Every finding on record at Bayonne University Hospital

Based on interview and record review it was determined that the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for the PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 3 2025 (April 1 - June 30, could affect all residents, and was evidenced by the following:On 9/9/25 at 11:20 AM, Surveyor #1 (S#1) reviewed the PBJ Staffing Data Report CASPER Report 1705D FY Quarter 3 2025 (April 1-June 30), reflected a triggered area that the facility failed to submit data for the Fiscal Year Quarter 3 to CMS =No Data Submitted for Quarter. The dates of the Quarter 3 included April 1, 2025, through June 30, 2025.On 9/9/25 at 11:32 AM, S#1 interviewed the License Nursing Home Administrator (LNHA) regarding submission of PBJ reports. S#1 reviewed with the LNHA the PBJ report for FY Quarter 3 2025, including the triggered area. S#1 asked if PBJ reports were submitted to CMS, and the LNHA responded that she had to check with Business Office, that the facility was not issued Medicare number until I do not remember the date, and it was effective retroactively for 2/24/25. The LNHA further stated that she had to check the exact date that she received the letter, because that was the date she set up the account for PBJ submissions and decided who was responsible to submit the PBJ reports. On 9/9/25 at 11:58 AM, Surveyor #2 (S#2) requested from the Chief Nursing Officer (CNO) the most current facility policy for PBJ submission.On 9/9/25 at 12:07 PM, the LNHA, Minimum Data Set/Director of Nursing (MDS/DON), provided information regarding obtaining their provider/supplier agreement, Medicare notification via e-mail dated 5/30/25, for their Medicare number. The LNHA stated that she did not remember if she contacted Medicare was contacted before, I acknowledge I could not find anything between May-to now for PBJ notification. She further stated, I contacted them today to set it up. The LNHA added that it was the DON's responsibility before to submit PBJ and now they had to figure it out who would be responsible for PBJ submission of reports.At that same time, the LNHA provided a copy of the email dated 9/9/25 at 11:42 AM (after surveyor inquiry) to CMS asking CMS how to set up account for transmitting the PBJ data.On 9/9/25 at 12:25 PM, S#1 notified the LNHA, MDS/DON, CNO, Medical Doctor for TCU, Quality Director and the Chief Hospital Executive of the concern with PBJ report for CMS submission for April 11-June 30th, not being submitted. The LNHA acknowledged the understanding of the concern. The LNHA stated that the facility was notified by the CMS that they had their provider number until 5/30/25, and that she reached out to CMS in setting up an account, and unable to locate the email. The LNHA also stated that the facility had no policy with regard to PBJ submission. On 9/9/25 at 12:48 PM, during the exit conference with the LNHA, MDS/DON, CNO, Medical Doctor for TCU, Quality Director and Chief Hospital Executive, there were no additional documentation provided by the LNHA.NJAC 8:39-41.3(a)

Based on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to provide the resident or resident representative written notification of the reason for transfer to the hospital and provide a copy of the notification to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for 1 of 1 resident (Resident #33) reviewed for hospitalization. This deficient practice was evidenced by the following:On 9/9/25 at 9:59 AM, the surveyor reviewed Resident #33's closed hybrid medical record (paper and electronic) which included the following:A review of a progress note dated 8/12/25, indicated that the resident was transferred to the hospital. A review of the Universal Transfer Form indicated that the resident was transferred to the hospital.On 9/9/25 at 10:20 AM, the surveyor asked the acting Chief Nursing Officer to have the person responsible for sending the written notification for transfer to come speak to the surveyor regarding the process.On 9/9/25 at 12:10 PM, the Licensed Nursing Home Administrator (LNHA) stated that the facility had a new Social Worker and that he was not aware that he needed to send the written notification. On 9/9/25 at 12:25 PM, the surveyor notified the LNHA, Director of Nursing (DON), ACNO, Quality Director (QD), Chief Hospital Executive (CHE), and Medical Director (MD) the concern that written notification of the reason for transfer was not given to the resident or resident representative and a copy sent to the LTCO. The LNHA did not provide any additional information.A review of the facility's Transfer and/or Discharge Policy with an effective date of March 2023, included the following:PolicyTransitional Care Unit must notify the resident and/or legal representative. The reason(s) for the move must be in writing and in a language and manner they understand. If possible, the notice will be at least 24 hours before the move. The notice will contain the following:The reason for transfer or discharge;The effective date of transfer or discharge;The location to which the resident is to be transferred or discharged ;A statement that the resident has the right to appeal the action to the NJ Department of Health and Human Services;The name, address and telephone number of the State Long Term Care Ombudsman.N.J.A.C. 8:39-4.1(a)31,32

Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure the daily report of licensed nurses, certified nursing assistant staffing, and the resident census, was posted at the beginning of the current shift for 1 of 3 days during the annual recertification survey. This deficient practice was evidenced by the following:On 9/5/25 at 8:45 AM, upon entry to the facility, the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) posted at the nursing station of the Transitional Care Unit (TCU). The NHRCSR posted was dated 8/29/25, for the [7:00 AM to 7:00 PM] shift. There was no NHRCSR for 9/5/25 posted. The primary nurse provided a copy to the surveyor.On 9/8/25 at 12:38 PM, the surveyor interviewed the Unit Secretary (US) in the room behind the nursing station. The surveyor asked the US what the process was for NHRCSR posting and she replied that the information were gathered from the Charge Nurse, then she printed them out when she arrived at the facility at 10:00 AM. The US also stated that she updated them before the US leave for the evening and night shifts to post. The US further stated that she worked every other weekend and she was responsible for that weekend, and nobody update the NHRCSR when the US was not around. At that same time, the surveyor notified the US of the above findings and concern with regard to 9/5/25 NHRCSR posting that was dated 8/29/25. The US stated, I probably forgot to do it, but I have done it on the computer. The surveyor asked if she was aware of the regulation for posting and she replied, 'No.On 9/8/25 at 1:34 PM, the survey team met with the License Nursing Home Administrator (LNHA), Chief Nursing Officer (CNO), Chief Hospital Executive, Director of Nursing/Minimum Data Set (DON/MDS), and Quality Director. The surveyor discussed the concern regarding NHRCSR posting, showed the copy of NHRCSR from last Friday 9/5/25, which was dated 8/29/25 (7 days late).On 9/8/25 at 1:38 PM, the DON/MDS stated that she was responsible for posting the NHRCSR when the US on vacation. The surveyor asked what about the weekend when the DON/MDS was not working or when she was off, and the DON/MDS replied, I ask her to do it starting from Friday when she's not working on the weekend. I will let her know who the discharges and the admissions coming for the weekend are.On 9/8/25 at 1:40 PM, the surveyor requested for the facility policy for staffing posting.On 9/9/25 at 9:10 AM, the LNHA provided a policy for posting dated 9/8/25, and stated that the facility did not have a posting policy, so we made one yesterday.A review of the facility's Daily Posting of Staffing Pattern Policy with an effective date 9/8/25, revealed, under Procedural Guidelines #3, the US will print out the daily staffing pattern reported to the NJ.gov (new jersey.government) website for posting.On 9/9/25 at 12:48 PM, during the exit conference with the LNHA, MDS/DON, CNO, Medical Director for TCU, Quality Director and Chief Hospital Executive, there was no additional information provided by the LNHA.NJAC 8:39-41.2