he could not produce the documents. On 09/23/22 at 8:53 AM, Surveyor #1 observed LPN #2 on the second-floor medication cart wearing a surgical mask. Surveyor #1 then interviewed LPN #2, who stated she was a new hire. The surveyor asked LPN #2 if she was vaccinated for COVID-19 and if she had been fit tested for an N-95 mask. LPN #2 replied, not fit tested , not boosted (a test to determine if a respirator mask appropriately fits to protect the wearer). She stated she was vaccinated for COVID-19 and confirmed that the facility was aware that she was not boosted. LPN #2 said that she signed a waiver form that the facility provided since she did not want a COVID-19 booster. Surveyor #1 inquired to LPN #2 if she had received COVID-19 testing, and she stated that the facility would let her know if she needed to take a test and that she could also let the URNIP know if she needed to take a COVID-19 test. Surveyor #1 asked LPN #2 if she was assigned to a particular unit. LPN #2 replied that she floated to different units. On 10/06/22 at 12:30 PM, Surveyor #1 observed LPN #2 on the 1st floor COVID-19 unit at the nursing station wearing a National Institute of Occupational Safety and Health (NIOSH) N-95 mask. Surveyor #1 further inquired about what N-95 mask she was required to wear. LPN #2 removed two different masks from the bins outside a resident room and told the surveyor that she could wear either one. LPN #2 stated the mask Surveyor #1 was wearing (N95 #8210) was very tight, and she said that she was fit tested for both masks by the Interim Licensed Practical Nurse Infection Preventist (ILPNIP). Surveyor #1 inquired if LPN #2 had a medical or religious exemption for the COVID-19 booster. LPN #2 reiterated that she had signed a paper waiver provided by the facility, which indicated she did not want the booster and stated no; it was not a medical or a religious exemption, only that it was a document that offered risks and benefits. On 10/06/22 at 1:46 PM, surveyor #3 interviewed the ILPNIP in the presence of the survey team. The ILPNIP stated that the facility had been telling staff they must get boosted for COVID-19. The ILPNIP said the facility should have a list of all the employees, a copy of the vaccination cards, and a spreadsheet to track when everyone was due. When asked about the new hire process, the ILPNIP stated the new hires should have received a booster or provided proof of COVID-19 Vaccination status. She then said, I mean, anyone can decline, and they shouldn't be employed in healthcare [if the COVID-19 vaccines are declined]. The ILPNIP stated it was mandated to be up to date with COVID-19 vaccines, per the federal government, Centers for Disease Service (CDC), and the state government. At that time, the ILPNIP confirmed that all staff were not up to date with COVID-19 vaccines and stated, I am acknowledging now since she had not been aware of all staff not being up to date with COVID-19 vaccines and she also confirmed that the staff were not being tested twice per week. On 10/07/22 at 11:01 AM, Surveyor #1 interviewed the Regional Licensed Nursing Home Administrator (RLNHA) regarding agency staff's vaccination status before working at the facility. The RLNHA confirmed there was no system in place to ensure that the staffing agencies were sending fully vaccinated staff who had been fit tested for N-95 masks. On 10/07/22 at 11:52 AM, surveyor #2 had observed LPN #1 providing care on 09/21/22, 09/22/22, 09/24/22, 09/26/22, 09/28/22, 09/29/22, 09/30/22, 10/03/22, 10/04/22 and 10/06/22. LPN #1 was wearing a black surgical mask during all observations. LPN #1 stated she had cared for the unsampled third-floor resident, who was symptomatic and tested COVID-19 positive on 10/06/22. LPN #1 stated she had worked at the facility for four months and confirmed she had not been fit tested for an N95 mask. On 10/07/22 at 12:58 PM, the ILPNIP provided the facility line listing, which revealed a symptomatic unsampled COVID-19-positive resident was identified on the third floor on 10/06/22. On 10/07/22 at 1:01 PM, the ILPNIP confirmed that LPN #2 was not up to date with her COVID-19 vaccines, and the ILPNIP confirmed she had been unaware. The ILPNIP stated, I will be honest with you she did not know why LPN #2 got through the system. The ILPNIP said there was no form she was aware of that the facility provided to staff for declining a COVID-19 vaccination. The ILPNIP stated, from my understanding, everyone needs to be up to date on their vaccines. The ILPNIP noted that once she had a complete list of the unvaccinated staff, the staff would have to find another place to work if the staff refused to vaccinate. On 10/11/22 at 8:49 AM, the ILPNIP provided a copy of the Resident/Employee Contact Tracing Record dated 10/11/22. The document revealed that LPN #1 was identified as the nurse who cared for eight residents who tested COVID-19 positive, including Residents # 44 and #52, who tested COVID-19 positive on 09/21/22 and the unsampled resident on 10/6/22; All eight residents resided on the third floor. LPN #2 was identified as a close contact for two residents, Resident #10 and an unsampled resident, on 10/03/22, who resided on the third floor. On 10/11/22 at 12:53 PM, the facility Human Resources Manager (HRM) provided the survey team with Time Card detail for LPN #1 and LPN #2. LPN # 1 worked forty-seven shifts since the facility outbreak began on 06/24/22, which was revealed in the Time Card detail from 06/21/22 through 10/11/22. LPN #2 worked twenty shifts from 09/19/22 through 10/11/22. 41858 The non-compliance remained on 10/12/22 for no actual harm with the potential for more than minimal harm that is not IJ based on the following: Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to: a.) develop and implement a policy to track and document facility staff vaccination status to ensure all eligible staff were vaccinated by the required dates; and, b.) follow the facility policy for contingency plans by failing to ensure unvaccinated staff wore an N95 respirator mask (a tight-fitting mask that protected the wearer from air particles) to mitigate the potential spread of COVID-19. This deficient practice was evidenced by the following: On 09/26/22 at 12:02 PM, five days after the survey began on 09/21/22, the DON provided the Staff Vaccination Matrix (SVM) to the survey team. She confirmed it was completed over the weekend because they did not have staff vaccination cards. On 09/26/22 at 2:18 PM, the ILPNIP provided an updated SVM to the survey team. A review of the SVM revealed that there were 94 total staff, 85 completely vaccinated staff, four partially vaccinated staff, two staff granted an exemption, and three staff temporary delay/new hires. Of the 94 total staff, 29 staff did not receive the booster dose. The SVM revealed that 62 staff of the 94 were up to date (received all recommended COVID-19 vaccines, including any booster dose (s) when eligible) with the vaccination requirement. A review was completed of the National Healthcare Safety Network (NHSN) data regarding the facility's reported percentage of fully vaccinated staff for the week ending 09/04/22. The facility reported the ratio of staff fully vaccinated was 100%. A review of the facility-provided SVM revealed that 95.7% of staff were vaccinated. On 10/04/22 at 2:10 PM, Surveyor #3 interviewed the Staffing Coordinator (SC), who stated she had a medical exemption. When asked what PPE she had to wear in the building, she said she wore a surgical mask, but she was told she had to wear an N95 if she had to go into a COVID-positive room. On 10/05/22 at 11:26 AM, Surveyor #3 observed the SC, wearing a surgical mask, on the 3rd floor at the nurses' station, conversing with one resident and one staff member. On 10/05/22 at 1:00 PM, Surveyor #3 requested testing for LPN#3, who was listed as a temporary delay per CDC/new hire on SVM from the Regional Administrator (RA). The RA gave the surveyor a copy of LPN #3's vaccination card, which showed she was fully vaccinated and boosted. Therefore, no testing was required. On 10/06/22 at 8:40 AM, the ILPNIP provided an updated SVM to the survey team. On 10/06/22 at 9:34 AM, Surveyor #3 observed the Maintenance Director (MD) (listed on the SVM as completely vaccinated but had not received the booster dose) touring the facility on the 2nd floor with the Life safety surveyor. The Maintenance Director wore a surgical mask. On 10/06/22 at 12:15 PM, Surveyor #4 interviewed CNA #1 while working on the 2nd floor. CNA #1 stated she received two doses of the COVID-19 vaccination. She wore a surgical mask and stated that this was what she had to wear in the building unless she cared for residents with COVID, then she would wear goggles, an N95, and a gown. A review of the SVM revealed CNA#1 was listed on the SVM as completely vaccinated but had not received the booster dose. On 10/06/22 at 12:42 PM, Surveyor #4 interviewed TNA #1, who stated she had two vaccinations but needed a booster that was due in July and was going to get the booster soon. She wore a surgical mask, and she stated that she could wear a surgical mask. She said she would need to wear an N95, a gown, gloves, and a face shield with Covid residents. TNA# 1 stated that right now, on the third floor, it was okay for her to wear a surgical mask. A review of the SVM revealed TNA#1 was listed on the SVM and was listed as partially vaccinated. On 10/06/22 at 1:50 PM, in the presence of the survey team, Surveyor #3 interviewed the ILPNIP. The ILPNIP reviewed the facility's policy, COVID-19 Management (A Policies), and confirmed that all staff who are exempt or not up to date should be wearing an N95, but they are not. She stated that staff is being told that they must be up to date and that it is mandated. The ILPNIP noted that staff would be removed from the schedule if they refused and did not have an approved exemption. At that time, the ILPNIP stated that they should have a list of all employees, copies of their vaccination cards, and a spreadsheet to track how many doses staff had received. She stated that new hires should have had to show their vaccination card. Surveyor #3 asked if employees could decline the COVID vaccine without an approved exemption. The ILPNIP stated that if that was the case, they should not be employed in healthcare .She said employees could not sign a declination form for the COVID-19 vaccine. She further stated that the Centers for Disease Control mandated at the Federal and State levels that everybody in healthcare must be up to date. Surveyor #3 reviewed the SVM and the vaccination cards with the ILPNIP, who acknowledged that there were inconsistencies. On 10/06/22 at 2:09 PM, in the presence of the survey team, the ILPNIP stated, I totally acknowledge staff are not up to date, tracking employees was not current, but we weren't aware until I took over the Infection Preventionist role. She then acknowledged that staff that was exempt or were not up to date were not being tested the way they should be during a COVID-19 outbreak, which was twice weekly. On 10/06/22 at 02:45 PM, in the presence of the survey team, Surveyor #3 made the ILPNIP, the LNHA, the DON, and the RA aware of the above concerns with employees not being boosted, employee vaccination not being tracked, and with employees that are exempt or not up to date wearing proper personal protection equipment according to the facility policy. A review of the SVM received on 10/06/22 from the ILPNIP which revealed the vaccination list, who is not up to date (IP List) received 10/10/22, staff vaccination cards and interviews revealed the following: 1. The LNHA was listed on the SVM as up to date, on the ILPNIP list as needing booster, vaccination card #1 (name redacted) lot #EN5318 02/03/21 hamilton; (name redacted) lot # EN5318 02/03/21 [another facility name] post-acute vaccination card # 2 1st (name redacted) [pharmacy name] and 2nd dose (name redacted) [pharmacy name], no date, boosted (name redacted) 03/31/22 generation pharmacy. On 10/11/22 at 10:52 AM, in the presence of the survey team, the LNHA stated he was up to date on his vaccines and provided proof. 2. Unit Secretary (US) #1 was listed on the SVM as up to date, on the ILPNIP list as needing a booster, vaccination card: (name redacted), 4/22/21, 5/20/21, 11/15/21. On 10/12/22 at 9:46 AM, Surveyor #3 interviewed US#1, stating she was up to date on her vaccines. 3. Housekeeper (HSK) #1 was listed on the SVM as completely vaccinated and needs a booster dose. On the IP list, nothing was recorded. Vaccination card: (name redacted) 06/28/22, 07/18/22, on 10/12/22 at 9:51 AM. Surveyor #3 interviewed HSK #1, who stated he was up to date on his vaccines. 4. LPN #4 was listed on the SVM as up to date, on the ILPNIP list as needing booster, vaccination card: (name redacted) 07/16/21, 08/06/2. On 10/12/22 at 9:53 AM, Surveyor #3 interviewed LPN #4, who stated she was up to date on her vaccines. 5. Behavior Aide (BA) #1 was listed on the SVM as partially vaccinated, on the ILPNIP list as needing a booster, vaccination card: (name redacted), 06/31/22. On 10/05/22 at 11:28 AM, Surveyor #3 interviewed BA #1, who stated she was up to date on her vaccines and gave the facility a copy of her vaccination card. On 10/12/22 at 9:56 AM, Surveyor #3 observed CNA#1 on the 2nd floor wearing a surgical mask. During an interview at that time, CNA#1 stated, I was told yesterday I need to get the booster today. On 10/12/22 at 1:46 PM, Surveyor #3 observed the SC on the 2nd floor wearing a surgical mask. On 10/12/22 at 2:00 PM, in the presence of the survey team, Surveyor #3 made the RA and Regional Nurse aware that CNA#1 and the SC were observed wearing only surgical masks, as mentioned above. They both acknowledged that the facility's policy was if not up to date or exemptions, staff should have been wearing an N95. A review of the facility's policy, COVID-19 Management (All Policies), revised on 5/31/2022, revealed it is the policy of this facility to follow CDC and DOH [Department of Health] guidelines for the management of the COVID-19 (Sars-COV-2). The policy addressed Staff COVID-19 Vaccination and Testing Requirements, Procedure: Employee Vaccinations for COVID-19 (per DOH order summary action). This facility will track and securely document the COVID-19 vaccination and/or testing status of all staff, including vaccination booster doses. Staff who need an exemption form can request it from Human Resources or their Department Head. Procedure: 3. All employees of this facility must be fully vaccinated, including booster vaccinations, as they are mandated or have an approved medical exemption. 4. For Staff who are partially vaccinated (one dose for multi-dose vaccine schedule or those who are eligible for the booster vaccines as it is mandated): Use of NIOSH-approved N95 or equivalent for source control. 5. Providing all personnel who decline to be vaccinated a written affirmation for their signature, which signifies that they were offered the opportunity for a COVID-19 vaccination but declined. For employees, the reason for declination must fall into a medical reason or religious reason. 7. Upon request from the DOH, the following must be presented: a. number and percentage of personnel that have been vaccinated for COVID-19, b. Number and percentage of personnel for which medical exemptions have been granted, c. The total number of covered personnel. 8. For staff who are not vaccinated do not fall into the exemption or are temporarily delayed in obtaining the vaccine as it is mandated and staffing is in crisis levels. a. This facility will communicate the staffing crisis to the appropriate government agency and will attempt to place identified staff members who aren't fully vaccinated in non-resident areas and to duties that can be performed remotely (i.e., telework), or to duties which limit exposure to those most at risk (e.g. assigning to residents who are not immunocompromised, unvaccinated). 9. This facility will require staff who have not completed their primary vaccination series (including .been granted an exemption or who have a temporary delay) to follow addition CDC-recommended precautions, such as adhering to universal source control and physical distancing measures in areas that are restricted from resident access, even if the facility or service site is located in a county with low to moderate community transmission. 10. Any employee who refuses testing and is not fully vaccinated per the current guidelines will not be permitted to work in this facility. N.J.A.C. 8:39-9.3(c);19.1(b); 19.4(a)

Complaint # NJ 6 Based on interview, closed record review and review of pertinent documents, it was determined that the facility failed to ensure the facility policies for Accidents, Occurrence Investigation and Prevention of Falls were followed to ensure: a.) a resident identified at risk for falls on [DATE], and at high risk for falls on [DATE], had a care plan initiated for the prevention of falls, b.) an assessment of any physical injuries was completed and documented post fall, c.) an accident report was completed and verified incident post fall, d.) post-fall, the Interdisciplinary Team re-evaluated the resident and revised interventions to prevent a recurrence, e.) a root cause analysis would be conducted post occurrence and immediate measures to protect the resident was implemented, and f.) any interventions are consistently documented per professional standards of practice. This deficient practice occurred for 1 of 1 closed records reviewed for hospitalization (Resident #193), who sustained four falls, including two falls that occurred on [DATE], and two falls that resulted in an emergent transfer to the hospital on [DATE] and [DATE]. The [DATE] fall resulted in Resident #193 sustaining an acute, traumatic right subdural hematoma, which required an emergent craniotomy and and required neuro intensive care. The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On [DATE] at 11:16 AM, the surveyor reviewed the entirety of the closed medical record for Resident #193 which was provided by the facility on [DATE] at 3:00 PM, and revealed the following: A hospital record dated [DATE] completed for Resident #193, prior to admission to the facility, revealed a Computerized Tomography scan of the Head or Brain without contrast (a scan utilizing computers and X-rays) was completed on [DATE]. The scan revealed There are no acute findings. The hospital Plan of Care dated [DATE] revealed Resident #193 had a Problem: At Risk for Falls, Patient is high risk for falls, has experienced falls, or falls have resulted in injury. After admission to the facility a Fall Risk Evaluation dated [DATE], revealed the resident scored an 8 on the Falls Risk Evaluation. On a subsequent Fall Risk Evaluation dated [DATE], revealed If the total score is 10 or greater, the resident should be considered at High Risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Resident #193 scored 11 on the evaluation which is considered high risk. A review of a Physical Therapy (PT) Evaluation and Plan of Treatment, dated [DATE], revealed Resident #193 was a fall risk. A review of the Interdisciplinary Care Plan for Resident #193 revealed four Care Plans which included: Anticoagulant Therapy, Wounds/Impaired Skin Integrity, ADL Dysfunction and Risk for Falls/Injuries. The Risk for falls/Injuries Care Plan revealed Problem: Pt [patient] is at risk for falls as r/t [result to] impaired mobility. Goal: will have minimal falls through review date. The interventions dated [DATE], with a target date [DATE], included the following: Keep call bell and frequently used items within reach, Keep room clutter free and well lit, keep bed in lowest position, encourage resident to wear appropriate no skid footwear, Assist with transfers X 1, PT/OT screen as needed, Check all that apply was D/C (discontinued) with a line through it on [DATE], and bed alarm, chair alarm, and floor mat was unchecked. The Care Plan for Resident #193 did not reflect any documented interventions to prevent falls despite being identified at risk for falls on [DATE], a Care Plan for falls was not initiated until twenty-one days later. The August and [DATE] Treatment Administration Record (TAR) and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Fall #1: A Nurses Note (NN) dated ,d+[DATE] and timed at 4A[4:00AM], Fall #1, Resident found by aide on floor, on [his/he] back lying on R[right] side of bed, no visible injuries, denies pain, 2 assist transferred resident back to bed and push bed towards wall, monitored through the night, VS [vital signs] ,d+[DATE]-[DATE].8. DTR [daughter] called and notify of incident and signed by a Licensed Practical Nurse (LPN #1). There was no documented evidence that the physician was notified of the fall, and no evidence that a documented physical assessment was completed. This fall was not documented on the Care Plan and Interventions were not revised to prevent further falls. Fall #2: A NN dated ,d+[DATE] and timed at 7A, 7:10A [7:00 AM, 7:10 AM], Fall #2 , after talking to daughter heard resident yelling out help me nurse, help me. Found [him/her] before has [sic.] bed sitting up on floor. Transfer back to bed and in w/c [wheelchair] out to nurses station and, VS ,d+[DATE]-[DATE].5. No apparent injuries. Denies hitting [his/her] head and signed by LPN #1. There was no documented physical assessment for resident #193. A subsequent un-timed and un-dated NN revealed, MD [physician] to be informed later of falls and also [daughter] for fall #2 signed by LPN #1. This fall was not documented on the Care Plan and Interventions were not revised to prevent further falls. A subsequent NN un-timed and dated [DATE], revealed resident received in the hallway sitting in [his/her] wheelchair, neuro checks (an evaluation to determine if the nervous system was impaired) initiated, no abnormal behavior, resident was compliant with adl [activities of daily living] care and meds [medications], vitals wnl [within normal limits], will continue to monitor signed by LPN #2. There was no documented evidence that the physician, or daughter was notified of the two falls that occurred on [DATE]. A NN dated [DATE], and timed at 1PM neuro checks in progress, s/p [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . All neuro checks WNL [within normal limits], no neuro [neurological] changes at this time. will cont. [continue] to monitor, signed by Registered Nurse (RN #1). There were no additional NN documented regarding any completed neuro checks or monitoring. There was no documented evidence of neuro checks having been completed in the medical record, or in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Fall #3: A NN dated [DATE], and timed at 10:00 AM, Resident received awake and lying in bed. Around 8:30 A.M. was found by CNA [certified nurse aide] on the floor lying face down. The CNA noted writer and resident was observed lying face down. No visible injury or bruising. Resident remained in stable condition. B/P ,d+[DATE], P68, R16, SP02 98, T97.6. Neuro checks in place. Resident c/o (complaint of) [headache] rated ,d+[DATE] [pain scale]. PRN [as needed] Tylenol (pain reviewed) 650 MG (milligrams) administered. MD (physician) made aware and daughter. The daughter requested for her [family member's] name to be removed due to being deceased , signed by LPN #2. A NN dated [DATE], and timed at 3:30 PM, Resident didn't return on the ,d+[DATE] shift and signed by LPN #2. Incident #4: A NN dated [DATE], and then continued on another page titled Interdisciplinary Progress Notes (IPN) revealed, Date and Time: TC ,d+[DATE] (No specific time documented) which revealed this morning when one of the aide went into the residents room and found [him/her] laying on [his/her]back with [his/her] head slightly elevated, with vomit on [his/her] face, on the side of the bed and on [his/her] pillow. I assessment [sic.] [Resident #193] had a 210 B/S [blood sugar] B/P [blood pressure] ,d+[DATE] (numerical portion was circled), HR [heart rate]-92, O2 [oxygen saturation] 97.2, temp [temperature] 96.8, when I called to to [Resident #193] [he/she] barely opened [his/her eyes] was breathing, BR [breath rate] -24, but was very [sic.] lethargic. I called his/her [Doctor] and was told to send [him/her] to the E.R. [emergency room ] [he/she] was transported to the E.R. at about 8 AM. [He/she] was sent with [his/her] face sheet and personal belongings and was signed by LPN #1. There was no documented nursing notes, or notes from other disciplines documented in the medical record on either an IPN or NN. A New Jersey Universal Transfer Form (UTF) had a Date of Transfer: [DATE], Time of Transfer:[blank] revealed Resident #193 was transferred to the hospital on [DATE] at an unknown time. The Reasons for Transfer:(Must include brief medical history and recent changed in physical function or cognition) Lethargy, V/S: BP,d+[DATE], P 100, R 14, T 97.2, Pain: [Blank], Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Sending Facility Contact: Title, Unit and Phone section was blank, the Form Completed by and Title section was blank. There was no information on the UTF that correlated with the [DATE] LPN #1 NN that indicated the recent changes in physical function. The Admission Record revealed Resident #193 had admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:41 PM, the surveyor conducted a telephone interview with LPN #1 regarding the documentation on [DATE], regarding Resident #193. LPN #1 asked the surveyor if she was in trouble and stated she did not recall the resident, or remember her documentation, or any incident on [DATE], and she was unable to speak to it. On [DATE] at 3:22 PM, the surveyor conducted and interview with the Director of Nursing (DON) and showed the DON the UTF for Resident #123 dated [DATE]. The surveyor inquired if there were any incidents or investigations for Resident #123 and she stated she will inquire. At that time the surveyor reviewed the UTF with the DON. The DON stated the UTF was incomplete. On [DATE] at 4:18 PM, the surveyor, in the presence of another surveyor, inquired to the Licensed Nursing Home Administrator (LNHA) and Regional Licensed Nursing Home Administrator (RLNHA) if there were any investigations for Resident #193. The LNHA stated no there were no investigations that the facility was aware of. On [DATE] at 4:30 PM the surveyor, in the presence of another surveyor, requested any information from the Interim Infection Preventionist Licence Practical Nurse (IIPLPN) related to the reason #193 was sent to the hospital on [DATE]. On [DATE] at 8:27 AM, the IIPLPN provided the surveyor a Daily Report dated [DATE], and showed the surveyor that Resident #193 was transferred to the emergency roiagnom on [DATE], for a change in mental status and had no other information related to [DATE]. On [DATE] at 9:56 AM, the surveyor interviewed the DON regarding what the process was if a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor inquired as to the documentation on [DATE] regarding Resident # 193. The DON stated we should have done a skin check before they went out to the hospital. The DON stated she wanted to know why the personal belongings were documented as sent with Resident #193 to the hospital, and what was the reason the resident vomited. The DON stated there should absolutely be specifics on the transfer sheet regarding the vomiting and how the resident was found, and the DON stated it is imperative. The DON also stated she would get a statement from the CNA and confirmed the UTF had to be accurate, filled out and include the contact information on the UTF. The DON stated the hospital needed to know that information and she stated, I would expect to see any additional information related to the resident, it doesn't end [the resident] going out. The DON stated I would want to know what happened and they have to notify the responsible party and the doctor. The surveyor requested the policy for the UTR, emergent transfer policy. The surveyor inquired to the DON if the resident had expired at the hospital, would the facility know. The DON stated she was unaware if Resident #193 expired, but the facility should know that information. The surveyor requested the assignment sheet for Resident #193 on [DATE]. On [DATE] at 2:30, the Unit Manger provided the assignment sheet for [DATE] at 2:30 PM. Upon review and discussion with the Human Resource Staff, the surveyor was unable to contact any additional staff that worked on [DATE]. On [DATE] at 12:54 PM, the RLNHA stated there was no faciliy policy for completion of the UTF and no facility discharge policy. On [DATE] at 10:49 AM, the surveyor interviewed the LNHA, regarding what the process was for injuries of unknown origin. The LNHA stated there should be an investigation for injuries of unknown origin. On [DATE] at 3:57 PM, the RLNHA, in the presence of the Regional Nurse and DON, informed the surveyor that there were no investigations for Resident #193. The RLNHA stated she had checked with the DON and she confirmed that the LNHA also had no investigations. The RLNHA stated 100% there should be an investigation completed for all falls or unusual occurrences. On [DATE] at 4:05 PM, the surveyor inquired to the DON regarding any incidents, investigations or reportable events for Resident #193. The DON stated I have nothing on Resident #193 and the DON stated that she and the LNHA could not locate any incidents or reportable event records for Resident #193. The DON stated that Resident #193 vomited, and none of the information was found out about what happened, nothing was on the transfer note. The RLNHA stated she was not aware that Resident #193 had any falls, and was unsure why the resident's belongings were sent to the hospital. At that time, the surveyor requested a time line of events for Resident #193 from the RLNHA. On [DATE] at 10:00 AM, the RLNHA provided the time-line for Resident #193. The RLNHA stated the that Resident #193 was identified as a fall risk on [DATE], with a fall risk assessment score of 8, then transferred to the hospital on [DATE] due to a change in mental status, readmitted to the facility on [DATE], and scored an 11 on the fall risk assessment. The RLNHA stated on [DATE], is when the Care Plan for falls was first initiated and reviewed the interventions. The surveyor inquired if the interventions were documented as being implemented and the RLNHA stated that from time to time and they were just in the nursing notes which the RLNHA confirmed were sporadic. The RLNHA confirmed the first falls occurred on [DATE], and there were no investigations completed, and no incident reports were completed regarding the [DATE], fall either. The RLNHA stated she spoke to LPN #1 regarding the incident that she documented with Resident #193 on [DATE]. The RLNHA stated that LPN #1 informed her that she does remember the incident and LPN #1 confirmed that Resident #193 sustained a fall, and stated to the RLNHA that she had remembered the fall. The RLNHA confirmed that there was no documented nursing physical assessment completed for Resident #193 and confirmed there was no documented nursing physical assessment for the two falls that occurred on [DATE], and on [DATE]. The RLNHA stated that LPN #1 confirmed that she did not document that Resident #193 had a fall on the UTF, and the RLNHA stated it doesn't even appear that the person fell per what was documented on the UTF and the RLNHA confirmed there were no neuro checks documented. [DATE] at 10:31 AM, the RLNHA stated to the surveyor that with any injury of unknown origin, an incident report with statements and a full head to toe investigation should have been completed. The RLNHA stated that the falls, possibly the first three, but definitely the last fall, if there were injuries it should have been reported to the Department of Health. On [DATE], the surveyor reviewed the hospital records provided by the receiving hospital for Resident #193's emergent transfer on [DATE], which revealed the following: The Hospital Patient Information sheet revealed Resident #193 was admitted to the Emergency Department from the nursing facility on [DATE] at 8:32 AM. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #193) was admitted after being found with altered mental status in nursing home and vomit in beard. CAT scan of head was performed in the emergency department and revealed a large right subdural hematoma (a serious condition where blood collects between the skull and the surface of the brain and is usually caused by a head injury) with a right intraparenchymal hemorrhage (blood pooling in tissues of the brain) status post [MEDICAL RECORD OR PHYSICIAN ORDER] A Internal Medicine Progress Note, dated [DATE], and Electronically Signed by the MD at 1:34 PM. The Patient (Resident #193) came to the hospital after experiencing a fall. Patient was diagnosed with an acute, traumatic, right subdural hematoma and was admitted to neuro intensive care after having an emergent craniotomy (emergency surgery to remove part of the bone from the skull to expose the brain). The following facility provided policies were reviewed: Accidents-Occurrence Investigation Policy Originated:,d+[DATE], revealed All accidents will be investigated, documented and reported to the New Jersey Department of Health as appropriate. Definitions: Accident: refers to any unexpected or unintentional incident, which may result in injury or illness to a resident . Fall: refers to unintentionally coming to rest on the ground, floor or other lower levels, but not as a result of an overwhelming external force (i.e. resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without an injury is still a fall unless there is evidence suggesting otherwise when a resident is found on the floor, a fall is considered to have occurred . Procedure: Responsibility Person responsible for area in which the accident occurred (Initiator). Action: Initiated the accident report and enters required information. Notifies RN/Clinical Care Manager; RN/Clinical Care Manager: Action: Investigates the situation and assesses the resident/patient, completes the nurse section of the Accident Report, Determines/implements immediate corrective action. Licensed Nurse RN/LPN: Notifies M.D. & Clinical Care Manager, Identifies relevant environmental risk factors, Notifies Plant Operations and/or housekeeping as appropriate, Documents the accident event and notification of family in the progress notes, Place resident/patient on 24 hour report X 72 hours, Documents resident/patient status in the progress notes X 72 hours, RN/CCM: Initiates/updates CCP with a new intervention, Clinical Care Manager: Reviews the accident report and other pertinent information with the interdisciplinary Team at morning report the following business day, RN/Clinical Care Manager: Initiates Incident report, Obtains statements from all staff, residents, visitors, volunteers present at the time of the accident, by the end of the shift, Obtains statements until a determination can be made as to the time of the accident, Clinical Care Manager: Reviews accident report, statements occurrence report, clinical record and surveillance data as indicated. Completes Summary of Findings and Determination regarding Abuse, Neglect, and Mistreatment, Initiates Corrective Action Plan, Notifies family/significant others of the findings of the Occurrence Investigation, Submits all documents to the A.D.N./D.N.S., D.N.S./A.D.N.: Reviews each case, relevant documents and the clinical record to validate findings and determine results, Forwards original accident reports to the Education Dept., DNS/ADN: Reviews significant injuries and injuries of unknown origin with the Administrative Team (Administrator/Associate Administrator/ Medical Director/Associate Medical Director), Administrative Team: Conducts root cause analysis, as needed, DON/Designee: Notifies DOH and other regulatory agencies as per regulations if: reasonable cause to suspect abuse, neglect and mistreatment has been determined, failure to follow the CCP, which resulted in resident injury, injuries of unknown origin. Policy and Procedure for the Prevention of Fall, undated; Communication of Risk, Residents at risk for falls will be communicated to the interdisciplinary team via the care plan, Evaluation of Fall Incidents, Assess residents for any obvious injuries, notify the medical provider and document a progress note reflecting the resident's appearance, evidence of injury and location, Monitor resident post incident to observe for latent injury, After a fall has occurred, the interdisciplinary team will re-evaluate the resident and revise intervention to prevent recurrence, PT/OT to screen residents and recommend interventions, if indicated, Quality Assurance, Complete an occurrence and conduct post occurrence and conduct post occurrence review to attempt to ascertain root cause analysis of the incident and implement immediate measures to protect the resident, Occurrence will be discussed in the morning report; current and alternative interventions/preventative measures will be explored and implemented upon agreement by the IDC team, Nursing department will track the number of falls per month by collecting data from accident/incident reports to identify trends and patterns. Charting and Documentation Policy, Effective [DATE]; 2. The following information is to be documented in the resident medical record: a. objective observations, d. changes in the resident's condition, e. events, incidents or accidents involving the resident, f. progress toward or changes in the care plan goals and objectives. Change in Condition Policy, Effective [DATE]; It is the policy of this facility to identify and communicate changes in condition to the physician and other team members to implement interventions to prevent further deterioration and possibly prevent hospitalization . All staff are encouraged to promptly report any changes in condition to the charge nurse, supervisor or DNS/ADNS or designee immediately, A complete assessment will be conducted of all systems including but not limited to: functional status, respiratory evaluation, abdominal pain or GI evaluation, GU/Urine evaluation, Skin evaluation, pain evaluation, vital signs, A care plan will be initiated and/or updated based on the reason for the change in condition as soon as feasible (in case of emergency/acute transfer, patient's safety comes first and family will be notified once patient is stabilized). N.J.A.C. 8:,d+[DATE].1(a)(b)

Based on observation, interview, medical record review, and other facility documentation, it was determined that the facility failed to a.) identify residents exposed to COVID-19 as persons under investigation (PUI) through contact tracing, implement mitigation strategies to prevent transmission of COVID-19, and to always perform appropriate hand hygiene This placed 20 out of 20 well and non-ill residents on the Second Floor nursing unit at risk for infection during a survey on 1/22/21. This deficient practice was identified for 1 of 2 non-COVID-19 (well) nursing units during a focused infection control survey on 1/22/21. On 1/21/21, the facility became aware that a Licensed Practical Nurse (LPN #1) tested positive for COVID-19 using a rapid [MEDICATION NAME] COVID-19 test, a nasal swab test that detected a body's immune response to COVID-19 in fifteen minutes. LPN #1 had been assigned to well and non-ill residents on the Second Floor nursing unit on 1/20/21 and 1/21/21. The facility did not conduct contact tracing to identify any residents that the LPN came in contact with forty-eight hours prior to testing positive to COVID-19. The facility did not conduct an exposure risk assessment to determine the level of exposure these residents had to the LPN. The facility did not have a policy to reflect the procedure for contact tracing or exposure risk assessment. The facility failed to identify the twenty well and non-ill residents on the LPN's assignment as Persons Under Investigation (PUI) post exposure to a Covid positive person. Upon known exposure these residents remained on the well non-exposed nursing unit and were not placed on transmission-based precautions (TBP) in an effort to mitigate the spread of [MEDICAL CONDITION]. During the survey conducted on 1/22/21, the surveyors observed staff on the well non-exposed section of the Second Floor nursing unit wearing at minimum a surgical mask or KN95 mask with eye protection as the only personal protective equipment (PPE). There was no signage that indicated any residents on the well non-exposed nursing unit were on TBP and no readily available PPE. In addition, staff were unaware of the appropriate TBP or protocols that should have been implemented for exposure to [MEDICAL CONDITION]. The facility's failure to identify residents on the well non-exposed nursing unit as exposed to COVID-19 or implement strategies to prevent the spread of COVID-19 posed a serious and immediate threat to safety and wellbeing of all non-ill residents. This resulted in an Immediate Jeopardy (IJ) situation that began on 1/21/21 when the facility was notified of the confirmed positive LPN. The facility Administration was notified of the IJ on 1/22/21 at 3:28 PM. The immediacy was removed on 1/25/21 at 10:54 AM based on an acceptable Removal Plan that was implemented by the facility and verified by the surveyors during an on-site revisit survey conducted on 1/26/21. The evidence was as follows: 1. On 1/22/21 at 9:00 AM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Regional DON. The DON informed the surveyors that the facility had two nursing units, Second Floor and Third Floor, currently in use. The DON stated that on the Second Floor there were residents who were COVID-19 positive, residents who were newly admitted or readmitted to the facility as a PUI on TBP for fourteen-days, and well non-exposed residents. The DON stated that for residents who were COVID-19 positive or PUIs, staff donned (wore) full PPE of a N95 (respirator) mask, face shields, bonnets (hair covering), gloves, and gowns. The DON stated that for residents who were well and non-ill /non-exposed, staff donned eye protection, a surgical mask or KN95 mask. The DON informed the survey team that the last staff member to test positive for COVID-19 was LPN #1 on 1/21/21. The DON stated that the LPN worked yesterday on the Second Floor well and non-ill section for approximately one hour before receiving a rapid [MEDICATION NAME] COVID-19 test. At that time, the LPN tested positive for COVID-19 and was immediately sent home for a minimum of ten days. The DON stated that the LPN was a full time employee who was permanently assigned to the well and non-ill residents on the Second Floor nursing unit. The DON stated that the residents the LPN cared for were checked to see if anyone was exhibiting signs and symptoms of COVID-19 that day. The DON stated that none of the residents were exhibiting any signs and symptoms of COVID-19 so residents were not given a rapid [MEDICATION NAME] COVID-19 test, but the facility was in the process of conducting their routine weekly COVID-19 PCR test (test for qualitative detection of nucleic acid from [DIAGNOSES REDACTED]-CoV-2/COVID-19) on residents. At this time, the LNHA informed the survey team, that the facility conducted no contact tracing for staff or residents who tested positive for COVID-19 because all staff wore PPE. At 9:50 AM, the surveyor entered the Second Floor well and non-ill nursing unit section. The surveyor observed no signs indicating any of these residents were on TBP. The surveyor also observed no readily accessible PPE bins. At 9:57 AM, the surveyor observed a Certified Nursing Aide (CNA) wearing a surgical mask with a KN95 over that mask and eye protection. The surveyor questioned the CNA about her mask. She stated that she preferred to wear the masks that way. The CNA stated that she had no permanent assignment, but today she was assigned to both well and non-ill residents and COVID-19 positive residents. The CNA stated that she worked from well to ill residents. The CNA stated that for the well residents, she only had to wear her mask and eye protection and gloves when performing care. At 10:00 AM, the surveyor interviewed LPN #2 who stated that she worked per diem, and today she was assigned to the well and non-ill residents on the Second Floor nursing unit. The LPN stated that when taking care of these residents, she was only required to wear a KN95 mask and eye protection. At 10:07 AM, the surveyor interviewed the Rehab Aide who stated that her job was to transfer residents to the rehabilitation gym. The Rehab Aide stated that she only interacted with the well and non-ill/non-exposed residents. The Rehab Aide stated that she was only required to wear a KN95 mask and goggles when interacting with these residents. At 10:10 AM, the surveyor interviewed a Temporary Nursing Aide (TNA) who stated that she only worked with the well and non-ill/non-exposed residents on the Second Floor. The TNA stated that she wore a KN95 mask and eye protection in these rooms and gloves when providing care. The TNA stated that residents do not wear masks when care was rendered and only wore masks when they left their rooms. At 10:23 AM, the surveyor interviewed a Housekeeper who stated that she only cleaned the well and non-ill/non-exposed rooms on the Second Floor nursing unit. The Housekeeper stated that she wore a surgical mask, eye protection, and gloves only when cleaning these rooms. At 10:28 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) who stated that staff on the well and non-ill/non-exposed side only wear a KN95 mask and eye protection. The LPN/UM stated that she was not involved in the process if a staff member tested positive to COVID-19. At 11:21 AM, the surveyor interviewed the DON who stated that the facility monitored all residents every shift for signs and symptoms of COVID-19 including temperature, vital signs, and screened for shortness of breath, loss of appetite, muscle weakness, and pain. The DON stated that the facility did conduct risk assessments, but not on COVID-19. The DON stated that she was probably going to start a quality assurance and performance improvement (QAPI) plan on that soon. At 11:25 AM, the Regional DON provided the surveyor with LPN #1's assignment sheets for the week. The assignment sheets revealed that the LPN worked in the forty-eight hours prior to testing positive for COVID-19 on 1/20/21 and 1/21/21 on the Second Floor nursing unit. At 11:31 AM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated that LPN #1 always worked on the well and non-ill side of the Second Floor nursing unit. At 11:38 AM, the LPN/Corporate Nurse Minimum Data Set (MDS) stated that the facility does not perform contact tracing. The facility sent their line list to the Local Health Department (LHD) and the LHD conducted contact tracing. The facility will verbally tell staff who tested COVID-19 positive At 12:10 PM, the surveyor re-interviewed the DON and ADON/IP who stated that the process for when a direct care staff member tested positive for COVID-19 was to send them home immediately making sure they were not touching anything when they left the facility in order to not contaminate anything further. The ADON/IP stated that the facility made sure that the residents cared for by a positive staff member exhibited no signs and symptoms of COVID-19. If the resident exhibited any symptoms, the facility performed a rapid [MEDICATION NAME] COVID-19 test. The facility already monitored all residents every shift for signs and symptoms of COVID-19, so no additional monitoring needed to be initiated. The staff wore PPE so the resident would not have a full exposure. The ADON acknowledged that the majority of her staff and residents who tested positive for COVID-19 were asymptomatic. The ADON/IP confirmed that the facility does not conduct an exposure risk assessment to determine what level of exposure a resident might have. The ADON/IP stated that staff wore either a surgical mask or a KN95 mask. Staff also wore goggles or a half face shield which was considered eye protection because it did not cover the face mask. The ADON/IP stated on the COVID-19 positive unit, staff had to wear a full-face shield that covered the face mask as well as a N95 mask. The ADON/IP stated that she did do rounds to ensure staff are wearing the appropriate PPE and wearing the PPE correctly. The ADON/IP stated that a surgical mask should not be worn under the KN95 mask, but on top of the KN95 mask. At 12:40 PM, the surveyor interviewed the LNHA who stated that everyday he emailed the LHD the NOVI Survey (COVID-19 Facility Outbreak Reporting Daily Survey) and line list. The LNHA stated that the LHD usually did not reply to those emails. The LNHA stated that the LHD has not recently offered any guidance to the facility. The LHD did not ask about risk levels of exposure to COVID-19. The LNHA stated that in the beginning, the LHD had a more active role with the facility, conducting on-site visits. The LNHA stated that he at this point feels that the LHD thinks the facility has a good grip on things. A review of the facility's Outbreak Plan dated last revised 1/6/21 included conduct control activities such as contact tracing of exposed individuals and monitoring for additional cases under the guidance of the local health authorities, and in keeping with guidance from the Centers for Disease Control (CDC). The plan also included to activate quarantine interventions for residents and staff with suspected exposure as directed by local and state public health authorities and in keeping with guidance from the CDC. The plan also included for the evaluation and management of residents and healthcare personnel during an outbreak. The facility will assess close contact including healthcare personnel and other residents based on their exposures to positive case(s) of the infectious disease. The healthcare personnel and residents with exposure will be identified and an appropriate risk assessment completed to determine if they have a high, medium, low, or no identifiable risk. Close contact is identified as being within approximately six feet of a positive case for prolonged period of time or having close contact with an infectious case, for example being coughed on. Close contacts should be quarantined for fourteen days after the exposure. Adhere to standard and TBP including the use of a face mask, gown, gloves, and eye protection for all confirmed or suspected case(s). A further review of the facility's Outbreak Plan under cohorting included under Cohort B - negative but exposed that this cohort consisted of symptomatic and asymptomatic residents who test negative for [MEDICAL CONDITION] with identified exposure to someone who was positive. Exposed individuals should be quarantined for fourteen days from last exposure, regardless of test results. All symptomatic residents in this cohort should be evaluated for causes of their symptoms. Residents who test negative for [MEDICAL CONDITION] could be incubating and later test positive. To the best of our ability, facility will separate symptomatic and asymptomatic residents, ideally having one group housed in private rooms. Even though symptomatic negative residents might not be a threat to transmit the infectious [MEDICAL CONDITION], they still may have another respiratory illness. Asymptomatic residents should be closely monitored for symptom development. At 3:20 PM, the survey team met with the LNHA, DON, ADON/IP, Regional DON, and LPN/Corporate Nurse MDS and reviewed the facility's Outbreak Plan. When asked why the facility did not follow their Outbreak Plan, the DON replied again that the LPN wore PPE so there was not a full exposure. The facility Administration confirmed that there was no contact tracing or risk assessment conducted. The LNHA confirmed that the facility had no policy regarding the procedure for contact tracing or a risk assessment for exposure. The LNHA stated that for contact tracing, the facility needed to look back forty-eight hours to determine who the LPN was in contact with. A review of the guidance of the New Jersey Department of Health/Communicable Disease Services (NJDOH/CDS) Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated revised 10/22/2020 included that cohort 2 COVID-19 negative, exposed consisted of both symptomatic and asymptomatic residents who tested negative for COVID-19 with an identified exposure to someone who was positive. These individuals should be quarantined for fourteen days from their last exposure, regardless of test results. The guideline further included that residents in Cohort Group 2 should be placed on TBP using COVID-19 recommended PPE consisting of an N95 mask, eye protection, gloves, and isolation gowns. A review of the NJDOH/CDS Testing in Response to a Newly Identified COVID-19 Case in Long-term Care Facilities dated 10/29/2020 included that regardless of attribution of the case, all facilities should take the following steps when a new case of COVID-19 is identified in their facility. The steps included to perform a risk assessment to determine any potential exposures/or infection control breaches at the facility. Determine any possible exposures the new case of COVID-19 (exempli gratia (e.g.) resident, healthcare personnel, essential caregiver) may have had prior to the [DIAGNOSES REDACTED]. Identify close contact including forty-eight hours prior to symptom onset/date of specimen collection of associated case, if applicable. Close contact is identified as being within approximately six feet of a COVID-19 case for a prolonged period of time, a cumulative of fifteen minutes or more over a twenty-four hour period starting from two days before illness onset (or, for asymptomatic residents, two days prior to test specimen collection) until the time the resident is isolated. Quarantine close contacts for fourteen days from last exposure and provide care using all COVID-19 recommended PPE (N95 mask, gown, gloves, eye protection). A review of the NJDOH/CDS Guidance for COVID-19 diagnosed and/or Exposed Healthcare Personnel dated 10/30/2020 included healthcare facilities should establish a plan for how exposures in a healthcare facility will be investigated and how contact tracing will be performed. The guidance also included that when a healthcare personnel was positive for COVID-19, facilities should do their due diligence to identify and notify close contacts (fifteen cumulative minutes of exposure at a distance of less than six feet to an infected person during a twenty-four hour period). Prolonged close contact should be determined by taking the cumulative contact the potentially exposed individual had with the infected case over a twenty-four hour period from two days before the symptom onset (or positive collection date in asymptomatic infected individual) until the positive case has been effectively isolated. The guidance also included that patients who are identified as a close contact of a positive healthcare personnel at a healthcare facility should be placed on appropriate transmission-based precautions and monitored for the onset of COVID-19 until fourteen days after their last exposure. The IJ was identified on 1/22/21 and the LNHA, DON, ADON/IP, Regional DON, and LPN/Corporate Nurse MDS were notified of the IJ at 3:28 PM. A removal plan was accepted on 1/25/21 at 10:54 AM which included that contact tracing and risk assessments were done on all twenty residents that LPN #1 exposed, residents were placed on a fourteen day TBP, signs and PPE bins were placed outside of these doors to notify staff of TBP, facility created policies for contact tracing and exposure risk assessment which the DON and ADON/IP were in-serviced on, and all staff were in-serviced on TBP 2. On 1/22/21 at 10:50 AM, the surveyor observed a Housekeeper wearing a KN95 mask covered by a surgical mask, face shield and gloves. The housekeeper had a wheeled cart with a blanket on top in the hallway outside room [ROOM NUMBER]. He removed garbage from the bin inside the room of a resident that was on TBP (precautions for patients who may be infected for which additional precautions are needed to prevent infection transmission). The Housekeeper placed the bag of garbage into the bin in the hallway and then returned to the room and placed a new black bag in the can in the room, wearing the same gloves. The housekeeper was then observed entering and exiting the bathroom of the resident's room with a garbage bag which he carried to the bin in the hallway. The surveyor did not observe hand hygiene. The Housekeeper then entered and exited room [ROOM NUMBER] wearing the same gloves. The surveyor did not observe hand hygiene. The Housekeeper then pushed the cart down the hallway with the same gloved hands and entered room [ROOM NUMBER] where he removed the trash from the garbage bin in the room, wearing the same gloves. The surveyor did not observe hand hygiene. The Housekeeper than pushed the bin down the hall and placed it outside room [ROOM NUMBER]. With the same gloved hands, he knocked on the door, briefly entered and exited the room. The Housekeeper than began to push the bin back down the hallway wearing the same gloves. Upon interview, the Housekeeper stated that he would wash his hands with soap and water for five to six minutes. He then pushed the cart passed the front elevators, down the other hallway and to the 2R (rear) elevator while wearing the same gloves. The Housekeeper pushed the buttons and entered the elevator with the bin of garbage and then pushed the buttons inside the elevator. The Housekeeper then exited the elevator in the basement pushing the cart with the same gloves. He then entered a code for the door, opened it and entered room [ROOM NUMBER] Loading and Receiving and went to the dumpster. The Housekeeper was then observed to remove one glove from his left hand, and with his right gloved hand he proceeded to throw the garbage bags into the dumpster. The Housekeeper then began to push the cart back into the building. The surveyor asked the Housekeeper when hand hygiene should be done. He stated that handwashing should take place when cleaning a resident's room, but that now he was just removing the garbage. He added that you should also wash your hands before you return to the unit. At that time the Housekeeper removed the glove from his right hand and held it in his left hand as he placed the cart in the hallway outside the break room. On the same day at 11:05 AM, the surveyor interviewed the Director of Housekeeping and he was aware of the above observations. The Director of Housekeeping confirmed that hand hygiene or handwashing should take place between resident rooms and that the Housekeeper should also have changed his gloves between rooms. The Director of Housekeeping confirmed that the Housekeeping staff had been in serviced on hand hygiene. On 1/22/21 at 1:49 PM, the surveyor reviewed the facility policy titled Handwashing/Hand Hygiene with a reviewed date of 10/17/2020, that read under Policy Interpretation and Implementation: 6. Wash hands with soap (antimicrobial) or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea including, but not l limited to infections caused by norovirus, salmonella, shigella and [DIAGNOSES REDACTED]icile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty. b. Before and after direct contact with residents; . k. After handling used dressings, contaminated equipment, etc. l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. m. After removing gloves. n. Before and after eating or handling precaution settings. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: a. Before aseptic procedures. b. When anticipating contact with blood or body fluids; and c. When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. At 1:56 PM, the surveyor reviewed an undated facility form titled, Guidelines for Providing Care, which read under number 2: Employees must wash their hands for twenty (20) seconds using soap and water. A. Before and after direct contact with a resident B. When hands are visibly dirty or soiled C. After contact with blood, body fluids, mucous membranes, secretions, or non-intact skin D. After removing gloves E. After handling items potentially contaminate with respiratory secretions F. Before eating and after using a restroom G. When there is likely exposure to a resident that has been [DIAGNOSES REDACTED]. The surveyor then reviewed an in-service for Porter, Housekeeping & Laundry titled, Handwashing 20 seconds' scrub! dated 9/20/20. The Housekeeper identified above had signed the form that he participated in the in-service. The information attached was Handwashing, with a review dated 7/20 read: It is the policy of the facility that Handwashing is performed to prevent the spread of bacteria: Before, during, and after preparing food Before meals Before and after care Before and after treatments After using the toilet Breaks After blowing your nose, coughing, or sneezing After personal Hygiene/handling After touching garbage Before and after donning gloves A review of the U.S. CDC's Cleaning and Disinfecting Your Facility updated on 7/28/2020, included, Additional considerations for employers: Educate workers performing cleaning, laundry, and trash pick-up to recognize the symptoms of COVID-19. Develop policies for worker protection and provide training to all cleaning staff on-site prior to providing cleaning tasks. Ensure workers are trained on the hazards of the cleaning chemicals used in the workplace in accordance with OSHA's Hazard Communication Standard. According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/2020 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. On 1/22/21 at 10:02 AM, the surveyor observed a female staff member donning (putting on) PPE prior to entering the COVID-19 confirmed area on the second floor. The surveyor observed that the staff member was wearing a surgical mask under a KN95 mask. At 10:20 AM, the surveyor observed this same staff member on the COVID-19 confirmed unit. She identified herself as a Certified Nursing Assistant (CNA). She CNA was wearing a gown, face shield, hair bonnet, KN95 mask with a surgical mask underneath. The CNA confirmed to the surveyor that she had been in-serviced on donning (putting on) and doffing (taking off) PPE. On the same day at 12:16 PM, the surveyor interviewed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) who confirmed that a surgical mask should be worn on top of the face mask and not underneath it. At 1:56 PM, the surveyor reviewed a CNA Inservice log signed by the aforementioned CNA, dated 6/4/2020 with the Topic: Stop the spread of germs, Apply PPE on COVID Unit and Exposure, Proper PPE-Masks, Gloves, Shields, Hair Covers, Foot Covers. The attached training information was CDC material titled, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 and read: Before caring for patients with confirmed or suspected COVID-19, healthcare personnel (HCP) must: Receive comprehensive training on when and what PPE is necessary, how to don (put on) and doff (take off), limitations of PPE, and proper care, maintenance, and disposal of PPE. Demonstrates competency in performing appropriate infection control practices and procedures. It continued as follows; Remember: PPE must be donned correctly before entering the patient area. The implementation of the removal plan was verified with an onsite visit on 1/26/21. On 1/26/21 at 9:52 AM, the surveyors toured the Second Floor nursing unit and verified through observations, interviews with facility staff, and review of in-service education and facility documents that the Removal Plan had been implemented. N.J.A.C 8:39-19.4(a)(b)(d)

COMPLAINT # NJ , NJ Based on observation, interviews and review of medical records (MRs) and other facility documentation, it was determined that the facility failed to consistently assess, implement timely interventions and obtain physician orders [REDACTED].#2. Resident #2 was noted with skin breakdown on the Right (R) buttock on 6/2/2016 during morning care by the resident's assigned Certified Nurses Aide (CNA) #1 who reported it to the Licensed Practical Nurse (LPN) #2. There was no indication that a physician was notified on 6/2/2016, therefore a treatment was not initiated until 6/3/2016 when the surveyor accompanied by the LPN Unit Manager (LPN UM) observed Resident #2. This deficient practice is evidenced by the following; Interviews, observations and review of the medical record (MR) occurred on day 1 of survey, 6/3/2016 unless otherwise noted. 1. According to the facility Admission Record, Resident #2 was admitted to the facility in 2/2012 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 3/8/2016, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment, was incontinent of bowel and bladder function and needed assistance with all activities of daily living (ADLs). The MDS revealed that Resident #2 was at risk for skin breakdown, however, had no PUs. A Braden Scale, used for predicting PU risk, dated 3/8/2016, revealed a score of 13 which indicated moderate risk. A Resident Plan of Care (CP), dated 12/9/2015, indicated Resident #2 was at risk for skin breakdown. Interventions included but were not limited to; monitor skin every (q) shift for evidence of breakdown, provide prompt incontinent care, apply moisture barrier q shift and as needed (PRN), air mattress and to notify the Physician and family of any change in condition. On 3/8/2016, the CP was re-evaluated and revealed Resident #2's skin was intact. Review of the CP on the day of survey, 6/3/2016, did not reveal any indication of skin changes for Resident #2. A 6/2016 Physician order [REDACTED]. Review of the 6/2016 Treatment Administration Record (TAR) confirmed the POS for the PeriGuard Ointment and TAR was signed as administered on each shift, 11 p.m.-7 a.m., 7 a.m.-3 p.m. and 3 p.m.-11p.m. from 6/1/2016 through 6/2/2016. During a tour of the facility at 10:05 a.m., accompanied by the Licensed Practical Nurse (LPN) Unit Manager (UM), the surveyor observed Resident #2 in bed wearing a cloth incontinent brief. The LPN UM removed the incontinent brief and Resident #2 was noted with a circular open area approximately 1.5 centimeter cm. by 1 cm. on the Right (R) inner buttock. There was no dressing on the area and no dressing noted in the cloth incontinent brief or in the bed. The LPN UM stated she had not been made aware of any change in Resident #2's skin condition. During an interview with the surveyor at 10:15 a.m. Resident #2's assigned CNA #1, stated she was aware of the open area and had noted it during morning care the day prior, on 6/2/2016, and reported it to the resident's assigned nurse, LPN #2 on the same day. During an interview with the surveyor at 1:40 p.m., the surveyor asked LPN #2 if CNA #1 had reported the open area noted on Resident #2. LPN #2 stated; If she told me I don't know, it was a busy day (6/2/2016). I checked it (the resident) and must have got side tracked. LPN #2 confirmed that she did not remember reporting it to the physician or the next shift. Review of NNs revealed no NN documentation for 6/1/2016 through the day of survey 6/3/2016. Review of a 24 hour nursing report, dated 6/2/2016, did not reveal any indication that a report of a change in skin condition was reported for Resident # 2. During an interview with the surveyor on 6/3/2016 at 11:05 a.m. and on 6/8/2016 at 2:15 P.M., the UM LPN and the Director of Nursing (DON) both confirmed that CNAs perform skin checks daily and report any findings to the nurse on the unit. The unit nurse should observe the skin and notify the physician timely to report the change in skin condition and obtain a physician order [REDACTED].>An Initial New Wound Evaluation Sheet and POS was faxed to the New Jersey Department of Health on 6/7/2016 and reflected that on 6/3/2016 a new R buttock Stage 2 PU measured 2 cm. by 0.7 cm. and treatment to clean the PU with Normal Saline solution (NSS) and apply [MEDICATION NAME] daily was initiated. Additionally, the DON faxed a summary of the investigation for Resident #2 on 6/17/2016 to the New Jersey Department of Health which included but was not limited to; The Periguard treatment was delegated to the resident's aides to administer during care and signed off by the nurse on the treatment sheet. The nursing assistant (CNA #1) on 7-3 (shift) was asked why she didn't report the open area on (Resident #2's) buttock and she said that she did. When the nurse (LPN #2) was asked about it she said the (CNA #1) did tell her but she was busy and forgot to address the issue. Review of an undated facility policy titled; Pressure Sore Policy revealed; It is the policy of this facility to aggressively prevent the formation of in-house acquired pressure sores. In the event a resident develops an unavoidable pressure sore .the facility will provide all of the necessary treatment and services to prevent infection, promote healing and prevent new sores from developing . Prevention Protocol: .the CNAs will conduct daily shin checks during care and report any changes in skin integrity to the licensed nurse. Preventative interventions will be documented in the resident's care plan. Development of Pressure Sore Protocols: Once a pressure sore is identified the initial assessment is described in the assessment flow sheet. The description includes the location of the sore, the stage, drainage and/or odor, the color and condition of the surrounding tissue. Notify the physician and initiate the wound date protocol unless otherwise indicated by the physician . NJAC: 8:39-27.1 (e)

Based on observation, interview and record review, it was determined that the facility failed to provide comprehensive care of a pressure ulcer. This included failure to evaluate and measure a pressure sore for Resident #9, 1 of 9 residents reviewed for new and high risk pressure ulcers. Resident #9 was admitted with a Stage 2 hip pressure sore measuring 1.5 x1.5 cm. The wound was never re-evaluated or treated with alternate healing modalities until 9/8/15 when it was assessed as being non-stageable and measured 4 cm x 3 cm. The evidence included the following: During the initial unit tour on 10/1/15, the Licensed Practical Nurse Unit Manager (LPN/UM) told the surveyor that Resident #9 had a facility-acquired pressure ulcer to the sacral area. On 10/1 at 12:50 p.m., the surveyor observed the resident seated in a wheelchair with cushion. The surveyor also observed a pressure relief low air loss mattress on the resident's bed. On 10/5/15, the surveyor reviewed the medical record which showed that Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 7/23/15 initial Resident Assessment Instrument (RAI) indicated that the resident was not able to walk and was dependent on staff for transfer in and out of bed/wheelchair. Further review of the medical record revealed that Resident #9 was admitted with a stage two pressure ulcer to the right hip which measured 1.5 cm x 1.5 cm with a physician's orders [REDACTED]. The surveyor looked through the medical record and noted that though treatment with Hydrogel was provided, there was no documented evidence of routine assessments and measurements regarding the wound. There was also no changes to the treatment regimen from admission date of [DATE] to 9/8/15. On 10/6/15 at 9:20 a.m., the surveyor went to see the resident and to observe treatment. The LPN/UM told the surveyor that Resident #9 was sent out to the hospital earlier that morning. When questioned about the missing wound documentation, she stated that the Wound Treatment Nurse was the person responsible for wound documentation. At that time, she called for the treatment nurse. The surveyor interviewed the LPN Treatment Nurse at 9:22 a.m. She told the surveyor that she only provided treatment and did not document or measure the wound. She also added that it was the Nurse Practioner (NP) who assessed, measured and recommended changes during weekly wound rounds. The LPN/UM who was still at the nurse's station and listening to the surveyor's interview of the treatment nurse, told the surveyor that the NP did not start seeing Resident #9 until 9/8/15. The Unit Manager then looked through a folder and handed the surveyor a 9/16/15 document written by the NP which indicated that the right hip pressure ulcer was unstageable and measured 4 cm x 3 cm., which represented a deterioration of the pressure ulcer. When the surveyor asked for the weekly measurements and assessments, she told the surveyor to wait for her to go look for it. She left the unit and returned about 20 minutes later and handed to the surveyor a September 2015 wound sheet. This showed a 9/9/15 measurement of 4 cm x 4 cm; a 9/16 measurement of 4 cm x 3 cm; a 9/23 measurement of 3 cm x 3 cm; and a 9/30 measurement of 2.8 cm x 1 cm. The surveyor noted that the NP made changes to the resident's treatment regimen on 9/8/15, the first day she evaluated the wound and that the wound had started to improve. There was no evidence that the pressure ulcer was measured and evaluated for the first seven weeks. On 10/7/15 at 9:30 a.m., the surveyor interviewed the facility administration. The Regional Director (RD) told the surveyor that they looked through the resident's record and could not find assessments and measurements for the first seven weeks following the resident's admission. When the surveyor inquired about the protocol for communication with the NP when a new resident came in with a pressure ulcer, the Director of Nursing (DON) stated that they normally faxed the information to the NP immediately and that she was not sure why it took that long for the NP to be made aware of the pressure ulcer. The RD added that there was a lack of communication between the treatment nurse and the NP and that she was working on that. The surveyor reviewed the facility's pressure sore policy on 10/7/15. The policy stated that staff would provide weekly measurements and provide a wound care consult. NJAC8:39-27.1 (e)

Complaint #: NJ , NJ Based on interview and review of medical records, it was determined that the facility failed to ensure that 1 of 7 sampled residents, (Resident #13), who resided on a locked behavioral unit, was protected from physical, verbal, and/or mental abuse from a fell ow resident, (Resident #12). Facility professional and direct care staff witnessed and/or had knowledge of an alleged verbal abusive incident, on April 15, 2014 at 1:00 p.m. in the day room after lunch, and then on 4/23/2014 a physical assault between Resident #12 and Resident #13, who were roommates. These incidents were documented in nurses notes in Resident #12's medical record. The immediate jeopardy situation, which began with the verbal abuse incident on April 15, 2014 at 1:00 p.m. for Resident #13, continued as Resident #12 and Resident #13 remained roommates after the April 15, 2014 incident until the April 23, 2014 incident at which time Resident #12 was transferred to a hospital for an evaluation and was later admitted for inpatient care. On April 23, 2014 at 1:00 p.m., in a nurses note for Resident #12, the following was documented: "Had a verbal/physical confrontation with his/her roommate." The surveyor observed documented in the 4/23/2014 1:00 p.m. nurses note the following: "Resident (#12) was nasty to the MD (medical doctor) today. Resident (#12) also had a verbal/physical confrontation with ___ (his/her) roommate. Resident (#12) was accused of striking roommate in the chest and threatening roommate by saying 'there will be more to come.' Nurse attempted to address the issue with Resident (#12), however Resident (#12) refused to listen and began to shout and curse saying 'I am always blamed (Resident #12) for things.' Resident #12 said for me to say what I want but if I touch (Resident #12), (Resident #12) will cut me. Safety precautions maintained by moving roommate into day room. Will continue to monitor." The surveyor observed the following documentation in a nurses note dated and timed April 23, 2014 at 2:30 p.m.; "Resident (#12) in room and threatening at roommate and staff." It further documented that Crisis was called at 2:30 p.m. and in facility at 3:00 p.m. Police unavailable for transport. Crisis will return at 4:30 p.m. In a nurses note dated and timed 4/23/2014 at 6:30 p.m., Crisis and Police arrived and Resident #12 was transferred to a hospital for a psychiatric evaluation. The immediate jeopardy to Resident #13's safety was brought to the attention of the facility Administration on May 12, 2014 at 5:20 p.m. The Jeopardy which began on April 15, 2014, had the immediacy removed on April 23, 2014 when the facility transferred resident #12 to the hospital and was lifted on the day of survey 5/12/2014 based on an acceptable plan of correction. This deficient practice is evidenced by the following: 1. According to a Medication Administration Record [REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 2/12/2014, documented Resident #13 to have a BIMS (Basic Interview Mental Status) score of 13, which indicated that resident was cognitively intact. A psychiatric consultation dated 11/4/2013, documented dementia (impaired short term memory), with targeted behaviors of resident being anxious mood/affect, hitting, motor restlessness and screaming. Resident requires minimal assist with most activities of daily living and ambulates independently on unit. On 5/12/2014, the surveyor reviewed the Behavior/[MEDICAL CONDITION] Drug Use care plan, dated 5/15/2013 and updated 2/24/2014, which failed to document the targeted behaviors of anxious, mood/affect, hitting, screaming, spitting, that were listed on the August 2013 Antipsychotic/Anxiolytic Summary. On surveyor review of Resident #13's medical record, the surveyor observed the following documentation in a nurses note, signed by a Licensed Practical Nurse (LPN), dated and timed 4/15/2014 at 2:30 p.m.; "Resident had several arguments with his/her roommate today." On 5/1/2014 at 2:00 p.m., the surveyor conducted an interview with the Social Worker (SW) and asked about allegations of Resident to Resident Abuse. The SW reported that on 4/23/2014 there was an incident between Resident #12 and Resident #13, and Resident #12 was sent out for a psychiatric evaluation. The surveyor asked if an incident report was made out to which the SW stated, "Well I would hope so." When asked about a Reportable Event Report, the SW replied, "If it's a reportable, it's done by the Administration." On 5/1/2014 at 3:50 p.m., the surveyor asked the Director of Nursing (DON) for any investigations of incidents relating to Resident to Resident abuse involving Resident #12 and Resident #13, which the facility failed to provide. When asked about Reportable Event reports related to the same, the DON replied, "I could not find any." On 5/12/2014 at 9:10 a.m., the surveyor asked the Administrator for any investigations of incidents relating to Resident to Resident abuse as well as any reportable events concerning allegations of Resident to Resident abuse. The facility provided an incident report dated 4/23/2014 between Resident #12 and Resident #13. The Administrator failed to provide a Reportable Event Form for the same incident. In a statement by a Certified Nursing Assistant (CNA #1) attached to the 4/23/2014 incident report, dated 4/23/2014 and timed 7:30 a.m., was the following documentation: "On 4/23/2014 by 7:30 a.m., while we are waiting for the breakfast to come I heard a noise. By the time I could figure out what room the noise is coming out it was over. Later I saw Resident #13 who started telling me a story of what happened to him/her. That his/her roommate punched him/her in the chest. Immediately I let my nurse on the high side (the part of the unit where Resident #13 resided) know." In a statement by a Licensed Practical Nurse (LPN #1) attached to the 4/23/2014 incident report, dated 4/23/2014 and timed 9:00 a.m., was the following documentation: "(Resident #13) received in room in w/c (wheelchair) c/o (complaint of) pain in chest and winced from discomfort when chest palpated. Redness (light) on chest area. (Resident #13) reported roommate punched__(him/her)in the chest after a verbal disagreement about the TV (television) set. Resident #13 also claims roommate threatened __(him/her) 'there will be more to come.' Resident claims the occurrence happened early this morning. Resident states 'I am afraid and I need to get out of that room.' Also states, 'I was sitting and reading my paper when he/she came over and messed with me.' " On 5/12/2014 at 9:50 a.m., the surveyor conducted an interview with Resident #13 and asked the resident to tell the surveyor about an incident where another resident had hit him/her. Resident #13 stated the following: "They moved __(Resident #12) to another place. I'm black and blue on my arm here, it's still sore in the middle, I'm living with it though. I was terrified of __(him/her). __(He/she) would look at me and growl. I told people about that, I do not remember who I told, they said they would look out for me. I feel safer now that __(he/she) is gone. Of course I'd be afraid if __(he/she) came back. You never knew what __(he/she) was up to." Resident #13 showed the surveyor a 3 inch round ecchymotic area on Resident #13's right upper outer arm. On 5/12/2014 at 10:14 a.m., the surveyor conducted an interview with CNA #2 and asked about reporting abuse and any injuries/bruises found on the residents. CNA #2 reported, "I'm not afraid of reporting any abuse. I would go to the nurse first. If no help, would go to the Administrator." On 5/12/2014 at 10:00 a.m., the surveyor conducted an interview with the Administrator and asked about the bruise and incident. The Administrator failed to provide an investigation regarding the bruise and/or injury of unknown origin. 2. According to an Admission Record Face Sheet, Resident #12 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #12 was discharged on [DATE] for a psychiatric evaluation and hospital stay, and was re-admitted on [DATE]. A Minimum Data Set (MDS), an assessment tool, dated 3/17/2014, was incomplete. None of the sections were completed. A psychiatric consultation dated 4/7/2014, (which was 6 days prior to the incident with Resident #13 on 4/15/2014), documented a history of chronic Paranoid [MEDICAL CONDITION] and mild Vascular Neurocognitive Disorder. Resident #12 ambulates independently on unit and won't allow staff to provide him/her care. Resident #12 has poor impulse control, poor judgement and has auditory hallucinations. Resident was non-compliant with taking medications, and psychiatric nurse practitioner suggested that another psychiatric stay might be beneficial in light of his/her refusal of treatment and medications. On surveyor review of Resident #12's medical record, the following documentation was observed in nurses notes: On 4/15/2014 at 1:00 p.m., LPN #1 documented: "Resident had an outburst today in the day room after lunch. Resident #12 got into an argument with another resident. When I approached Resident #12 to calm him/her down, he/she threatened to 'cut me'. Resident #12 also stated he/she would 'beat me down.' When this occurred, we all left the area directly around Resident #12 until he/she calmed down." On 4/16/2014 at 10:30 p.m., the surveyor observed documented in an LPN nurse note. "Resident #12 gets angry and asks 'do you want to fight me.' " On 5/1/2014 and 5/12/2014 the surveyor requested the care plans for Resident #12, which the facility failed to provide. The Administrator stated, "I can't find care plans for Resident #12. The only ones I have are the Initial Plan of Care care plans from 5/9/2014." The facility failed to provide an initial care plan related to behaviors. On 5/12/2014 at 10:03 a.m., the surveyor introduced herself to Resident #12 and attempted to conduct an interview about the care at the facility. Resident #12 was sitting on his/her bed holding a teddy bear and a plastic bag. Resident #12 stated, "Get out, I'm not saying anything." Surveyor apologized for bothering her and left the Resident's room and went into the locked area of the nursing station. At 10:23 a.m., the surveyor observed Resident #12 walk very quickly out of his/her room and push his/her way into the locked nursing station door behind a CNA, and put his/her face up close to the surveyors face and asked what the surveyor wanted. Staff came to attempt to redirect the resident away from the locked nursing station and calm the resident down. Resident #12 was able to be re-directed out of the area after about 5 minutes when the Administrator came and interceded by talking with Resident #12. On 5/12/2014 at 4:30 p.m., during continued interviews with the Administrator and DON, the surveyor asked about how staff are educated about abuse prevention on hire and throughout the year. The Administrator replied "On hire, they are given something to read and sign off that they read everything. I don't like how it's done here. We are looking at changing it, there are a lot of things that need to be changed here. Everything is not reported even to me, and then things fall through the cracks. I was not aware of the verbal altercation between Resident #12 and Resident #13. I'm really not happy that this is all coming out now. We do not have a set list of what the nurses need to go over during orientation, they possibly did not go over the reporting of incidents." The surveyor observed the following documentation in the undated facility policy titled "Policy on Resident Abuse: "All employees must immediately report any sign of injury sustained by a resident whether or not the nature of the injury is known. Care planning for all residents with behaviors or needs that might trigger a negative reaction, such as heavy care, psychiatric conditions, communication disorders. Immediate incident reporting and investigation of all falls, bruising, skin tears, increased depression, fearful behaviors." In the policy sub-section titled "Protection", the following was documented: "All residents involved in an investigation are monitored closely to avoid further disruption of daily quality of life. Immediate removal of threat, whether employee, other resident, social circumstance or physical hazard to provide security and safety." In the policy sub-section titled "Reporting", the following was documented: "All violations and alleged or suspected incidents of any form of abuse/neglect will be reported to appropriate state agencies within one business day." The immediate jeopardy to Resident #13's safety was brought to the attention of the facility Administration on 5/12/2014 at 5:20 p.m. The immediate jeopardy began on 4/15/2014 and continued until Resident #12 was transferred from the facility to the hospital on [DATE] at 6:30 p.m. which removed the immediacy of the immediate jeopardy situation. The deficient practice continues at a lower scope and severity level of "E" based on the facility's failure to fully implement a Plan of Correction to address systemic changes to prevent re-occurrence. NJAC 8:39-27.1 (a)

Complaint #: NJ , NJ Cross Reference F-223 Part A: Based on interview, review of medical records and facility documents, it was determined that the facility failed to follow their policy on "Abuse", and "Reporting and Recording of Accidents/Incident Reports", for 2 of 7 sampled residents, (Residents #12 and #13). Facility professional and direct care staff witnessed and/or had knowledge of alleged verbal abusive incident, on April 15, 2014 at 1:00 p.m. in the day room after lunch between Resident #12 and Resident #13, who were roommates. This incident was never reported, investigated or interventions put into place, and a second incident of physical altercation on 4/23/2014 occurred resulting in Resident #12 being transferred to a hospital for a psychiatric evaluation. This resulted in an immediate jeopardy situation, which began on April 15, 2014 at 1:00 p.m. On 4/16/2014 at 10:30 p.m., in a nurses note, the surveyor observed documentation that Resident #12 "Gets angry" and asked the nurse, "Do you want to fight me?" On April 23, 2014 at 1:00 p.m., in a nurses note for Resident #12, Resident #12 "Had a verbal/physical confrontation with his/her roommate." The roommate, Resident #13 was moved from the room to the day room. On April 23, 2014 at 2:30 p.m., Resident #12 threatened roommate and staff, and the Crisis Center was called. Resident #12 was assessed and transferred to a hospital for a psychiatric evaluation the same day at 6:30 p.m. The facility failed to provide documentation that the facility's staff implemented six of the seven elements of the facility policy on Resident Abuse; Training, Prevention, Identification, Investigation, Protection and Reporting. The incidents that involved Resident #12 and Resident #13 were as follows: 4/15/2014 at 1:00 p.m., 4/16/2014 at 10:30 p.m., and on 4/23/2014 at 9:00 a.m., 1:00 p.m., and 2:30 p.m. The immediate jeopardy was brought to the attention of the facility Administration on 5/12/2014 at 5:20 p.m. The immediate jeopardy began on 4/15/14 at 1:00 p.m. and was corrected on 5/12/2014 at 6:30 p.m., based on an acceptable plan of correction, which had been implemented by the facility. 1. All policies on abuse and the investigation of abuse will be reviewed and updated by Administration. 2. All staff will be inserviced on the policies and procedures of abuse, reporting, protection of residents and removing threat, starting immediately with the staff present and continuing until all staff have been inserviced. 3. All residents have the potential of being affected by the staff not following policies and procedures for abuse. 4. All staff will be inserviced on the policies and procedures of abuse, reporting and protection of residents starting immediately with the staff present and continuing until all staff have been inserviced. 5. All new hires will receive one to one inservices on abuse on hire prior to start of facility orientation, by nursing. 6. Staff will be inserviced on abuse quarterly, by nursing. 7. Management will report all incidents that meet the criteria for reporting to State Agencies. Part B: The deficiency continues at a scope/severity of D. Based on a review of documentation and interviews, it was determined that the facility staff failed to follow their policy on "Abuse", and "Reporting and Recording of Accidents/Incident Reports", for 2 of 7 sampled residents (Resident #1 and Resident #10). 3. According to an Admission Record Face Sheet, Resident #1 was re-admitted to the facility on [DATE], from the hospital, with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 1/22/2014, documented Resident #1 to have memory problems and was moderately impaired cognitively with decisions poor; cues/supervision required. A psychiatric consultation dated 1/20/2014, documented dementia (impaired short term memory), with behavior disturbance. The reason for consult was documented as "patient with occasional angry outbursts. Positive angry mood." Resident #1's antipsychotic medication was adjusted up (increased) with the potential benefit of treatment documented as "to decrease angry outbursts." Targeted behaviors were listed as: "Irritability, Kicking, Screaming and Spitting." Resident requires extensive assist with all activities of daily living. On surveyor review of Resident #1's medical record, the surveyor observed the following documentation in a nurses note, dated and timed 3/19/2014 at 2:30 p.m.; "Resident became very verbally and physically abusive towards roommate, punching __(the roommate) in the face, screaming and yelling with the use of expletives. Tried to hit staff members, went as far as spitting on staff. Very combative when attempt to place __(him/her) in a quiet environment. Increase agitation and abuse both physically and verbally demonstrated. Crisis was called for evaluation and treatment." According to a "Psychiatric Screening Center Transfer Form", Resident #1 was not a candidate for in-patient psychiatric care and referred back to the facility for follow-up psychiatric care. On 5/1/2014 at 3:25 p.m., the surveyor conducted a interview with a Licensed Practical Nurse (LPN #3), and asked what interventions were put into place after this incident. LPN #3 replied, "We moved Resident #1's roommate to another room." On 5/12/2014, the surveyor reviewed all of Resident #1's care plans. The Restorative Care care plan dated 3/28/2014, the Enteral Feeding care plan dated 10/11/2012, the Activity care plan dated 12/5/2012 and updated 8/16/2013, the Risk for Falls/Injuries care plan dated 12/5/2012 and updated 3/11/2014, the Weight Loss care plan dated 1/24/2013 and updated 11/2013, the Activities of Daily Living care plan dated 12/5/2012 and updated 11/7/2013, the Skin Integrity care plan dated 12/5/2012 and updated 11/7/2013, the Pain Management care plan dated 12/5/2012 and updated 11/7/2013. The Behavior/[MEDICAL CONDITION] Drug Use care plan, dated 12/5/2012 and updated 11/7/2013 failed to document the targeted behaviors of "Irritability, Kicking, Screaming and Spitting" which were listed on the January 2014 Psychiatric Consultation. As noted above, the Behavior/[MEDICAL CONDITION] Drug Use care plan was last updated 11/7/2013 and failed to contain documentation related to the January 2014 psychiatric note, the incident of 3/19/2014, and the follow-up psychiatric consult on 4/7/2014 which included targeted behaviors of "Hitting, Verbal Threats, and Physical Threats." 4. According to a May 2014 Medication Administration Record [REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 1/21/2014, documented Resident #10 to have memory problems and was severely impaired cognitively and never/rarely made decisions. The MDS documented that Resident #10 required extensive assist with all aspects of activities of daily living. A psychiatric consultation dated 12/9/2013, documented End Stage SDAT (Senile Dementia of the Alzheimer Type). It went on to document that Resident #10 is "either somnolent or crying, by staff." The plan was documented as follows: Decrease [MEDICATION NAME] (a anti-anxiety medication) secondary to daytime sedation; Continue [MEDICATION NAME] (a anti-depressant) and [MEDICATION NAME] (to increase appetite). The plan documented was to: "Manage impulsive crying, depression, and decrease anxiety; increase sleep and increase appetite." On surveyor review of Resident #10's medical record, the surveyor observed the following documentation in a nurses note, dated and timed 3/19/2014 at 2:00 p.m.; "Resident was sitting in hallway when __(Resident #10) was punched in the face by another resident, (Resident #1). No swelling or lacerations noted. Placed in close supervisory area with close monitoring." On 5/12/2014, the surveyor reviewed all of Resident #10's care plans. The Risk for Falls/Injuries care plan dated 8/2013 and updated 11/7/2013, the Wheelchair Positioning care plan dated 5/6/2014, the Speech Therapy care plan dated 3/25/2014, the Skin Integrity care plan dated 2013 and updated 14/11/2013, the Weight Loss care plan dated 8/2013 and updated 4/7/2014, the Pain Management care plan dated 8/3/2013 and updated 11/7/2013, the Urinary Incontinence care plan dated 8/20/2013 and updated 11/7/2013, the Activities of Daily Living care plan dated 8/2013 and updated 11/7/2013, the Behavior/[MEDICAL CONDITION] Drug Use care plan, dated 8/2013 and updated 11/7/2013 failed to document the targeted behaviors of "Impulsive crying, depression, anxiety" which were listed on the December 2013 Psychiatric Consultation. The care plan failed to include documentation of the 3/19/2014 resident to resident abuse and what the facility put in place to prevent further potential for abuse to Resident #10. On 5/1/2014 at 3:50 p.m., the surveyor conducted a interview with the Director of Nursing (DON) and asked about a facility incident report, investigation and Reportable Event Form for the 3/19/2014 incident between Resident #1 and Resident #10. The DON replied, "I could not find any." On 5/12/2014 at 12:20 p.m., the surveyor conducted a interview with the Administrator and asked about a facility incident report, investigation and Reportable Event Form for the 3/19/2014 incident between Resident #1 and Resident #10. The Administrator replied, "Let me see what I have on that." The facility failed to provide these documents as requested. On 5/12/2014 at 4:30 p.m., during continued interviews with the Administrator and DON, the surveyor asked about how staff are educated (Training/Subsection II of the policy) about abuse prevention on hire and throughout the year." The Administrator replied "On hire, they are given something to read and sign off that they read everything. I don't like how it's done here. We are looking at changing it, there are a lot of things that need to be changed here. Everything is not reported even to me, and then things fall through the cracks. I was not aware of the verbal altercation between Resident #12 and Resident #13. I'm really not happy that this is all coming out now. We do not have a set list of what the nurses need to go over during orientation, they possibly did not go over the reporting of incidents." On 5/12/2014 at 5:15 p.m. the surveyor conducted an interview with both the Director of Nursing (DON) and the Administrator and asked about how frequently education on abuse prevention is given. The DON replied, "I need to revise policies, I need help in doing inservices." The Administrator stated, "Inservices are done 2 times a year, but we have not had any yet this year." The surveyor continued the interview with the Administrator and DON and asked about how the facility prevents abuse (Prevention/Sub-section III of the policy) from occurring by utilizing Care Planning. The facility policy documented "Care planning for all residents with behaviors or needs that might trigger a negative reaction, such as heavy care, psychiatric conditions, communication disorders." The Administrator and DON stated that they were aware that care plans were not being completed as required. The surveyor asked the DON and Administrator about the (Identification/Sub-section IV of the policy) incident reporting aspect of the Abuse Policy. The policy documented that "Immediate incident reporting and investigation of all falls, bruising, skin tears, increased depression, fearful behaviors. Anyone witnessing or suspecting any type of abuse toward a resident by any individual (including staff, family, friends, volunteer, other resident) will immediately report the instance to the supervisor on duty. The facility policy, dated 10/20/2011 and titled "Reporting and Recording of Accident/Incident Reports", documented the following: "To document all incidents and accidents occurring to residents, employees and visitors. The facility failed to provide documentation that incident reports were completed for the following incidents of resident to resident abuse: 3/19/2014 at 2:30 p.m., 4/15/2014 at 1:00 p.m., 4/16/2014 at 10:30 p.m., 4/23/2014 at 9:00 a.m. and 1:00 p.m. On 5/12/2014 at 2:03 p.m., the surveyor asked LPN #1 about the completion of incident reports. LPN #1 reported, "I write them up and put them on the clipboard on the unit; what they do with them afterward I do not know." The surveyor asked the DON and Administrator about the (Investigation/Sub-section V of the policy) aspect of the Abuse Policy. The undated facility "Policy on Resident Abuse" documented "An incident report will be completed and the supervisor will obtain the names of all witnesses or persons involved and obtain statement. A statement should also be obtained from the resident if possible." The surveyor asked the DON and Administrator about the (Protection/Sub-section VI) aspect of the Abuse Policy. The undated facility "Policy on Resident Abuse" documented the following: "All residents involved in an investigation are monitored closely to avoid further disruption of daily quality of life." On 5/1/2014 at 3:50 p.m., the surveyor conducted an interview with the DON and asked when Resident #10 was moved from the room he/she shared with Resident #1. The DON failed to provide the date as requested. The surveyor asked the DON and Administrator about the (Reporting/Sub-section VII) aspect of the Abuse Policy. The undated facility "Policy on Resident Abuse" documented the following: "All violations and alleged or suspected incidents of any form of abuse/neglect will be reported to appropriate state agencies within 1 business day." The facility failed to provide the surveyor, when requested on 5/1/2014 and 5/12/2014, documentation that these incidents were reported as per the facility policy. The surveyor observed documented in the facility policy titled "Reporting and Recording of Accident/Incident Reports", and dated 10/20/2011, the following: "All accidents/incidents shall be reported to the nursing supervisor immediately. Incident reports must be filled out completely with the necessary information needed. Nursing supervisor will initiate the investigation immediately into the cause of the accident/incident and obtain necessary statements from staff involved. Incident reports must be submitted to the Director of Nursing (DON) within 24 hours. The DON will review the incident report. Any alleged resident abuse will be reported to the Administrator. Suspected or alleged resident abuse will be reported to the proper authorities and the investigation will be initiated. The Office of the Ombudsman and the Department of Health will be notified of suspected abuse cases and of any substantial injuries of unknown origin. The DON and Interdisciplinary Care Team will meet weekly to discuss the incident/accident reports, trends and causes. Appropriate interventions will be discussed and communicated to the staff to prevent reoccurrence." The Administrator stated, "There's a lot of things that need to be changed here. A lot of what goes on does not come to me, things fall through the cracks." NJAC 8:39-13.4 (c) 2, (i through vi)