Every finding on record at New Jersey Veterans Memorial Home Menlo

Based on observation, record review, interviews, and policy review, the facility failed to ensure staff used respectful and appropriate identifiers during meal service on one of six resident units (Independence Unit) reviewed for dignity. This failure had the potential to contribute to a negative outcome related to the promotion and respect of resident well-being and quality of life. Findings include: Review of the facility's policy titled, Dignity, revised 02/12/25, revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Residents are treated with dignity and respect at all times.provided with a dignified dining experience.Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs . 1.During an observation on 09/02/25 at 12:23 PM, the Independence unit dining room had approximately ten to twelve residents seated and prepared for lunch service. The following observations were made:At 12:35 PM, the meal cart was placed near the dining room for staff to begin meal service.Two staff members pointed at a table near the meal cart, and Certified Nurse Aide (CNA) 2 responded saying, They're a Feeder.At 12:40 PM, CNA3 pointed at a resident and asked a colleague if they also were a Feeder?At 12:41 PM, Charge Nurse (CHN) 1 stated that residents were Feeders. 2. During an additional observation on 09/05/25 at 12:29 PM, the Independence unit dining room had approximately ten to twelve residents seated and prepared for lunch service. The following observation was made:CNA1 pointed at the recently arrived meal cart parked near the dining room, and asked a colleague if a resident was now a Feeder? Review of the assignment sheets on Freedom unit, Independence unit, Eagle unit, Liberty unit, Old [NAME] unit, and the Stars and Stripes unit were placed each shift at the nurses' stations. Review of the assignment sheets on Freedom unit, Independence unit, Eagle unit, and Stars and Stripes unit identified residents by name that would require assistance at meals as Feeders on each assignment sheet. These assignment sheets were placed each shift at the nurses' stations. During an interview on 09/05/25 at 1:04 PM, CNA1 verified that the staff used the term Feeder when a resident required meal assistance. During a concurrent interview on 09/05/25 at 2:20 PM, CNA4 and CNA2 both verified that staff used the word Feeder to identify which residents required assistance with meals. CNA4 and CNA2 both stated they were not aware if the label Feeder was a dignity issue or not. During an interview on 09/05/25 at 2:35 PM, the Charge Nurse (CHN) 1 said that she helped fill out the assignment staffing form for Independence unit. She stated that the word Feeder was used to identify which residents needed assistance with meals. CHN1 confirmed that it was a word used to identify residents and was not aware if it was a dignified way to identify residents or not. During an interview on 09/05/25 at 2:43 PM, the Director of Nursing (DON) stated that the unit clerk and the unit supervisor would complete the assignment sheets on each unit. Upon the review of the assignment sheet, and the assignment tab labeled Feeders, he said that he would change the form to read Assist with Meals. He confirmed that using the label Feeders described an action and not a resident need, and that it was not appropriate to say in the presence of residents. NJAC 8:39-4.1(a)

Based on record review, and interviews, the facility failed to invite one resident (Resident (R)2) out of a total sample of 35 residents to participate in the care plan process. This failure had the potential to deny residents the opportunity to be able to make decisions about the care they receive. Findings include: During an interview on 09/02/25 at 12:50 PM, R2 stated that she has not been to a care plan meeting since being admitted to the facility. R2 also stated that she was not aware that residents were to be invited. A review of R2's electronic medical record (EMR) located under the MDS 3.0 tab revealed an annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/25; admission date of 07/09/24; Brief Interview for Mental Status (BIMS) 15 out of 15 indicating cognitively intact; diagnosis of unspecified dementia, Type2 diabetes mellitus, Parkinson's disease, spinal stenosis, cervical region; muscle weakness, cellulitis or right lower limb The facility failed to provide evidence that R2 was invited to the care meetings that were being held. During an interview on 09/04/25 at 3:35 PM, the Social Services Director (SSD) stated that the facility does a verbal invite with the residents and sends a letter to the resident representative. The SSD also stated that the facility did not chart that R2 was invited to the care plan meeting, so we cannot say that [R2] was invited. During an interview on 09/05/25 at 11:05 AM, the Deputy Chief Executive Officer (DCEO) stated that the residents should always be able to participate in care planning unless deemed not cognitively able to. During an interview on 09/05/25 at 1:46 PM, the Director of Nursing (DON) stated that all residents should be invited to participate in the care plan meeting. A review of the policy titled Care Plan - Comprehensive with a revision date of 11/17/24 stated An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Reflect the resident's expressed wishes regarding care and treatment goals. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments.' NJAC 8:39-27.1(a)

Based on record review, interview, document review, and policy review, the facility failed to update the code status in all records to Do Not Resuscitate (DNR) for two of 33 (Resident (R)16 and R171) residents reviewed for code status out of a total sample of 35 residents. This failure increased the likelihood of causing severe harm or death if CPR (Cardiopulmonary Resuscitation) was performed against a resident's wishes if found unresponsive with no pulse or no breathing.Findings include: Review of the facility's policy Practitioner Orders for Life-Sustaining Treatment (POLST) Policy with a review date of 09/03/25 indicated, .The facility will honor a valid POLST in good faith. POLST complements-[sic] but does not replace-[sic] advance directives. If directives conflict and clarification is not possible, the most recent document guides care.: For revisions, complete new POLST, mark prior as VOID, update EHR [electronic health record] and chart. Enter orders into EHR consistent with POLST. 1.Review of R16's undated Face Sheet' located under the Snapshot tab in the electronic medical record (EMR) indicated R15 was admitted to the facility on [DATE] with the diagnosis of dementia. Review of R16's Recapitulation Physician Order Sheet located in the hard chart and dated for 09/01/25 through 09/30/25, revealed an order dated 11/27/24 which indicated R16 was a Full Code. Review of R16's Physician Orders located in the hard chart indicated an order dated 09/02/25 for R16's code status to be DNR/DNI [Do Not Resuscitate/Do Not Intubate]. Review of R16's POLST located in the hard chart and dated 08/22/25 indicated R16's POA had signed for R16 to be a DNR/DNI with long term artificial nutrition. The spine of the hard chart did not indicate the code status of R16. Review of R16's Care Plan located under the Care Plan located in the EMR dated 12/02/24, indicated a Focus of I have a POLST to clearly state my wishes when my health begins to decline. The interventions indicated, I do not wish to be resuscitated if I stop breathing. I do not wish to receive chest compressions if my heart stops beating. I do not wish to receive artificial nutrition if I am no longer able to / or [sic] take food by my mouth. During an interview on 09/03/25 at 11:54 AM, Registered Nurse (RN)1 stated, We don't have a list of residents that are a DNR. We look at the POLST in the front of the resident's chart, and there is also an order in the hard chart that says what their code status is. We also put a sticker on the spine of the hard chart to reflect the current code status. During an interview on 09/03/25 at 1:10 PM, RN2 stated, Their [residents] charts have it [code status] in there. I also look at this, [name of unit] Resident Roster. Review of the Resident Roster indicated R16 was a Full Code. During an interview on 09/03/25 at 1:16 PM, RN1 was asked who is responsible for updating the Resident Roster when changes occur. RN1 stated, These are updated by the unit clerk, charge nurse, or the nurse when they receive changes in their care. During an interview on 09/03/25 at 1:23 PM, Unit Clerk (UNC)1 was asked the current code status for R16 and UC1 replied, [R16] is a full code. I know because he has been here a long time. UC1 did not refer to the POLST or the hard chart before answering. During an interview on 09/03/25 at 5:03 PM, Licensed Practical Nurse (LPN)2 looked at the Resident Roster and stated, He [R16] is a full code. Then LPN2 went to R16's hard chart and reviewed the POLST in the front of the chart. LPN2 went to RN1 and stated, This POLST doesn't match the cheat sheet we have for [R16]. RN1 began reviewing the current POLST and stated, This [cheat sheet] hasn't been updated to reflect the current POLST that we have. RN1 was asked if this should match and RN1 stated, Yes. During an interview on 09/04/25 at 7:46 AM, the Director of Nursing (DON) stated, The POLST supersedes orders on the Recapitulation Physician Order Sheet for code status. I only expect the nurses to refer to the POLST if there is any question of the code status. During a review of R16's Hemodialysis Notebook on 09/04/25 at 3:00 PM, which is taken to dialysis with each appointment time, reflected in the front of the notebook of a POLST form dated 08/09/22 and signed by R16's POA (Power of Attorney) that indicates R16 was a Full Code with a defined trial period of artificial nutrition. During an interview on 09/04/25 at 3:05 PM, RN1 stated, This is the old POLST. The current POLST should be here in this [hemodialysis] book for DNR/DNI. During an interview on 09/04/25 at 4:00 PM, the DON reviewed the POLST form in the front of the dialysis notebook and stated, This should have been replaced with the current POLST form. 2.Review of R171's Facesheet located in the EMR under the ADT tab revealed she was admitted to the facility on [DATE] and had diagnoses which included dementia. Review of R171's Interdisciplinary Progress Notes located in the EMR under the Charting tab revealed a Quarterly 2 Assessment Review note dated 06/12/25: Attempt CPR [cardiopulmonary resuscitation], no artificial nutrition [POLST - Practitioner Orders for Life-Sustaining Treatment] The note further stated that family attended a meeting on 06/12/25 and was looking into changing the POLST. Review of R171's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/25 and located under the Charting tab of the EMR revealed a Staff Assessment for Mental Status was completed which revealed R171's cognition was severely impaired. Review of the front of R171's paper chart revealed a POLST dated 06/15/25 and signed by a physician which indicated family's wishes to not attempt resuscitation (DNAR). Review of R171's paper chart under the Physicians Orders tab revealed two Physician's Order summaries, signed by a physician on 07/30/25 and 09/02/25. Each summary was also signed and dated by two nurses. Both documents conveyed full code (perform CPR) and were ordered as of 04/01/15. Neither documented the DNAR order from the POLST dated 06/15/25. During an interview on 09/03/25 at 2:35 PM, Registered Nurse (RN) 3 stated she looked at the POLST in the front of the paper chart to determine the orders and resident/family wishes for code status. During an interview on 09/03/25 at 2:40 PM, Unit Manager (UM) 1 reported she looked at the front of the paper chart at the POLST to identify the orders and resident/family wishes for code status. UM1 stated R171's POLST reflected she was not to receive CPR. When UM1 reviewed the Physician's Order documents dated 07/30/25 and 09/02/25, she stated they were to reflect the POLST, and since they did not, she planned to correct the Physician's Order immediately. During an interview on 09/04/25 at 7:46 AM, the Director of Nursing (DON) stated the physician order summary, labeled as Physician's Order in residents' paper charts were printed monthly by the pharmacy and reflected the orders given by the physician for the resident. The DON stated the code status order was an exception because the POLST was a separate order, which could be updated at any time and superseded any orders on the physician order summary. The DON stated he expected that the physician order summaries would have been updated by 09/02/25 for R171's POLST which was dated 06/15/25. NJAC 8:39-4.1(a)NJAC 8:39-27.1(a)

Based on record review, interview, and policy review, the facility failed to ensure a written transfer notice that contained all required information was provided for three of three residents and/or their representatives (Resident (R) 4, R1, and R6) reviewed for hospital transfer out of 35 sample residents. This failure had the potential to result in the resident and their Resident Representative (RP) not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.Findings include: 1.Review of R4's admission Record located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE]. Review of R4's General Notes, located under the Notes tab of the EMR, dated 01/01/25 through 08/27/25, revealed R4 was discharged to the hospital on [DATE] and again on 07/16/25. Review of the EMR Evaluations and Documents tab along with review of the Progress Notes tab revealed no evidence that a written notice of transfer was provided to R4 or her RP. During an interview on 09/05/25 at 4:50 PM the Social Worker (SW) stated when a resident was discharged she sent out the bed hold policy and transfer notice to the family but did not keep a copy of what was sent and she did not document in the resident medical record the date it was sent, and who it was sent to. She stated she had no documentation to show that a transfer notice was provided to the resident or responsible party. 2.Review of R1's undated Face Sheet' located under the Snapshot tab in the EMR indicated R1 had been admitted to the facility on [DATE] with the diagnosis of congestive heart failure and chronic obstructive pulmonary disease. Review of R1's annual Minimum Data Set (MDS) located under the MDS 3.0 tab in the EMR, with an Assessment Reference Date (ARD) of 06/16/25 indicated R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact. Review of R1's Nursing Progress Notes located under the Charting tab in the EMR, a note dated 07/09/25 at 12:44 PM which indicated, .resident complaining of nauseous, cramps in legs and unable to ambulate. BP [blood pressure] 86/43, O2 sat [oxygen saturation] 97% on RA [Room Air]. put Trendelenburg position [sic] Re-check vitals after 5 [sic] min. BP 97/51 O2 sat 90% on RA. Oxygen administer [sic] via NC [nasal cannula] at 3LPM [liters per minute], -11:20am A call was placed to [name of doctor] to make him aware of resident change in status [sic]. MD [Medical Doctor] ordered for resident to be transfer to. ER [emergency room] for Hypoxia [low oxygen saturation]. Further review of the nursing progress notes did not indicate documentation to reflect the resident was provided in writing the reason for transfer to the hospital on [DATE]. During an interview on 09/04/25 at 1:50 PM, the Social Services Director (SSD) stated, I send a copy of this letter to the resident's RP [Resident Representative] and/or POA [Power of Attorney] that says the reason for admission to the hospital. Asked if she keeps documentation that was provided to the resident which explains the reason for transfer and the SSD stated, No, I do not. During an interview on 09/05/25 at 9:00 AM, R1 was asked if he had received a letter from the facility that stated the reason for transfer to the hospital on [DATE]. R1 stated, I don't have anything like that. During an interview on 09/05/25 at 4:15 PM, the Director of Nursing (DON) was asked what his expectation of the SSD's documentation of the written reason for transfer that is provided to the resident and/or RP and the DON stated, I will have to get back to you on this. The DON returned to the conference room at 5:30 PM and stated, I don't have anything further to add. The DON also confirmed that the facility did not have a policy on transfer notices. 3.Review of R6's Facesheet located in the electronic medical record (EMR) under the ADT tab revealed he was admitted to the facility on [DATE] and was hospitalized from [DATE] to 08/05/25. Review of R6's paper chart revealed a New Jersey Universal Transfer Form dated 07/08/25 and addressed to the hospital detailing pertinent resident information needed by the hospital to evaluate R6 and provide care to him. Review of Interdisciplinary Progress Notes located in the EMR under the Charting tab revealed R6 was sent out to the hospital for evaluation on 07/08/25. A note dated 08/06/25 at 2:19 AM documented that he was readmitted to the facility after treatment in the hospital for cellulitis and congestive heart failure. Review of R6's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/25 and located under the Charting tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. Review of the paper chart revealed no notice of transfer form directed to R6 regarding his transfer to the hospital. During an interview on 09/05/25 at 12:35 PM, R6 reported he was hospitalized several times during his time at the facility. R6 was unable to recall receiving any written notice of his transfer to the hospital; he was not notified of the appeal process or provided the State Long Term Care Ombudsman contact information. During an interview on 09/05/25 at 12:46 PM, Licensed Practical Nurse (LPN) 1 reported when she sent a resident out to the hospital she sent a New Jersey Universal Transfer Form and other information the hospital needed to care for the resident. When asked if there was any paper that went to the residents informing them of why they were being transferred, their appeal rights, and the ombudsman's contact information, LPN1 stated there was no paperwork with that information that nursing provided to the resident. During an interview on 09/05/25 at 5:05 PM, the Social Services Director (SSD) reported she mailed the family members a notice of transfer letter but did not notify the resident. Nursing notified the residents since they were with the residents at the time of transfer. NJAC 8:39-4.1(a)31,32

Based on observations, record review, interviews, and policy review, the facility failed to accurately assess one resident (Resident (R)143) for nutritional needs regarding R143's weight gain out of a total sample of 35 residents This failed practice had the potential to cause unmet nutritional needs.Findings include: A review of R143's electronic medical record (EMR) located under the MDS 3.0 tab revealed the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/25; admission date of 06/11/25; Brief Interview of Mental Status (BIMS) unable to assess indicating severe impaired cognition; Alzheimer's disease; height of seventy inches, weight of one hundred sixty pounds, with a weight loss of 5% or more in the last month or weight loss of 10% or more in the last six months and not on a physician prescribed weight loss regimen. A review of R143's EMR Assessments tab revealed a nutritional assessment dated [DATE] that indicated R14 received a regular puree diet with nectar thick liquids; with an admission weight of 160 pounds (lbs.). A review of R143's weights revealed that on admission R143 weighed 159.8 lbs. and on 07/10/25 R143 weighed 167.2 lbs. which is a 4.63% weight gain in one month. On 09/03/25 R143 weighed 174.2 lbs. which is a 9.01% weight gain in three months. During an interview on 09/05/25 at 5:15 PM the Registered Dietitian (RD) stated that when MDS was completed there was an entry error showing an unplanned weight loss. The RD stated that the Registered Dietitian is the one that completes the nutritional status on the MDS. During an interview on 09/05/25 at 11:05 AM the Deputy Chief Executive Officer (DCEO) stated that MDS should reflect accurate information. DCEO also stated that the assessment drives the care of the residents and the level of assistance needed. During an interview on 09/05/25 at 11:45 AM the Director of Nursing (DON) stated that the MDS should always have accurate information to ensure that the information is correct when developing the comprehensive plan of care. During an interview on 09/05/25 2:27 PM, the MDS Coordinator (MDSC) verified that the MDS was not correct and a modification had to be completed to reflect the status of R143. A review of the facility policy titled Resident Assessments indicated that A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. The results of the assessments are used to develop, review and revise the resident's comprehensive care plan. NJAC 8:39-33.2(d)

Based on observation, record review, and staff interview, the facility failed to ensure one of one resident (Resident (R)133) reviewed for wander guards out of a total sample of 35 residents was appropriately screened and had documentation to support the use of the wander guard. This failure had the potential to restrict R133's movement about the unit when the alarm would sound when R133 was near an exit door. Findings include: Review of R133's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including dementia, depression, and psychotic disorder. Review of R133's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 07/20/25, revealed he scored ninety-nine out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Further review revealed no wandering behavior indicated. Review of R133's Care Plan, located under the Care Plan tab of the EMR dated 07/12/25, revealed I have Dementia, I have expressed my desire to go home, and this places me at risk of wandering and elopement. Interventions in place were to apply a code alert and complete an elopement risk assessment. Review of R133's Physician Orders, located under the Orders tab in the EMR dated 01/17/25 revealed wander guard to right ankle. Review of R133's Elopement Risk Assessment located under the Observations tab in the EMR dated 04/14/25 and 07/15/25 revealed R133 was not at risk for elopement. Review of R133's General Notes, located under the Notes tab of the EMR, dated 01/01/25 through 08/27/25, revealed no documentation of any wandering or exit seeking behaviors. During an interview on 09/05/25 at 10:07 AM, Registered Nurse (RN)4 stated R133 was total care and preferred to be out of bed. He enjoyed socializing with other residents. RN4 stated R133 was confused but he was not exit seeking. She said he had never tried to get off the unit or get out of the building. During an interview on 09/05/25 at 10:24 AM, Licensed Practical Nurse (LPN)2 said R133 was confused at times. He liked to roll around the nursing station in his wheelchair and speak with the nurses. He was not exit seeking and had never tried to leave and never spoke about it. She said he had a wander guard before, but she did not think he had one now, but she would have to check. During an observation on 09/05/25 at 10:46 AM of R133 sitting in wheelchair at a table in the TV room, CNA5 pulled back R133's right pants leg and verified the wander guard placement. During an interview on 09/05/25 at 2:32 PM Director of Nursing (DON) stated if a resident was assessed not to be an elopement risk they should not have a wander guard. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure a resident's nasal cannula and nebulizer mask were stored properly when not in use for one of two residents reviewed for oxygen therapy (Resident (R) 94) out of a total sample of 35 residents. This failure had the potential to increase the risk of a respiratory infection for residents receiving respiratory therapies. Findings include:Review of R94's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was readmitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD). Review of R94's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/25 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine out of 15 which indicated the resident was severely cognitively impaired. The resident was coded as receiving oxygen therapy. Review of R94's Physician Order, dated 02/04/24 and located in the resident's EMR under the Orders revealed an order oxygen at 2 Liters per Minute (lpm) via nasal cannula continuously. Further review revealed an order dated 09/18/23 for a nebulizer treatment three times daily as needed for shortness of breath and wheezing. Observation on 09/02/25 at 4:50 PM and 09/03/25 at 2:35 PM revealed R94's oxygen nasal cannula was lying at the foot of the resident's bed, uncovered and the nebulizer mask was on the floor during the first observation and then was uncovered on the TV stand during the second observation. During an observation and interview on 09/03/25 at 2:35 PM, Licensed Practical Nurse (LPN) 2 verified that R94's nasal cannula and nebulizer masks were uncovered. LPN2 stated the reason the cannula and nebulizer mask should be covered in a bag was an infection control issue. During an interview on 09/05/25 at 2:32 PM, the Director of Nursing (DON) said all nasal cannulas and nebulizer masks should be covered in a bag when not in use. Review of the facility's policy titled Care of Respiratory Equipment revised 04/2025 revealed, all respiratory equipment will be cared for using good infection control principles to prevent the transmission of nosocomial infections to residents. All reusable equipment must be stored in plastic bags or following the manufacturer's recommendations after cleaning. NJAC 8:39-27.1(a)

Based on record review, interview, and policy review, the facility failed to have collaboration of care involving dialysis for one of three residents (Resident (R)16) reviewed for dialysis out of a total sample of 35 residents. This failure had the potential for inaccurate or missing clinical information not being communicated to the right people.Findings include: Review of R16's undated Face Sheet located under the Snapshot tab in the electronic medical record (EMR) indicated R16 was readmitted to the facility on [DATE] with the diagnosis of end stage renal disease requiring dialysis. Review of R16's admission Minimum Data Set (MDS) located under the MDS 3.0 tab in the EMR, with an Assessment Reference Date (ARD) of 08/05/25 indicated R16 was receiving dialysis while a resident in the facility. Review of R16's Care Plan located under the Care Plan tab in the EMR indicated a Focus dated 07/31/25 for I am at risk for complications for renal failure/ESRD [end stage renal disease] [sic] requiring dialysis. The interventions were . Dialysis three times a week Monday, Wednesday, and Friday. Check left AV graft [arteriovenous fistula] every shift for bruit and thrill. Monitor access site for signs of bleeding and symptoms of infection. Another Focus dated 07/31/25 was for I have a [sic] AB graft and a subclavian Perma cath [catheter]. The interventions were I will follow left arm precautions with no BP [blood pressure], blood work or BS [blood sugar] by fingerstick in my left arm/hand. My right subclavian perma cath [sic] will have a protective dressing on at all times except when being accessed. Review of R16's Hemodialysis Communication Record located in the hard chart for dialysis indicated the following failures:07/30/25 In the section To be completed by the licensed nurse prior to dialysis treatment the Access site swelling, drainage, pain. and AV Fistula/Graft Thrill were left blank on the communication record.08/01/25 In the section To be completed by the licensed nurse prior to dialysis treatment the AV Fistula/Graft Bruit and Thrill were left blank on the communication record.08/18/25 In the section To be completed by the licensed nurse prior to dialysis treatment the Access site swelling, drainage, and pain were left blank on the communication record.08/20/25 In the section To be completed by the licensed nurse prior to dialysis treatment the Access was documented as None There were also no vital signs documented on the communication record. During an interview on 09/04/25 at 3:05 PM, Registered Nurse (RN)1 stated, The top and bottom sections of this form are to be out by the nurse here and the middle section is to be filled out by the dialysis nurse. Asked if the sections that the facility nurse is to be completed are to be left blank and RN1 stated, No, the sections are to be completely filled out by the nurse. During an interview on 09/05/25 at approximately 4:15 PM, the Director of Nursing (DON) stated, The vital signs are to be documented prior to the dialysis treatment on the form. This resident has two access sites. The dialysis is using the AV graft in the arm for now because the perma cath has just recently been placed. The nurses should have the access questions answered. Review of the facility policy Care of a Dialysis Resident dated 01/06/25 indicated, . 1. Residents who are on dialysis will be assessed [sic] including vital signs before leaving for the dialysis center. 2. Residents who are [sic] go to dialysis will use the dialysis communication form as a tool for communication between the Facility and Dialysis Center. Information to be included each visit includes the Resident's vital signs and any pertinent information. Information will be recorded on the communication form by the sending nurse. 3. The dialysis communication form will be sent with the resident. NJAC 8:39-5.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails, documented discussion related to risk versus benefits, and signed informed consent for one of four residents (Resident (R)133 reviewed for side rails out of 35 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.Findings include: Review of R133's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including dementia, depression, and psychotic disorder. Review of R133's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 07/20/25, revealed she scored ninety-nine out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Further review of the MDS indicated that side rails were not in use. Review of R133's Care Plan, located under the Care Plan tab of the EMR dated 10/09/24, revealed I am at risk for falls. Interventions in place were I prefer to have the upper 2 side rails up when I am in bed to assist me with mobility and transfers. Review of R133's Physician Orders, located under the Orders tab in the EMR, dated 08/25/25, revealed no order for bilateral quarter side rails. During an interview on 09/05/25 at 10:07 AM, Registered Nurse (RN)4 stated the facility did not have side rail assessments and there was no process for side rail use. She stated the facility did not use side rails because they were restraints, but they used enablers. During an interview on 09/05/25 at 10:24 AM, Licensed Practical Nurse (LPN)2 stated the facility did not have side rails, but they had enabler bars that were used for repositioning. LPN2 stated the facility was restraint free. She said that all residents had enablers but there was no process or assessment for them. Observation on 09/05/25 at 10:35 AM of R133 room with LPN2 revealed she considered the quarter inch side rails as an enabler. During an interview on 09/05/25 at 10:54 AM, Unit Manager (UM)2 said the facility used enablers but did not use side rails. UM2 stated that all residents had enablers. UM2 stated the enablers were offered two different sizes but the residents did not sign an informed consent, and there was no discussion of risk and benefits or informed consent, or alternates attempted prior to side rail use. During an interview on 09/05/25 at 2:32 PM, Director of Nursing (DON) was unsure of any process for side rail use. The DON agreed there were side rails on some beds in the facility including on R133's bed. Review of the facility's policy titled Bed Safety and Bed Rails undated revealed, Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one- eighth lengths. Some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. For the purpose of this policy bed rails include a. side rails; b. safety rails; and c. grab /assist bars. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent:a. The assessed medical needs that will be addressed with the use of bed rails.b. The residents' risks from the use of bed rails and how these will be mitigated.c. The alterative that were attempted but failed to meet the resident's needs; andd. The alternatives that were considered but not attempted and the reasons. NJAC 8:39-27.1(a)

Complaint #NJ00156516 Part A Based on interviews, record review, and review of other facility documentation, it was determined that the facility failed to ensure nursing staff appropriately removed an indwelling urinary catheter (soft plastic or rubber tube that is inserted into the bladder to drain urine) in accordance with professional standards of nursing practice which necessitated a transfer to the hospital for treatment, and a urinary tract infection. This deficient practice was identified for 1 of 3 Residents reviewed for indwelling urinary catheter care (Resident #179) and 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. The facility's failure to have a system in place to ensure that nursing staff appropriately removed an indwelling catheter posed a serious and immediate threat to the health, and welfare of all residents who required catheter care. An adverse outcome had occurred and was likely to occur as the identified non-compliance resulted in an immediate Jeopardy (IJ) situation that began on [DATE] at 2:50 PM when the Registered Nurse (RN) improperly removed the indwelling catheter. The RN used scissors to cut through Resident #179's indwelling catheter, which then caused the remaining catheter to retract into the bladder. The Immediate Jeopardy (IJ) situation was identified during an onsite survey conducted on [DATE], and the facility was notified of the IJ, on the same day, at 3:20 PM. The facility submitted an acceptable removal plan on [DATE] at 2:55 PM. The team verified the removal plan during an onsite visit conducted on [DATE]. Findings included: On [DATE] at 10:30 AM, the surveyor toured the 200 Unit of the facility and observed that Resident #179's door was closed. On the door, the surveyor observed signage posted which identified the required PPE (Personal Protective Equipment) to enter the room. The surveyor observed staff donning (putting on) and doffing (removing) with the required PPE before entering and exiting the room. An interview with the Registered Nurse/Unit Manager (RN/UM) revealed that Resident #179 was on isolation for Extended Spectrum Beta Lactamase (ESBL, antibiotic-resistant bacteria) and Methicillin Resistant Staphylococcus Aureus (MRSA, antibiotic-resistant bacteria) in the urine. On [DATE] at 11:29 AM, the surveyor donned the appropriate PPE, knocked at the door, waited for Resident #179 to answer, and entered the room. The surveyor observed Resident #179 in bed, awake with eyes open, and the surveyor observed a splint to the left arm. The surveyor explained the purpose of the visit, and Resident #179 agreed to be interviewed. Resident #179 was alert and stated that he could not move their left arm. Resident #179 answered all questions appropriately. The surveyor observed an indwelling urinary catheter covered with a catheter drainage bag hung on the bed frame. On [DATE] at 09:30 AM, the surveyor returned to the 200 Unit, the door was open, and Resident #179 was not inside the room. Upon inquiry, the RN/UM informed the surveyor that Resident #179 had tested + for COVID-19 in the evening during routine testing and was transferred to the 700 Unit. On [DATE] at 08:30 AM, the surveyor observed Resident #179 on the 700 Unit. The door was closed. Signage with the required PPE was posted on the door. The surveyor reviewed the medical record for Resident #179 on [DATE]. According to the Admission Face Sheet (an admission summary), Resident #179 was readmitted to the facility on [DATE] following a hospitalization for urinary retention. Resident #179 had diagnoses which included, but were not limited to, hypertension, diabetes mellitus, depression, hyperlipidemia, and End Stage Renal Disease. A review of Resident #179's Plan of Care, updated on [DATE] and [DATE], revealed that Resident #179 had decreased range of motion (ROM) and muscle strength related to co-existing chronic medical conditions. Resident #179 also was at risk for infection due to urinary retention. The care plan goal was for Resident #179 to not have a urinary tract infection and to receive the care needed to maintain their current functional status. The Annual Minimum Data Set Assessment (MDS), an assessment tool used by the facility to prioritize care, dated [DATE], revealed that Resident #179 scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS), which indicated intact cognition. The section H of the MDS, which addressed Bladder and Bowel, Resident #179 received a score of 9 for H 0300. The score was indicative of the presence of an indwelling catheter in the bladder. The Interdisciplinary Progress Notes (IDPN) revealed that on [DATE] at 3:00 PM, a Registered Nurse documented in the IDPN, Per assigned desk nurse statement, in the process of removing resident catheter. She cut it and put a towel under it to prevent the urine from draining into the resident's pants. Before she could pull the catheter out part of the catheter retracted. It was reported to the writer. Director of Nursing (DON) and Assistant Director of Nursing (ADON) made aware. NP (Nurse Practitioner) made aware and gave order to transfer Resident #179 to the Emergency Department (ED) for retracted [indwelling urinary] catheter . Resident #179 was picked up at 2:55 PM by 911 crew. A late IDPN entry dated [DATE], timed 3:30 PM, read, Dc' d [indwelling urinary] catheter retracted in the process of removing it. Resident transferred to ED. On [DATE] at 11:52 AM, the surveyor interviewed the RN/UM regarding the IDPN dated [DATE]. The RN/UM stated that the Registered Nurse (RN #1), who oversaw the unit on [DATE], cut the indwelling urinary catheter in the process of removing the indwelling urinary catheter. She stated that there was an order to remove the indwelling urinary catheter on [DATE]. RN #1 proceeded to execute the order to remove the urinary catheter. The RN/UM stated that RN #1 reportedly had never removed a urinary catheter before. She cut the urinary catheter with a pair of scissors instead of using a syringe to remove the water to deflate the balloon. The remaining urinary catheter then retracted into the bladder. Resident #179 was transferred to the ED for evaluation and treatment the same day. The hospital discharge summary was requested and was not available for review by the surveyor. The RN/UM stated she would inform the DON of the request for the hospital discharge summary. On [DATE] at 12:30 PM, the surveyor interviewed the Director of Nursing (DON). The DON confirmed that she was aware of the above incident and informed the surveyor that RN #1 was currently suspended pending disciplinary action. The surveyor requested the investigation and the employee file for review. The surveyor also requested RN #1's telephone contact to conduct an interview. On [DATE] at 9:23 AM, the surveyor interviewed a random Registered Nurse (RN) assigned to the 200 unit regarding nursing resource materials available to the staff. The RN directed the surveyor to the binder outside the nursing station that contained all the policies and procedures. The surveyor located in the binder policy # 4:035 B titled, Indwelling Catheter Replacement, dated [DATE], which outlined the following: Indwelling Catheter replacement must have a physician order indicating size and schedule. Indwelling catheter replacement must be done by a registered nurse whose clinical skill has been checked by the instructor of nursing. If the physician and/or registered nurse, who has demonstrated clinical competence for this procedure is not available, send Resident to the emergency room for indwelling Catheter. The policy did not include a procedure to remove an indwelling urinary catheter. On [DATE] at 11:00 AM, the surveyor conducted a telephone interview with RN#1, who confirmed she was the nurse who received the order to remove the indwelling urinary catheter on [DATE]. RN #1 stated that she was overwhelmed that day and did not want to leave the procedure for the next shift. RN #1 stated she went to Resident #179's room with the Certified Nurse Aide (CNA), and she then used a pair of scissors from the treatment cart, cut the indwelling urinary catheter, and urine was splashing all over. She stated she then looked for the indwelling urinary catheter but could not locate it on the bed. RN #1 stated she realized that the indwelling urinary catheter retracted into the bladder. She stated she applied a towel to protect the resident's clothing, informed the RN/UM what had happened, and went to the desk and called and reported the incident to the Nurse Practitioner (NP). The NP then gave an order to transfer Resident #179 to Emergency Department for evaluation and treatment, and she reported the incident to the DON and initiated the 911 call for transfer. She stated that the DON informed her to leave the floor once she completed her statement. RN #1 stated that she had not received any in-service education on how to remove an indwelling urinary catheter at the facility. She stated she was aware that besides deflating the balloon, another simple way was to cut the indwelling urinary catheter. She stated, I made a mistake. RN #1 stated that she met with the DON in the office and explained what had happened. The DON informed her that she was suspended. The surveyor then asked RN #1 to elaborate on her work history prior to being employed by the facility. RN #1 stated that she worked as a floor nurse for a long-term care facility and a psychiatric hospital before working at the current facility. She stated she had been a Registered Nurse for [AGE] years. RN #1 stated after being hired by the facility, during orientation, she was able to demonstrate and was evaluated on the skill sets of inserting an indwelling urinary catheter. However, she was not evaluated on indwelling urinary catheter removal. A review of RN #1's orientation file provided by the Nurse Educator (NE) confirmed that she received in-service education on inserting a urinary drainage catheter on [DATE] during orientation. The surveyor requested RN #1's employee file from the DON. RN #1's employee file contained three written warnings, one for a medication error, the second for not donning the proper PPE during an outbreak, and the most recent was for an allegation of verbal abuse toward a family member. RN #1 also stated that she was informed during her hearing with the Employee Relation Officer ([NAME]) that she did not document all the required information on the hospital transfer form prior to sending Resident #179 to the ED. The surveyor then asked RN #1 if there were any resource materials on the floor that she could have used prior to removing the indwelling urinary catheter. She stated that she did not review any indwelling urinary catheter removal procedure before cutting the urinary catheter with scissors. She stated that she was provided with a form titled Wisconsin Technical College (Nursing Skills 21.13 Checklist for [indwelling urinary catheter Removal] during her hearing with [NAME] on [DATE]. On [DATE] at 10:15 AM, the surveyor reviewed the Facility assessment dated [DATE]. According to the documentation provided, the Facility Assessment had to identify and analyze the facility's resident population, which must be considered when determining staffing and resources needed to care for the residents. Understaffing training, it is revealed, Licensed nursing staff receive training and demonstrate competencies in areas of responsibility related to providing skilled nursing care to residents of the facility. Nurses receive updated and additional training as necessary to meet the changing needs of our residents. Training and competencies include, but not limited to: Licensed nurse training and/ or competencies. Oxygen set up Oxygen masks . Nasal cannula / Non-Rebreather /Simple face mask Wound care / Dressing Change Suctioning skill/ Trach care Glucometer Medication Pass Indwelling catheter replacement CPR The facility's Indwelling Catheter Replacement policy did not cover Foley Catheter Removal. On [DATE] at 10:37 AM, the surveyor conducted an interview with the NP responsible for Resident #179's care. The NP stated that she wrote an order to remove the indwelling urinary catheter and initiate a voiding trial. She received a call from the nurse, who stated that something had happened. The nurse stated she cut the indwelling urinary catheter to remove it, and the catheter retracted. The NP stated, I came on the unit, examined the Resident, the resident was not in pain. I gave an order to transfer Resident #179 to the ED for evaluation and treatment. The NP stated, I had never heard of such a procedure. The NP further stated that she was not informed of any follow-up or recommendations from the ED. The NP stated that she reviewed the After Visit Summary the next day and could not identify what treatment was provided. She said she called the hospital and spoke to the staff, but the hospital staff could not comment on what treatment was provided. The NP stated she asked for the Urology report and was informed that the Urologist was not called in to see Resident #179. The NP then explained to the ED, what had happened, and that the issue needed to be addressed immediately. The NP stated the Urologist was then made aware that Resident #179 had the retracted catheter in the bladder. On [DATE] at 12:03 PM, the surveyor interviewed the NE in charge of orientation and staff competencies. The surveyor inquired about specific competencies and skill sets necessary to care for resident needs. The NE provided the surveyor with the orientation package. A review of the orientation package confirmed that indwelling urinary catheter removal was not included in the competencies. RN #1 did not receive in-service training for indwelling urinary catheter removal. The NE stated that Licensed Staff had to go to general orientation classes for two days and then work with a mentor on the floor for 14 days (for full time) employees. Mandatory training was scheduled yearly, and skill sets for competencies were completed every two years. Based on the orientation package provided, the facility staff did not receive competency training for indwelling urinary catheter removal. The NE stated that he was aware of the adverse outcome with the Foley catheter on the [DATE] incident. He was informed that Resident #179 was transferred to ED for treatment because the indwelling urinary catheter was improperly removed. The surveyor requested in-service education training provided after the incident, but none had been provided. When asked how nursing staff competency education was being tracked, the NE added the DON would inform him of any needed in-service education training. The Orientation package provided by the facility was reviewed with the NE on [DATE] and did not include Foley Catheter Removal. The current policy revealed how to insert an indwelling urinary catheter only. The facility was unable to provide the rationale for nursing staff not being trained or assessed for competency on how to remove an indwelling urinary catheter. On [DATE] at 4:40 PM, the surveyor conducted a second interview with RN #1. She stated that she had performed the skill to remove an indwelling urinary catheter before deflating the balloon. She stated that cutting the indwelling urinary catheter was a simple procedure that she had not used prior. She stated that she overheard nurses saying that you could cut the indwelling urinary catheter to remove it, and that was why she cut the indwelling urinary catheter. She stated that after the incident, she went to the internet, watched a video, and realized that she did not follow the proper technique. RN #1 stated that she cut the catheter 4 to 5 inches below the insertion site, not by the port, to evacuate the water. The surveyor then asked RN #1 to elaborate on the procedure for indwelling urinary catheter removal. She stated: 1. Verify the order, identify the patient, explain the procedure, provide privacy, use a syringe to deflate the balloon by aspirating the water, and gently pull the indwelling urinary catheter. She stated she was very concerned regarding the resident's well-being. She kept calling every day to inquire regarding Resident #179's status. RN #1 was able to elaborate on the process of properly removing an indwelling urinary catheter. She could not provide the rationale for cutting the indwelling urinary catheter, which caused Resident #179 to be transferred to the ED for treatment. On [DATE] at 09:30 AM, The DON provided the Investigation Report for review. The surveyor reviewed the final report, which revealed the following: Physical Evidence On [DATE], the charge nurse reported that in the process of removing Resident #179's indwelling urinary catheter, she cut the catheter and part of it retracted into the bladder. Resident #179 was immediately discharged to the hospital for intervention. CT urogram (used to examine the kidneys and bladder) without contrast was performed in the hospital with the impression there is significant bladder wall thickening with peri cystic inflammation suggesting cystitis (inflammation of the urinary bladder), no hydronephrosis or renal calculi identified, a note is made of small bilateral pleural effusion (abnormal fluid collection between thin layers of tissue lining the lung and the wall of the chest cavity), and urinary bladder is partially collapsed around Foley catheter. No further intervention was taken at the hospital. Recommendations: [DATE] Urology consult by ___, with recommendation for bladder ultrasound. [DATE] Bladder ultrasound taken on with conclusion of bladder not visualized, to consider ST scan not ordered. On [DATE] resident was seen by the Cardiology group and cleared for cystoscopy. On [DATE], cystoscopy was performed for removal, and a new Foley catheter was placed. The resident was referred for follow-up with Urologist. Resident's care plan revision: Bladders scan every shift Monitor for signs and symptoms of infection Observe Resident for any abdominal pain Encourage fluids Refer to MD if no urinary output Staff Education All nurses were given competency for Foley catheters. Conclusion A Cystoscopy was performed on Resident #179; the retracted piece of the indwelling urinary catheter was removed, and a new indwelling urinary catheter was re-inserted. The resident is being monitored for any signs and symptoms of infection. A bladder scan is being performed every shift to monitor for bladder retention. Resident #179 will be seen by a urologist on [DATE] at the facility. The RN who cut the Foley catheter remains on suspension pending investigation. On [DATE] at 9:51 AM, an interview was conducted with the DON, who stated that she made her last rounds at 2:50 PM and was informed that Resident #179 had to be sent out because the nurse cut the indwelling urinary catheter. When asked if the nurse provided the rationale for cutting the indwelling urinary catheter, the DON added that the indwelling urinary catheter removal was a skill set that was taught in school, and all licensed staff should know how to remove an indwelling urinary catheter. The DON did not interview RN #1 to identify the causal factor, implement corrective action, or prevent recurrence. The DON stated that during her career, she had never heard of cutting the indwelling urinary catheter as a skill set to remove the indwelling urinary catheter. The DON stated that RN #1 was suspended pending disciplinary action, and the incident had been reported to the Department of Health. On [DATE] at 11:17 AM, a second surveyor interviewed the Physician Assistant (PA) covering for the Urologist. He stated they had been assigned to the facility for about 1 ,d+[DATE] to 2 years. Their responsibilities consisted of reviewing all urology consults and changing all indwelling urinary catheters monthly. Resident #179 was seen at the hospital for urinary retention ([DATE]- [DATE]), and an indwelling urinary catheter was inserted prior to discharge to the facility. He was made aware of the adverse outcome of the indwelling urinary catheter removal by the NP. Resident #179 had to have a scheduled cystoscopy to remove the remaining catheter in the bladder. He stated if the resident had a cardiac history, medical clearance had to be obtained to ensure that the resident was stable to sustain the procedure under anesthesia. The PA stated that based on the report obtained from the facility, Resident #179 was able to void and did not develop signs/ symptoms of infection. The PA was unaware that Resident #179's urine culture and sensitivity tested positive for E Coli, ESBL, and MRSA on [DATE] and that Resident #179 had to be placed on Macrobid (antibiotic) to treat the urinary tract infection. On [DATE] at 12:06 PM, the surveyor interviewed the CNA who assisted the RN #1 on [DATE]. The CNA stated that Resident #179 got out of bed three times weekly. It was almost 3:00 PM, and Resident #179 had been dressed and was up and sitting in a wheelchair. The nurse asked her to assist with removal of the indwelling urinary catheter. She stated, she went to the room, pulled Resident #179's pants down just enough to see the indwelling urinary catheter. The CNA stated the catheter was long, the nurse retrieved a pair of scissors from her packet and cut the yellow part that goes into the penis. The nurse then told me to pull out the long part from the pants. The CNA stated that the nurse asked her, What happened to the other part? The CNA stated, I do not know, and the RN #1 stated, It went back inside. The RN #1 then attempted to retract the penis to see if she could visualize the other part of the catheter and she could not. RN #1 then called the UM, explained what had happened, and I was told to return Resident #179 to bed. Upon further inquiry, the CNA stated, I never assisted any other staff at the facility to remove an [indwelling urinary catheter]. I worked in the ED before, and I know when you insert an [indwelling urinary catheter], you have to put water into the port to inflate the balloon and when you had to remove them, [indwelling urinary catheter] you have to take the water out. The surveyor then asked why she did not offer any guidance to RN #1. The CNA replied, She is an RN. She is supposed to know. On [DATE] at 09:43 AM, the surveyor interviewed RN #1 with another surveyor present. RN #1 stated that she attended and graduated from one of the State Colleges. During her academic years, she was taught how to remove an indwelling urinary catheter, but the skill sets were not demonstrated. She stated that in nursing school, she was not evaluated on the skill sets to remove an indwelling urinary catheter. RN #1's failure to remove the Foley catheter in accordance with professional standards of nursing practice resulted in harm, unnecessary transfer to the hospital for treatment and a urinary tract infection. Resident #179 had to have a Cystoscopy (procedure to look inside the bladder with a camera) to remove the retracted indwelling urinary catheter. RN #1 did not seek assistance from other nursing staff to remove the indwelling urinary catheter. She did not inform the Nurse Educator that she needed assistance with the indwelling urinary catheter removal. Part B Based on interview and document review, it was determined that the facility failed to ensure: a.) the facility policy was followed to document all pertinent information on a universal transfer form prior to a resident being transferred to the hospital, and b.) thoroughly review instructions/recommendations on the After Visit Summary (hospital discharge summary) to facilitate continuation of care. This deficient practice was identified for 1of 3 Residents reviewed for indwelling urinary catheter care (Resident #179) and was evidenced by the following: 2. On [DATE] at 11:30 AM, the DON provided a copy of the reportable event forwarded to the Department of Health. The surveyor reviewed the report and observed that the facility did not include the New Jersey Universal Transfer Form (NJUTF) that was identified as not completed. Pertinent information regarding the reason for transfer was not entered to inform the ED of the reason for transfer. On the NJUTF the following information was documented, Tube/catheter. Resident # 179 was sent back to the facility with the remaining catheter in the bladder. The Urologist was not called and informed that the nurse cut the indwelling urinary catheter and the remaining catheter was still inside Resident #179's bladder. The ED was informed of the retracted catheter remaining in the bladder on [DATE], one day after the resident was transferred to the ED, by the NP. On [DATE] at 11:34 AM, the DON provided the surveyor a copy of the undated facility's policy Resident Transfer Form. The policy revealed: Purpose: The purpose of this procedure is to ensure continuity of care in transfer from the facility to the hospital or other extended care facility. Procedure: 1. In the event a resident needs to be transferred to a hospital or other long-term care facilities, the charge nurse is responsible for filling out a Resident Transfer Form. 2. The form must be completed totally, and all information must be up-to-date and accurate. 3. The attached copy of the completed transfer form is to be placed in the resident's chart. 4. Information received in reference to resident transfers will be forwarded to the units by the nursing office. 5. The Nursing Services Clerk will transcribe the information to the Universal Transfer Form and date and sign the form. The form will be placed in a sheet protector and placed in the front of the chart. The facility failed to enter all the pertinent information on the NJUTF to facilitate continuity of care. The reason for the transfer was not documented, and the ED had not been informed that Resident #179's indwelling urinary catheter was cut. The remaining catheter remained in the resident's bladder. The Urologist was not called and informed of the incident. Resident #179 returned to the facility with the remaining catheter not being removed from the bladder. 3. The surveyor reviewed the After Visit Summary dated [DATE], which revealed that during the ED visit, Resident #179 received Rocephin [a broad spectrum antibiotic] 1 gram (gm), intravenously at the hospital for preventive measure of UTI. Please give Cephalexin (Keflex; antibiotic) 500 mg (milligrams) every 12 hours for the next 7 days for treatment of Urinary Tract Infection. The physician, or the NP was not made aware of the recommended continued medication order. The surveyor reviewed the [DATE] Medication Administration Record (MAR) and the order was not transcribed. On [DATE] at 10:23 AM, in the presence of the survey team the surveyor conducted an interview with the Assistant Director of Nursing (ADON ). The ADON confirmed that staff missed the instructions on the After Visit Summary for the Keflex order. The ADON stated, on [DATE] during the final investigation regarding the adverse outcome with the Foley Catheter Removal, she discovered that Resident #179 did not receive the Antibiotic ordered on [DATE]. She reported the incident to the DON, and the administrator. She stated, she consulted with the (MD ) who ordered Urine analysis, urine culture and sensitivity, Keflex 500 mg twice daily for 10 days for preventive measure. The facility received the urine culture result on [DATE] and the final report revealed the following: Urine Culture Colony Count Source: Colony Count: 100, 000 + Grams-Negative Rods Gram-Positive Cocci in clusters Extended Spectrum Beta Lactamase ( ESBL )- Positive ESBL is an enzyme that causes an organism to become resistant to extended-Spectrum cephalosporins, monobactams and extended-spectrum penicillins. Contact precautions indicated. Positive for MRSA. Contact precautions indicated. The NP was informed of the result on [DATE]. Resident #179 was placed on contact isolation. Keflex was discontinued and Macrobid 100 mg was ordered twice daily for 5 days. On [DATE] at 10:05 AM, the surveyor conducted an interview with the Medical Director (MD) in the presence of the team. The MD confirmed that the facility discussed with him the adverse outcome with the urinary catheter removal. He stated he was consulted by both the DON and the Assistant Director of Nursing regarding Resident #179's not receiving the Antibiotic ordered at the hospital since [DATE]. He gave a verbal order to obtain Urine Analysis, urine culture and sensitivity and ordered Keflex 500 milligrams every 12 hours for 10 days for UTI. The surveyor observed a signed verbal order in the clinical record dated [DATE]. The MD stated, apparently this nurse had heard that cutting the [indwelling urinary catheter] was the easiest way to take the [indwelling urinary catheter] out. She opted for the easiest way. I am not sure where the education came from. I just do not know how it happened; the nurse needed to be suspended. The MD further stated, he started in July and identified that staff education, lack of oversight from the physician, infection control, mishandling of patient's care, policies and standards procedure needed to be addressed. He added the facility needed a system to track significant issues. [DATE] at 3:02 PM, the surveyor conducted a telephone interview with the Registered Nurse (RN #2) who received Resident #179's After Visit Summary on [DATE]. The RN #2 confirmed that she was assigned to Resident #179 on the third shift (11:00 PM-07:00 AM ) She stated that she did not see the instructions for the Keflex order and did not inform the NP. RN #2 stated that she reviewed the After Visit Summary with the Supervisor of Nursing (SON ) and they both missed the instructions to administer Keflex. The Keflex order was not documented on the After Visit Summary dated [DATE], and Resident #179 received the Keflex 15 days later ([DATE] ). RN #2 stated, she was made aware of the mistake by the ADON, and DON. The RN stated, I do not know how I missed the order. I reviewed the After Visit Summary that day and did not see the order. The SON and the NP both reviewed the After Visit Summary and missed the order. Resident #179 did not receive the antibiotic for 15 days. Resident #179's UA and C&S result was positive for E.Coli, ESBL and MRSA on [DATE]. The facility was unable to provide a rationale for the nurses failing to thoroughly review the After Visit Summary and then failing to communicate the recommendations to the physician/NP. On [DATE] at 12:32 PM, during an additional interview with the NP in the presence of the survey team.

Reference F 600, F 658, F 880 and F 886 Based on observations, interviews, review of medical records and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure: a) that an alert and oriented resident (Resident #24) who was being verbally abused by an Agency Nurse was not prevented from leaving the unit to seek help by a Certified Nurses Aide (CNA) on [DATE], who was permitted to work for seven shifts without any additional abuse training or investigation to rule out possible abuse until surveyor inquiry b) that a resident's (Resident #179) Foley urinary catheter was removed in accordance with professional standards of practice which resulted in transfer to an acute care hospital on [DATE] and the resident returned to the facility on [DATE] with a portion of the severed catheter which remained in the bladder and the resident was consequently ordered a prophylactic antibiotic to prevent infection to be administered at the facility that the resident did not receive, prior to a required urological surgical procedure after awaiting cardiac clearance to extract the foreign body that remained in the bladder and later resulted in the resident receiving additional antibiotic treatment for ESBL (Extended-spectrum beta lactamases, a bacterium with antibiotic resistance) and MRSA (methicillin-resistant Staphylococcus aureus, a bacterium with antibiotic resistance) in the urine c) that immediate contact tracing was completed in response to to newly identified COVID-19 staff and residents in accordance with local health department guidance provided on [DATE] d) that immediate action was taken to prevent the spread of COVID-19 during an outbreak which began on [DATE] by failing to complete contact tracing and complete immediate follow-up resident and staff testing upon identification of COVID-19 positive staff and residents to prevent the continued spread of infection. This posed a serious and immediate threat to the safety and well-being of all residents who resided at the facility, were made subject and vulnerable to abuse, had foley urinary catheters, and were placed at risk for contracting COVID-19, which is a harmful and deadly virus. The failure of the LNHA to ensure the facility operated in a manner that ensured residents were cared for in a manner and an environment that enabled residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being posed a serious and immediate threat to the health, safety, and welfare of all residents who resided at the facility in compliance with federal, state and local requirements as outlined in the Administrator Job Description, resulted in an immediate jeopardy (IJ) that was identified on [DATE] at 4:16 PM, and was sent to the facility via e-mail at 4:18 PM. A Removal Plan was received on [DATE] at 9:37 AM, and the survey team verified the implementation of the Removal Plan on [DATE] at 9:26 AM. This deficient practice was evidenced by the following: A review of the facility's Job Specification 60293, Chief Executive Officer, Care Facility ([DATE]), revealed that the duties of the CEO/LNHA included but were not limited to: Oversees the development, implementation, and monitoring of clinical programs designed to meet the level of functioning and/or care needs of clients. Ensures the implementation of department policies and statutes applicable to the operation of the care facility. Oversees the development and management of a quality assurance system to comply with standards promulgated by accrediting and certifying agencies; .Federal Department of Health and Human Services and NJ Department of Health and Senior Services. Provides protection of clients' civil and legal rights . Findings included: Refer F600 On [DATE], the LNHA failed to ensure residents were free from abuse after a resident (Resident #24) was prevented from leaving an abusive situation by Certified Nursing Aide (CNA #1), who continued to work with other residents following no investigation. This deficient practice was identified for 1 of 5 residents reviewed for abuse (Resident #24). On [DATE] at 10:38 AM, the surveyor interviewed Resident #24, who stated on [DATE], they received Percocet and Xanax every six hours and asked an aide to find the nurse to administer the medications. An Agency Nurse (LPN #1) entered my room and informed me that they would administer my medications and take my vital signs and proceeded to leave the room and closed the door. The resident stated that they proceeded to use the call bell, and LPN #1 came back into the room to tell me to stop pushing the call bell; she pulled down her mask and attempted to bite my finger as I pointed at her. The resident continued that they got out of bed to get away from LPN #1. LPN #1 lunged her nurse's cart at me three times and hit their left foot, causing a wound to re-open. The resident stated that they were trying to get away from LPN #1 and get to the Registered Nurse Supervisor (RN Supervisor). The resident stated as they were attempting to leave the unit in the hallway, the nurse assaulted them by pulling the wheelchair (w/c) ,d+[DATE] times, which positioned the resident on only two back wheels, and the two front wheels were lifted off of the floor. The resident stated that there was a (CNA #1) there, but they could not recall the name of who tried to calm the crazy nurse down. A review of the Resident Facesheet (an admission summary) reflected that the resident was admitted to the facility in September of 2021 but did not include admitting diagnoses. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated [DATE], reflected a brief interview of mental status (BIMS) score of 15 out of 15, which indicated the resident was fully cognitively intact. It further reflected the resident had verbal and behavioral symptoms directed toward others that occurred four to six days in the last seven days of assessment. Section I Active Diagnoses included the resident having hypertension (high blood pressure), anxiety, depression, psychotic disorder, and PTSD. It further included a seven-day look back period. The resident received daily antianxiety, antidepressant, and opioid medications. A review of the individualized comprehensive Care Plan (CP) included a problem area initiated on [DATE], for at risk for altercation in mood/behavior; history of major depressive disorder, anxiety, use of Seroquel (antipsychotic medication) for agitation, use of Xanax for anxiety, and Remeron for anxiety/depression/mood with interventions that included to observe for efficiency of medications; monitor for target behaviors or behaviors not easily redirected; refer to nurse if noted behaviors worsening, unable to redirect; keep the room well lit, open blinds for sunlight; and give medications Remeron, Xanax, Seroquel as ordered. A further review of the CP included a diagnosis of PTSD, however, did not include a problem area or interventions pertaining to the resident's diagnosis of PTSD. On [DATE] at 10:00 AM, the surveyor reviewed the facility provided investigation report for Resident #24's incident which occurred on [DATE]. A review of the staff statements included a statement provided by CNA #2, which detailed that they were taking care of a resident when they heard a noise in the hallway and came out into the hallway and saw Resident #24 trying to leave the floor. She stated that, I stopped them from leaving the floor. CNA #2 stated that both she and another CNA called the charge nurse, but I did not know what was going on. CNA #2's statement appeared to be what the surveyor witnessed CNA #1 do in the surveillance video. No statement from CNA #1 in the investigation report was provided. On [DATE] at 10:31 AM, the surveyor reviewed the surveillance video with the Assistant Licensed Nursing Home Administrator (ALNHA) #1, Employee Relations/Legal Specialist, another surveyor, and the Employee Relations/Legal Specialist confirmed CNA #1 was the aide who was blocking the door. CNA #2 was the aide observed later walking up the hallway towards LPN #1, CNA #1, and the resident during the altercation. At this time, the surveyor reviewed the investigation packet with ALNHA #1, who confirmed there should have been a statement from CNA #1 included in the investigation report. On [DATE] at 10:59 AM, the DON provided the surveyor with CNA #1's statement dated [DATE], which was the exact same statement provided by CNA #2. At this time, the surveyor asked the DON to read both CNA #1 and CNA #2's statements, and she confirmed that both statements were the same but was signed by the corresponding CNA. At this time, the surveyor requested to watch the video footage again with the DON. On [DATE] at 11:10 AM, the surveyor with the DON, Employee Relations/Legal Specialist, and another surveyor viewed the video footage. When comparing the surveillance footage with the statements, the surveyor asked the DON if the statements clearly reflected what had happened. The DON reported that she completed a three-page reportable to the New Jersey Department of Health (NJDOH) and told RN #1 to watch the video to see if anything should be added to her statement. Then the DON reported she had left for vacation. The DON stated that the ADON had watched the video with RN #1, who did not want to change her statement. The DON stated the purpose of an investigation was to determine a root cause analysis and confirmed these statements were not clear. The DON stated when she returned from vacation, the investigation was completed by the ADON, and she did not review it even though she was responsible for oversight of all aspects of nursing. The DON confirmed the resident had the right to leave the unit, and no staff, including the two CNAs, should have stopped the resident from leaving the unit. The surveyor reviewed the video with the DON. The DON acknowledged CNA #1 was standing in front of the exit door blocking Resident #24 from exiting the unit, which was an issue because this was considered a restraint. The DON stated that even if the resident was confused, which Resident #24 was not, staff could not stop the resident from leaving. The DON stated staff had to ensure the resident's safety and could follow the resident from a distance, but staff could not prevent the resident from leaving the unit. The DON stated the ADON was on vacation but confirmed the investigation was incomplete. She had to re-open the investigation to clarify the statements and determine why CNA #1 stood in front of the door. On [DATE] at 01:14 PM, the surveyor re-interviewed Resident #24, who stated CNA #1 was stopping LPN #1 from verbally abusing them, but confirmed CNA #1 was preventing them from leaving the unit and told them they were not allowed to leave the unit. The resident stated CNA #1 could have done more since she was not letting them leave, and they did not know why. On [DATE] at 10:30 AM, the surveyor reviewed the nursing schedules since [DATE], which revealed CNA #1 worked seven shifts at the facility after the incident. On [DATE] at 09:51 AM, the surveyor interviewed Resident #24, who stated they were imprisoned for twenty months and preferred the door to their room remain open because the closed door triggered their PTSD, causing anxiety. The resident stated on [DATE]; they were waiting for LPN #1 to administer their routine Percocet and Xanax medication so they could go back to sleep. LPN #1 closed their room door and started yelling at them, and the resident reported they just wanted to escape LPN #1, who grabbed their wheelchair and almost tipped the chair over. Resident #24 stated that they remembered the aide (CNA #1) saying their name and that they knew her and they could not leave, but Resident #24 stated they could not determine who the aide was at the time. Resident #24 stated they just wanted the RN Supervisor, which made them feel angry because they were being prevented from escaping from LPN #1, and CNA #1 was not helping the situation. CNA #1 could have opened the door to let me leave, but she would not let me leave, which made me mad. The resident stated they had never been prevented from leaving the unit before, so they could not understand why that was happening. The facility's failure to ensure all residents were free from abuse, including verbal, physical, restraints, and involuntary seclusion by not investigating the actions of CNA #1 after a written statement acknowledged she stopped the resident from leaving the unit as well as video footage confirming she blocked the exit door preventing the resident from leaving the unit posed a serious and immediate threat for abuse which can cause serious physical and emotional harm or impairment. This resulted in an Immediate Jeopardy situation. The IJ was identified on [DATE], and the LNHA, ALNHA #1, ALNHA #2, DON, and Director of Veterans Health Care Services were notified of the IJ at 02:55 PM. A written Removal Plan was accepted and verified onsite on [DATE], which included staff members will be immediately relieved from their duties; to ensure the safety of the residents, a comprehensive investigation will commence at the time of the event to ensure a thorough and complete review of all contributing factors have been conducted; all staff in-serviced on the Abuse and Neglect Policy. Refer to F658 Based on interviews, record review, and review of other facility documentation, it was determined that the facility failed to ensure nursing staff appropriately removed an indwelling urinary catheter (soft plastic or rubber tube that is inserted into the bladder to drain urine) in accordance with professional standards of nursing practice which necessitated a transfer to the hospital for treatment, and a urinary tract infection. This deficient practice was identified for 1 of 3 Residents reviewed for indwelling urinary catheter care (Resident #179) and 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. The facility's failure to have a system in place to ensure that nursing staff appropriately removed an indwelling catheter posed a serious and immediate threat to the health and welfare of all residents who required catheter care. An adverse outcome was likely to occur as the identified non-compliance resulted in an immediate Jeopardy (IJ) situation that began on [DATE] at 2:50 PM when the Registered Nurse (RN) improperly removed the indwelling catheter. The RN used scissors to cut through Resident #179's indwelling catheter, which then caused the remaining catheter to retract into the bladder. The Immediate Jeopardy (IJ) situation was identified during an onsite survey conducted on [DATE], and the facility was notified of the IJ, on the same day, at 3:20 PM. The facility submitted an acceptable removal plan on [DATE] at 2:55 PM. The team verified the removal plan during an onsite visit conducted on [DATE]. Findings included: On [DATE] at 10:30 AM, the surveyor toured the 200 Unit of the facility and observed that Resident #179's door was closed. On the door, the surveyor observed signage posted which identified the required PPE (Personal Protective Equipment) to enter the room. The surveyor observed staff donning (putting on) and doffing (removing) with the required PPE before entering and exiting the room. An interview with the Registered Nurse/Unit Manager (RN/UM) revealed that Resident #179 was in isolation for Extended Spectrum Beta Lactamase (ESBL, antibiotic-resistant bacteria) and Methicillin Resistant Staphylococcus Aureus (MRSA, antibiotic-resistant bacteria) in the urine. On [DATE] at 11:29 AM, the surveyor donned the appropriate PPE, knocked at the door, waited for Resident #179 to answer, and entered the room. The surveyor observed Resident #179 in bed, awake with eyes open, and the surveyor observed a splint to the left arm. The surveyor explained the purpose of the visit, and Resident #179 agreed to be interviewed. Resident #179 was alert and stated that he could not move their left arm. Resident #179 answered all questions appropriately. The surveyor observed an indwelling urinary catheter covered with a catheter drainage bag hung on the bed frame. On [DATE] at 09:30 AM, the surveyor returned to the 200 Unit, the door was open, and Resident #179 was not inside the room. Upon inquiry, the RN/UM informed the surveyor that Resident #179 had tested + for COVID-19 in the evening during routine testing and was transferred to the 700 Unit. On [DATE] at 08:30 AM, the surveyor observed Resident #179 in the 700 Unit. The door was closed. Signage with the required PPE was posted on the door. The surveyor reviewed the medical record for Resident #179 on [DATE]. According to the Admission Face Sheet (an admission summary), Resident #179 was readmitted to the facility on [DATE] following hospitalization for urinary retention. Resident #179 had diagnoses that included but were not limited to, hypertension, diabetes mellitus, depression, hyperlipidemia, and End Stage Renal Disease. A review of Resident #179's Plan of Care, updated on [DATE] and [DATE], revealed that Resident #179 had decreased range of motion (ROM) and muscle strength related to co-existing chronic medical conditions. Resident #179 also was at risk for infection due to urinary retention. The care plan goal was for Resident #179 to not have a urinary tract infection and to receive the care needed to maintain their current functional status. The Annual Minimum Data Set Assessment (MDS), an assessment tool used by the facility to prioritize care, dated [DATE], revealed that Resident #179 scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS), which indicated intact cognition. Section H of the MDS, which addressed Bladder and Bowel, Resident #179 received a score of 9 for H 0300. The score was indicative of the presence of an indwelling catheter in the bladder. The Interdisciplinary Progress Notes (IDPN) revealed that on [DATE] at 3:00 PM, a Registered Nurse documented in the IDPN, Per assigned desk nurse statement, in the process of removing the resident catheter. She cut it and put a towel under it to prevent the urine from draining into the resident's pants. Before she could pull the catheter out, part of the catheter retracted. It was reported to the writer. Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware. NP (Nurse Practitioner) made aware and gave the order to transfer Resident #179 to the Emergency Department (ED) for retracted [indwelling urinary] catheter . Resident #179 was picked up at 2:55 PM by 911 crew. A late IDPN entry dated [DATE], timed 3:30 PM, read, Dc' d [indwelling urinary] catheter retracted in the process of removing it. Resident transferred to ED. On [DATE] at 11:52 AM, the surveyor interviewed the RN/UM regarding the IDPN dated [DATE]. The RN/UM stated that the Registered Nurse (RN #1), who oversaw the unit on [DATE], cut the indwelling urinary catheter in the process of removing the indwelling urinary catheter. She stated that there was an order to remove the indwelling urinary catheter on [DATE]. RN #1 proceeded to execute the order to remove the urinary catheter. The RN/UM stated that RN #1 reportedly had never removed a urinary catheter before. She cut the urinary catheter with a pair of scissors instead of using a syringe to remove the water to deflate the balloon. The remaining urinary catheter then retracted into the bladder. Resident #179 was transferred to the ED for evaluation and treatment on the same day. The hospital discharge summary was requested and was not available for review by the surveyor. The RN/UM stated she would inform the DON of the request for the hospital discharge summary. On [DATE] at 12:30 PM, the surveyor interviewed the Director of Nursing (DON). The DON confirmed that she was aware of the above incident and informed the surveyor that RN #1 was suspended pending disciplinary action. The surveyor requested the investigation and the employee file for review. The surveyor also requested RN #1's telephone contact to conduct an interview. On [DATE] at 9:23 AM, the surveyor interviewed a random Registered Nurse (RN) assigned to the 200 unit regarding nursing resource materials available to the staff. The RN directed the surveyor to the binder outside the nursing station that contained all the policies and procedures. The surveyor located in the binder policy # 4:035 B titled, Indwelling Catheter Replacement, dated [DATE], which outlined the following: Indwelling Catheter replacement must have a physician order indicating size and schedule. Indwelling catheter replacement must be done by a registered nurse whose clinical skill has been checked by the instructor of nursing. If the physician and/or registered nurse, who has demonstrated clinical competence for this procedure, is not available, send the resident to the emergency room for an indwelling Catheter. The policy did not include a procedure to remove an indwelling urinary catheter. On [DATE] at 11:00 AM, the surveyor conducted a telephone interview with RN#1, who confirmed she was the nurse who received the order to remove the indwelling urinary catheter on [DATE]. RN #1 stated that she was overwhelmed that day and did not want to leave the procedure for the next shift. RN #1 stated she went to Resident #179's room with the Certified Nurse Aide (CNA), and she then used a pair of scissors from the treatment cart, cut the indwelling urinary catheter, and urine was splashing all over. She stated she then looked for the indwelling urinary catheter but could not locate it on the bed. RN #1 stated she realized that the indwelling urinary catheter retracted into the bladder. She stated she applied a towel to protect the resident's clothing, informed the RN/UM what had happened, and went to the desk and called and reported the incident to the Nurse Practitioner (NP). The NP then gave an order to transfer Resident #179 to Emergency Department for evaluation and treatment, and she reported the incident to the DON and initiated the 911 call for transfer. She stated that the DON informed her to leave the floor once she completed her statement. RN #1 stated that she had not received any in-service education on how to remove an indwelling urinary catheter at the facility. She stated she was aware that besides deflating the balloon, another simple way was to cut the indwelling urinary catheter. She stated, I made a mistake. RN #1 stated that she met with the DON in the office and explained what had happened. The DON informed her that she was suspended. The surveyor then asked RN #1 to elaborate on her work history before being employed by the facility. RN #1 stated that she worked as a floor nurse for a long-term care facility and a psychiatric hospital before working at the current facility. She stated she had been a Registered Nurse for [AGE] years. RN #1 stated after being hired by the facility, during orientation, she was able to demonstrate and was evaluated on the skill sets of inserting an indwelling urinary catheter. However, she was not evaluated for indwelling urinary catheter removal. A review of RN #1's orientation file provided by the Nurse Educator (NE) confirmed that she received in-service education on inserting a urinary drainage catheter on [DATE] during orientation. The surveyor requested RN #1's employee file from the DON. RN #1's employee file contained three written warnings, one for a medication error, the second for not donning the proper PPE during an outbreak, and the most recent was for an allegation of verbal abuse toward a family member. RN #1 also stated that she was informed during her hearing with the Employee Relation Officer ([NAME]) that she did not document all the required information on the hospital transfer form prior to sending Resident #179 to the ED. On [DATE] at 10:15 AM, the surveyor reviewed the Facility assessment dated [DATE]. According to the documentation provided, the Facility Assessment had to identify and analyze the facility's resident population, which must be considered when determining staffing and resources needed to care for the residents. Understaffing training, it is revealed, Licensed nursing staff receive training and demonstrate competencies in areas of responsibility related to providing skilled nursing care to residents of the facility. Nurses receive updated and additional training as necessary to meet the changing needs of our residents. Training and competencies include, but are not limited to: Licensed nurse training and/ or competencies. Oxygen set up Oxygen masks . Nasal cannula / Non-Rebreather /Simple face mask Wound care / Dressing Change Suctioning skill/ Trach care Glucometer Medication Pass Indwelling catheter replacement CPR The facility's Indwelling Catheter Replacement policy did not cover Foley Catheter Removal. On [DATE] at 10:37 AM, the surveyor interviewed with the NP responsible for Resident #179's care. The NP stated that she wrote an order to remove the indwelling urinary catheter and initiate a voiding trial. She received a call from the nurse, who stated that something had happened. The nurse stated she cut the indwelling urinary catheter to remove it, and the catheter retracted. The NP stated, I came on the unit, examined the resident, and the resident was not in pain. I gave an order to transfer Resident #179 to the ED for evaluation and treatment. The NP stated, I had never heard of such a procedure. The NP further stated that she was not informed of any follow-up or recommendations from the ED. The NP stated that she reviewed the After Visit Summary the next day and could not identify what treatment was provided. She said she called the hospital and spoke to the staff, but the hospital staff could not comment on what treatment was provided. The NP stated she asked for the Urology report and was informed that the Urologist was not called in to see Resident #179. The NP then explained to the ED, what had happened, and that the issue needed to be addressed immediately. The NP stated the Urologist was then made aware that Resident #179 had the retracted catheter in the bladder. On [DATE] at 12:03 PM, the surveyor interviewed the NE in charge of orientation and staff competencies. The surveyor inquired about specific competencies and skill sets necessary to care for resident needs. The NE provided the surveyor with the orientation package. A review of the orientation package confirmed that indwelling urinary catheter removal was not included in the competencies. RN #1 did not receive in-service training for indwelling urinary catheter removal. The NE stated that Licensed Staff had to go to general orientation classes for two days and then work with a mentor on the floor for 14 days (for full-time) employees. Mandatory training was scheduled yearly, and skill sets for competencies were completed every two years. Based on the orientation package provided, the facility staff did not receive competency training for indwelling urinary catheter removal. The NE stated that he was aware of the adverse outcome with the Foley catheter on the [DATE] incident. He was informed that Resident #179 was transferred to ED for treatment because the indwelling urinary catheter was improperly removed. The surveyor requested in-service education training provided after the incident, but none had been provided. When asked how nursing staff competency education was being tracked, the NE added that the DON would inform him of any needed in-service training. The Orientation package provided by the facility was reviewed with the NE on [DATE] and did not include Foley Catheter Removal. The current policy revealed how to insert an indwelling urinary catheter only. The facility was unable to provide the rationale for nursing staff not being trained or assessed for competency on how to remove an indwelling urinary catheter. On [DATE] at 4:40 PM, the surveyor conducted a second interview with RN #1. She stated that she had performed the skill to remove an indwelling urinary catheter before deflating the balloon. She stated that cutting the indwelling urinary catheter was a simple procedure that she had not used prior. She stated that she overheard nurses saying that you could cut the indwelling urinary catheter to remove it, and that was why she cut the indwelling urinary catheter. She stated that after the incident, she went to the internet, watched a video, and realized that she did not follow the proper technique. RN #1 stated that she cut the catheter 4 to 5 inches below the insertion site, not by the port, to evacuate the water. The surveyor then asked RN #1 to elaborate on the indwelling urinary catheter removal procedure. She stated: 1. Verify the order, identify the patient, explain the procedure, provide privacy, use a syringe to deflate the balloon by aspirating the water, and gently pull the indwelling urinary catheter. She stated she was very concerned regarding the resident's well-being. She kept calling every day to inquire regarding Resident #179's status. RN #1 elaborated on the process of properly removing an indwelling urinary catheter. She could not provide the rationale for cutting the indwelling urinary catheter, which caused Resident #179 to be transferred to the ED for treatment. On [DATE] at 09:30 AM, The DON provided the Investigation Report for review. The surveyor reviewed the final report, which revealed the following: Physical Evidence On [DATE], the charge nurse reported that in the process of removing Resident #179's indwelling urinary catheter, she cut the catheter and part of it retracted into the bladder. Resident #179 was immediately discharged to the hospital for intervention. CT urogram (used to examine the kidneys and bladder) without contrast was performed in the hospital with the impression there is significant bladder wall thickening with peri cystic inflammation suggesting cystitis (inflammation of the urinary bladder), no hydronephrosis or renal calculi identified, a note is made of small bilateral pleural effusion (abnormal fluid collection between thin layers of tissue lining the lung and the wall of the chest cavity), and urinary bladder is partially collapsed around Foley catheter. No further intervention was taken at the hospital. Recommendations: [DATE] Urology consult by ___, with recommendation for bladder ultrasound. [DATE] Bladder ultrasound taken on with conclusion of bladder not visualized, to consider ST scan not ordered. On [DATE] resident was seen by the Cardiology group and cleared for cystoscopy. On [DATE], a cystoscopy was performed for removal, and a new Foley catheter was placed. The resident was referred for a follow-up with a Urologist. Resident's care plan revision: Bladders scan every shift Monitor for signs and symptoms of infection<[TRUNCATED]

Part A Based on interview and review of pertinent documents, it was determined that the facility, who has been in an active COVID-19 outbreak status since 11/23/21, failed to conduct immediate and thorough contact tracing to further prevent the spread of COVID-19 (a deadly virus) by failing to ensure: a.) a process was in place to conduct comprehensive contact tracing upon the identification of a single new case of COVID-19 in a staff or resident. b.) a facility contact tracing policy was completed and implemented, c.) appropriate staff were trained on the contact tracing policy, d.) the facility followed all Centers for Disease Control (CDC), local health department, state health department, and all current guidance related to infection control. The deficient practice was identified during a review of eight sampled COVID-19 positive residents (Residents #444, #446, #3, #445, #447, #46, #76, and #179), dates ranging from 12/28/21 through 08/16/22 and a review of six sampled COVID-19 positive staff members dates ranging from 08/1/22 through 08/16/22 and was identified by the following: The facility's system wide failure to conduct and retain complete COVID-19 close contact tracing upon the identification of a single new case of COVID-19 posed a serious and immediate risk to the health and well-being of all staff and residents who resided at the facility and who were placed at risk for contracting a contagious infectious and potentially deadly virus. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 09/06/22 at 4:16 PM. The survey team verified the removal plan during an on-site visit conducted on 09/08/22 at 12:47 PM. Reference: Contact Tracing for COVID-19 CDC https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/contact-tracing.html Reference F 886L On 08/16/22 at 10:24 AM, during the entrance conference, the Administrative team informed the survey team that the facility was currently experiencing an outbreak of COVID-19, which began on 11/23/21. The survey team was provided with the facility's ongoing line listing (a document that is transmitted to the department of health and lists all COVID-19 cases during an outbreak) and a blank copy of the Contact Tracing Form undated that the team was told was currently being used for tracking close exposures. The surveyor asked to review the facility Contact Tracing. The facility provided and the surveyor reviewed the Resident & Staff COVID-19 Incident Reports updated 4/21, which included but were not limited to please be as detailed as possible and type all responses 9. Explain contact tracing that has been completed in detail. The surveyor reviewed the facility and provided Incident Reports for the following COVID-19 positive residents: #444 who was fully vaccinated and resided in the Old [NAME] unit, presented symptomatic with a cough and sneezing and tested positive on 12/28/21. The contact tracing section failed to list any staff or residents who may have been a close contact (persons who may have been exposed to an infectious contagious disease and may require quarantine measures to help prevent further spread of the disease). #446, who was fully vaccinated and resided in the Eagle unit, presented symptomatic with a cough and tested positive on 01/4/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #445, who was fully vaccinated and resided in the Freedom unit, presented symptomatic with fever and shortness of breath and tested positive on 01/30/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #447, who was fully vaccinated and resided in the Freedom unit, presented symptomatic with a fever and shortness of breath and tested COVID-19 positive on 02/03/22. The form identified Resident #447 as leaving the facility three times per week to attend hemodialysis treatment (treatment to remove impurities from the blood). The contact tracing section failed to list any facility staff, hemodialysis staff, transport staff, visitors, or residents who may have been identified as a close contact. #3, who was fully vaccinated and resided in the Freedom unit, presented asymptomatic (having no symptoms) and tested COVID-19 positive on 08/03/22. The contact tracing section failed to list any staff or residents who may have been identified as a close contact. #46, who was fully vaccinated and resided in the Freedom unit, presented symptomatic with a cough and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #76, fully vaccinated and resided in the Freedom unit, was asymptomatic and tested positive on 08/11/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #179, who was fully vaccinated and resided in the Freedom unit, was asymptomatic and tested positive on 08/16/22. The contact tracing section failed to list any staff or residents who may have been a close contact. A review of the facility provided COVID-19 Resident & Staff Incident Reports for the positive staff members revealed the following: Licensed Practical Nurse (LPN) #2 was asymptomatic and tested positive on 08/1/22. The contact tracing section failed to list any staff or residents who may have been a close contact. Noted LTC facility 07/30/22, 7 (am) - 3 (pm). passed medication, did not have close contact with any staff residents. An Administrative staff member presented symptomatic with nasal congestion and an itchy throat and tested positive on 08/6/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN #1 presented symptomatic with a runny nose and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN was noted to have worked on 08/06/22. On 08/29/22 at 8:39 AM, during an interview with the surveyor, in the presence of the survey team, the facility Infection Preventionist Registered Nurse (IP RN) was asked to provide contact tracing for the residents and staff members who had tested COVID-19 positive. The IP/RN stated that when someone was exposed to COVID-19, she was responsible for completing the contact tracing to identify any close contacts. However, she stated she would not list or include any staff or residents in her contact tracing. She then stated she could not provide any additional documentation related to any staff or residents who may have been exposed to COVID-19 because she kept that information in a personal notebook. The IP/RN stated that she was alone, no secretary, no help, and that she did not document any potential exposers to COVID-19 that may have occurred to others. The surveyor then requested a list of the exposed close contacts. The IP/RN stated she would not be able to provide a list. The IP/RN also stated that there was no facility policy or procedure on contact tracing, and she was unaware that she was responsible for completing and retaining any contact tracing documents. On 08/29/22 at 9:32 AM, during an interview with the surveyor, a Licensed Practical Nurse Unit Manager (LPN/UM) in the Liberty Unit stated that if a resident tested COVID-19 positive, the IP/RN would isolate the resident and do the investigation. She further stated that if a staff member tested COVID-19 positive, they would be sent home, and the IP/RN would do all the paperwork. On 08/29/22 at 9:40 AM, during an interview with the surveyor, the RN Employee Health Nurse stated that she was responsible for the routine COVID-19 testing for the staff and residents and when a resident would return to the facility. She stated that the IP/RN would complete all contact tracing and that she would not be provided any of the contact tracing information. The RN Employee Health Nurse further stated that contact tracing was important to warn others who were exposed to COVID-19 so that they would be tested . On 08/29/22 at 11:27 AM, the IP/RN provided six incomplete facility Contact Tracing Forms for the requested COVID-19 positive staff. The IP/RN again stated to the surveyor that there was no policy for contact tracing, so she would use the Center for Disease Control and Prevention (CDC) guidance. On 08/30/22 at 10:58 AM, during an interview with the surveyor, the IP/RN stated that the facility had enough testing supplies to perform facility-wide COVID-19 testing. When asked again about documented COVID-19 positive close contacts and the actions taken, the IP/RN stated she would talk to the staff but not write things down. She again stated that she would keep the information in a personal notebook and would throw out that information when the case was resolved. The IP/RN stated she was unaware of any formal documentation or form to use, so she would not be able to inform the surveyor of the exposed staff or residents or their COVID-19 testing in response. The IP/RN stated that contact tracing would be used to prevent the spread of infection in the facility. On 08/31/22 at 9:37 AM, the IP/RN provided incomplete contact tracing for the requested COVID-19 positive residents. The contact tracing forms revealed the following missing or incomplete information for the residents: # 444: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection, no breaks/meals rooms & areas, no actions taken listed for follow up testing, and there was nothing documented under reviewed by facility infection control nurse. The only potential contacts listed were one Certified Nursing Assistant (CNA) on each shift for the day of the COVID-19 positive test and previous 48 hour lookback. # 446: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection. The only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and the previous 48 hour look back. No actions were taken for follow-up testing, and the facility infection control nurse noted nothing under review. # 3: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection, no known exposures to residents, the only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no actions taken listed for follow up testing, and nothing noted under reviewed by facility infection control nurse. # 445: no name of interviewer, contact tracing does not include the date 01/30/22 which the resident tested positive or 01/29/22, which was 24 hours prior, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection, the only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no breaks/meals rooms & areas, no action taken by the facility for follow up testing, and nothing noted under reviewed by facility infection control nurse. # 447: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no breaks/meals rooms & areas, the only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no actions taken by the facility for follow up testing, and nothing noted under reviewed by facility infection control nurse. # 46: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection. The only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no action taken by the facility for follow up testing, and nothing noted under review by facility infection control nurse. # 76: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection. The only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no known exposures to residents, no breaks/meals rooms & areas, and no action taken by the facility for follow up testing, and nothing noted under reviewed by facility infection control nurse. # 179: no name of interviewer, no date of interview, no demographic and locating information, no history of prior positive COVID-19 tests, no date of COVID-19 specimen collection. The only potential contacts listed were one CNA on each shift for the day of the COVID-19 positive test and previous 48 hour lookback, no breaks/meals rooms & areas, no action taken by the facility for follow up testing, and nothing noted under reviewed by facility infection control nurse. A review of the contact tracing forms for the COVID-19 positive staff revealed the following missing or incomplete information: LPN #2: No known exposures to residents were listed, and it was noted on the form that the LPN worked normally during the 3:00 PM - 11:00 PM shift, and no actions had been taken by the facility. The contact tracing form noted, LTC facility 7/30/22, 7 (am) to 3 (pm) passed medication and did not have close contact with any staff or residents. LPN #3: the form was not completed until 08/31/22 after the surveyor inquiry. The surveyor inquired where the IP RN retrieved the information since she had indicated she had discarded all of her documents related to contact tracing. The IP/ RN stated to the surveyor that she had completed from memory. Administrative staff: The form was not completed until 08/31/22 after the surveyor inquiry. The IP RN stated she had completed the document from memory. LPN #1: There was a known exposure and had listed the initials of one resident, the area was left blank, and there was no documentation of the identified resident who was exposed to COVID-19 as having a follow up COVID-19 test. A section under review by the facility infection control nurse was blank. Food Service Worker #2: form not completed until 08/31/22 after surveyor request. IP RN stated she had completed it from memory. Food Service Worker #1: form not completed until 08/31/22 after surveyor request. IP RN stated she had completed from memory. Nothing was noted under reviewed by the facility infection control nurse. On 08/31/22 at 11:21 AM, during an interview with the surveyor, in the presence of the survey team, the IP/RN stated the contact tracing forms she had provided were all filled out yesterday (08/30/22) based on memory. When asked about additional staff who may have had close contact, such as the nurses caring for the residents who tested COVID-19 positive, the IP/RN stated the nurses were not with the residents long enough. The IP/RN stated that exposure would be traced back 48 hours prior for someone who had been within six feet for 15 minutes or more. She further stated, I know from memory that none of the nurses were. Although, she was unable to provide any documented evidence of interviews, reviews of assignment sheets, or any process related to contact tracing to determine a possible COVID-19 exposure. The IP/RN stated that the facility implemented routine broad based COVID-19 testing. She stated the facility tested the staff thrice a week in December 2021 and the residents once or twice a week. The IP/RN stated she was not sure why that stopped. The IP/RN stated that the close contacts were not all tested when exposed. On 08/31/22 at 1:12 PM, during an interview with the surveyor, in the presence of the survey team, the facility Licensed Nursing Home Administrator (LNHA) stated the facility was familiar with the process for contact tracing. At 1:14 PM, the IP/RN joined the interview and told the surveyor that it was the facility process for her to keep her notes. The IP/RN further stated that she remembered from December 2021 onward that none of the nurses who cared for the COVID-19 positive residents spent over 15 minutes with the residents and that no treatments were done either. The LNHA stated that what the IP/RN stated was incorrect, and the facility required formal tracking (contact tracing). The LNHA further stated that the IP/RN should have conducted the contact tracing at the time of the exposure and not from her memory. The LNHA stated that the IP/RN's statement that the nurses did not spend more than 15 minutes was not fully accurate. On 09/01/22 at 9:22 AM, during an interview with surveyors in the conference room, the IP RN stated that she consulted with the local health department (LHD) mostly about deaths, not contact tracing. The IP RN stated, the nurses (facility) I spoke to were in and out (of the resident rooms); I should have kept my contact tracing and personal notes, and the IP/RN stated, we didn't have a policy for contact tracing. The IP/RN confirmed to the surveyor that there was no facility contact tracing policy and stated, unfortunately, no. The surveyor inquired to the IP/RN if she was able to confirm if the nurses who tested COVID-19 positive did not spend 15 minutes or more with residents, and the IP/RN stated she cannot say 100% if the nurses did not stay 15 minutes or more. The IP/RN again stated that contact tracing was important to not spread the virus in the facility. The surveyor requested communication information from the LHD. A review of the communication with the LHD provided by the IP/RN on 09/02/22 at 9:30 AM, revealed emails sent to the LHD as follows: 01/04/22, the IP/RN asked for a meeting, and the LHD asked for her concerns; 01/25/22 the IP RN asking for clarification if she needed to test the roommate of a COVID-19 positive resident and would she need to test again in 48 hours; 04/22/22 the IP/RN asking about quarantining residents not up to date with COVID-19 vaccinations in response to COVID-19 positive residents on the same unit; and 07/18/22 regarding staff going on vacation and coming back COVID-19 positive if they would need to be reported. The IP/RN could not provide any communication to her from the LHD regarding guidance on contact tracing. On 09/02/22 at 9:47 AM, the IP/RN stated that if someone tested COVID-19 positive on a Saturday, she was told she could wait until Monday but could not state who gave her that directive. She stated, the nurses on the weekend would verbally tell her, but there was no documentation regarding the conversation. The IP/ RN acknowledged that close contacts should have included visitors, and physicians, therapy staff but that she did not have documentation that they were ever included on the contact tracing forms. On 09/02/22 at 11:34 AM, during a telephone interview with the survey team, the Medical Director (MD) stated he started at the facility in July 2022. He stated that he had not had any discussions about contact tracing yet, but he was aware of the facility statistics. The MD further stated that he had finished reviewing the Infection Control manual, which was not complete regarding close contacts, and that it would be on the agenda to discuss with the IP RN during their next meeting. On 09/02/22 at 12:04 PM, during an interview with two surveyors, the Assistant Nursing Home Administrator (ANHA) stated she was responsible for the oversight of the IP/RN. She stated her responsibilities were to ensure that the IP/RN completed her job functions and was supported. The ANHA stated a form should be used regarding contact tracing and that the IP/RN had no choice but to follow the facility directives and complete the form. The ANHA stated that the contact tracing form should be done that day (the day of the exposure). The ANHA further stated that if it was not documented, how do we know. She stated that the contact tracing forms were completed to prevent the spread of infection and that exposed close contact should not have been working until they have been tested for COVID-19. On 09/06/22 at 11:31 AM, the surveyor attempted to reach either of the two representatives from the LHD that the IP/RN stated she was in contact with. Two phone messages and email communication was sent. There was no response from either LHD Representative assigned to the facility. On 09/06/22 at 12:03 PM, during a follow-up interview with the survey team, the IP/ RN was asked again if she had received any guidance from the LHD, given the facility had been active COVID-19 outbreak since 11/23/21. The IP/RN stated that she would have to check her emails but believed the LHD may have sent her links to reference. At 12:13 PM, the IP/RN presented the surveyor with additional guidance from the LHD dated 01/19/22, which had not been provided previously. The IP/RN and the surveyor reviewed a guidance in part which included but was not limited to: if the facility can perform contact tracing and can identify close contacts, testing should be done as follows: staff .with exposure with COVID-19 positive individual, residents .who had close contact with a COVID-19 positive individual. If the facility is unable to perform contact tracing and is unable to identify close contacts, testing should be done as follows: staff .test all staff facility wide or at a group level if staff are assigned to a specific location where the new case occurred. Residents .test all residents facility wide or at a group level if staff are assigned to a specific location where the new case occurred. The IP/RN again stated she had stopped doing things this way because the facility was short staffed, so if someone tested positive over the weekend, they (facility staff) were short staffed, so nobody was immediately tested . The IP/RN stated we were told to just do routine testing by the administration. The IP/RN stated when she found out that was incorrect, she followed what the administration had told her to do but could not provide a name or a directive. On 09/06/22 at 12:28 PM, during an interview with two surveyors, the LHNA stated they were never made aware that the IP/RN had stopped following the LHD guidance. The LHNA further stated that the guidance should have always been followed. At 1:04 PM, the LHNA further stated that upon questioning other administrative staff, there was no administrative staff who instructed the IP/RN to stop following the LHD guidance. On 09/07/22 at 10:54 AM, during an interview with the survey team, the MD stated that contact tracing should include all who were exposed, such as food service workers, nurses, residents, visitors, and everyone. A review of the facility provided, Outbreak Response Plan revised 2/22, included but was not limited to the following: Purpose - to protect our residents, families, and staff from harm resulting from an outbreak of an infectious disease organism; the IP would be responsible for conducting routine audits of Infection Control in the facility, establish and implement policies and procedures for screening for exposure, will collaborate with facility medical director, public health authorities, regarding interventions to implement responses; Contact Tracing Form - to include name of interview/contact tracer, date of interview, name of resident, history prior positive COVID, date of a + (positive) COVID, date of symptoms/asymptomatic subtract 2 days prior to test result date or symptoms listed (this is the contact tracing date), known exposures, staff in close contact, activities/locations/shift times visited, breaks/meals contacts, outside employment, actions taken by the facility, and reviewed by the Infection Control nurse. The facility's Outbreak Response Plan had not been followed. A review of the facility provided, Facility Assessment, dated 02/17/22, included but was not limited to Interventions for Controlling Infectious/Communicable Diseases for all Individuals with Residents and Facility Contact - daily surveillance by Infection Control to monitor for any new infections or spread of infections; during the COVID-19 pandemic, the home (facility) identified the need to improve upon the Infectious Disease Outbreak Response Plan. A review of the facility provided CDC guidance the IP RN stated she was referencing, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 (COVID-19) Spread in Nursing Homes updated 02/02/22, included but was not limited to: older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens such as SARS-CoV-2; a strong infection prevention and control program (IPC) is critical to protect residents and healthcare personnel (HCP); even as nursing homes resume normal practices, they must remain vigilant for SARS-CoV-2 infection in order to prevent spread and protect residents and HCP; New Infection in HCP or Residents - because of the risk of unrecognized infection among residents, a single new case of SARS-CoV-2 in any HCP or resident should be evaluated as a potential outbreak; perform contact tracing to identify any HCP who have had a higher-risk exposure or resident who may have had close contact with individual SARS-CoV-2 infection regardless of vaccination status. The CDC guidance had not been followed by the facility for contact tracing. A review of the facility provided, [redacted] Testing of Residents and Healthcare Personnel for COVID-19 dated August 2021, included but was not limited to: Purpose - will comply with all local and/or state health departments for guidance; all residents shall be tested if there is a new confirmed case (resident or staff) in the facility. A review of the facility provided IP responsibilities, undated, included but was not limited to: The IP is accountable for decreasing the incidence and transmission of infectious diseases between patients, staff, visitors, and the community; establishing a routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections, infection risks, communicable disease outbreaks and to maintain or improve resident health status. A review of the facility provided, Job Specification Infection Control Nurse dated 06/05/21, included but was not limited to: Conducting surveillance rounds to eliminate risks of infection to residents, patients, and personnel; evaluating and maintains records of infections among residents, patients, and staff; acts as the infection control liaison between all hospital departments and medical services, the infection control committee, and hospital administration; prepares clear, technically sound, accurate, and informative reports on epidemiologic and infection matters containing findings, conclusions, and recommendations; and establishes and maintains records, reports, and files. 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. A review of the Centers for Medicare and Medicaid Services (CMS) directive QSO-20-38-NH, dated revised 03/10/22, included but was not limited to the definition of Close contact, which refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over 24 hour period. Guidance - 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 forth by the HHS Secretary. The testing summary included that for newly identified COVID-19 positive staff or residents in a facility that can identify close contacts, the facility should, regardless of vaccination status, test all staff that had a higher-risk exposure with a COVID-19 positive individual and test all residents who had close contact with a COVID-19 positive individual. Testing during an outbreak revealed -that upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g., facility-wide) testing. Documentation of testing - upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested , the dates that staff and residents who tested negative are retested , and the results of all tests. NJAC 8:39-19.2(a); 19.4(a); 19.4(d)(f)(g) Refer to F 886 37175 Part B. F 880 remains a deficiency at a scope and severity of a D based on the following: Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain proper infection control practices identified during 1 of 2 wound treatment observations (Resident #81). This deficient practice was evidenced by the following: On 08/17/22 at 01:20 PM, during the initial tour of the facility, the surveyor observed Resident #81 seated in a motorized wheelchair in the main recreation area, participating in activities. A review of the Face Sheet (an admission summary) reflected that Resident #81 was admitted to the facility in November of 2014 with diagnoses that included cardiac dysrhythmia (irregular heartbeat), hypertension (high blood pressure), and chronic ischemic heart disease (inadequate supply of blood to the heart). A review of the annual Minimum Data Set (MDS), an assessment tool dated 03/08/2022, indicated a Brief Interview for Mental Status (BIMS) score at 00 out of 15, which indicated the resident had severe cognitive impairment. A review of the quarterly MDS dated [DATE] revealed that the resident had a stage 2 pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). A review of the 8/17/22 physician's telephone order revealed an order to clean the left buttock wound with normal saline, apply alginate and cover with bordered foam gauze, and apply zinc oxide to the peri-wound twice a day and when needed for 7 days. The same physician's order was also noted on the August 2022 Treatment Administration Record (TAR). On 08/25/22 at 9:00 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound treatment for Resident # 81's facility acquired Stage 2 pressure ulcer to the left buttock. The surveyor observed the LPN wash her hands for 45 seconds. She donned (put on) gloves and cleaned the overbed table with disinfectant sanitizing wipes. The surveyor observed the LPN place a barrier on the table and taped a plastic bag on the side of the table. The LPN then placed an open pack of 4 x 4 gauze, two (2) border gauze, one (1) bottle of normal sterile saline (NSS), and a pair of metal scissors on the barrier. The LPN doffed (removed) her gloves and performed hand washing for 30 seconds, then donned a new pair of gloves and assisted the resident onto their left side. The Certified Nursing Assistant (CNA) was also present and assisted the resident during wound care. The wound was exposed, and no dressing was present because the CNA reportedly had performed care prior to the observation. The surveyor observed the LPN pour the NSS onto a piece of gauze, cleansed the left buttock wound from inner to outer motion, and threw the gauze into the plastic bag. The LPN reached into her pocket with her gloved hand, removed a pen, dated the border gauze, and then p [TRUNCATED]

Based on interviews and review of pertinent documents, it was determined that the facility failed to ensure: a.) a process was followed to initiate immediate action, and conduct COVID-19 testing upon the identification of a single COVID-19 positive result, b.) that staff who were exposed were COVID-19 tested prior to working at the facility, c.) Federal, State and infection control guidelines were followed, and d.) the facility Infectious Disease Outbreak Response Plan was followed to prevent exposure and mitigate the spread of COVID-19, a deadly highly transmissible infectious disease. The facility's system wide failure to immediately conduct COVID-19 testing upon the identification of a single new case of a COVID-19, posed a serious and immediate risk to the health and well-being of all staff and residents who resided at the facility and who were placed at risk for contracting a contagious infectious and potentially deadly virus. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 09/01/22 at 2:37 PM. The removal plan was verified as implemented by the survey team during an onsite visit conducted on 09/06/22 at 4:31 PM. The evidence was as follows: Refer to 880L On 08/16/22 at 10:24 AM, during the entrance conference held with the Administrative team. The survey team was informed that the facility was currently experiencing an outbreak of COVID-19 which began on 11/23/21. The surveyor requested the contact tracing (process to identify people who have come in contact with someone diagnosed with an infectious disease) for seven residents and four staff members. The surveyor reviewed what the facility Infection Preventionist Registered Nurse (IP/RN) provided, Resident & Staff COVID-19 Incident Reports updated 04/21, which included but was not limited to please be as detailed as possible and type all responses, 9. Explain contact tracing that has been completed in detail, and 10. Describe action(s) taken. The review was as follows: #444 who was fully vaccinated and resided on Old [NAME] unit, presented symptomatic with a cough, and sneezing and tested positive on 12/28/21. The contact tracing section failed to list any staff or residents who may have been a close contact. #446 who was fully vaccinated and resided on Eagle unit, presented symptomatic with a cough, and tested positive on 01/4/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #445 who was fully vaccinated and resided on Freedom unit, presented symptomatic with fever and shortness of breath, and tested positive on 01/30/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #447 who was fully vaccinated and resided on Freedom unit, presented symptomatic with a fever and shortness of breath, and tested positive on 02/3/22. Resident #447 was noted to be transported to hemodialysis three days a week. The contact tracing section failed to list any facility staff, hemodialysis staff, transport staff, visitors, or residents who may have been a close contact. #46 who was fully vaccinated and resided on Freedom unit, presented symptomatic with a cough, and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #76 who was fully vaccinated and resided on Freedom unit, was asymptomatic and tested positive on 08/11/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #179 who was fully vaccinated and resided on Freedom unit, was asymptomatic and tested positive on 08/16/22. The contact tracing section failed to list any staff or residents who may have been a close contact. Licensed Practical Nurse (LPN) #2 was asymptomatic and tested positive on 08/1/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN #3 presented symptomatic with cough, body aches and congestion and tested positive 08/1/22 and the last day worked at the facility was 07/28/22. An Administrative staff member presented symptomatic with nasal congestion and an itchy throat and tested positive 08/6/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN #1 presented symptomatic with a runny nose and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. On 08/29/22 at 8:39 AM during an interview with the surveyor, the facility IP/RN was asked to provide contact tracing for eight residents reviewed between 12/28/21 through 08/16/22 and for six staff members reviewed from 08/01/22 through 08/16/22, all were noted on the facility line-list as have been tested COVID-19 positive. The IP/RN stated that when someone was exposed, she would do the contact tracing but would not list the staff or residents. She stated she would not be able to provide any documentation of staff or residents who may have been exposed because she kept that information in a personal notebook. She further stated that she was alone, no secretary, no help and that she did not document the exposed people. The IP/RN stated that she also followed the facility's Outbreak Response Plan. On 08/29/22 at 9:32 AM, during an interview with the surveyor, a Licensed Practical Nurse Unit Manager (LPN/UM) on Liberty Unit stated that if a resident tested COVID-19 positive, the IP/RN would isolate the resident and do the investigation. She further stated that if a staff member tested COVID-19 positive, they would be sent home and the IP/RN would do all the paperwork. The LPN/UM further stated that she was not sure if testing was done when someone was exposed, but she knew the facility had a team to do routine testing of the residents and staff. On 08/29/22 at 9:40 AM during an interview with the surveyor, the RN Employee Health Nurse stated that she was only responsible to test the staff and residents routinely and upon return to the facility if the resident had gone out. The RN Employee Health Nurse further stated that contact tracing was important to warn others who were exposed so they may be tested as there was a 2 to 14 day incubation period for COVID-19. On 08/29/22 at 11:27 AM, the IP/RN provided incomplete facility, Contact Tracing Forms for the six requested COVID-19 positive staff. The IP/RN stated there was no policy for contact tracing so she would use the Center for Disease Control and Prevention (CDC) guidance and stated she would provide that information. On 08/30/22 at 10:58 AM during an interview with the surveyor, the IP/RN stated that the facility had enough testing supplies to perform facility wide COVID-19 testing. The IP/RN had provided the CDC guidance, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 02/02/22. The surveyor reviewed the guidance with the IP/RN and asked about the directive that asymptomatic residents with close contact to someone COVID + (positive), regardless of vaccination status, should have two viral tests. Testing is recommended immediately and if negative, in 5-7 days after the exposure. The surveyor asked the IP/RN to provide documentation of the tests and follow up tests. The IP/RN stated she would talk to the staff but did not write things down. She again stated that she had kept the information in a personal notebook and would throw out that information when the case was resolved. The IP/RN stated she was unaware of any formal documentation or form to use and retain so she would not be able to inform the surveyor of the exposed staff or residents or their COVID-19 testing in response. The IP/RN stated that contact tracing would be used to prevent the spread of infection in the facility. A review of the facility provided, Outbreak Response Plan revised 02/22, included but was not limited to the following: Purpose - to protect our residents, families, and staff from harm resulting from an outbreak of an infectious disease organism; the IP would be responsible for conducting routine audits of Infection Control in the facility, establish and implement policies and procedures for screening for exposure, will collaborate with facility medical director, public health authorities, regarding interventions to implement responses; Contact Tracing Form - to include name of interview/contact tracer, date of interview, name of resident, history prior positive COVID, date of a + (positive) COVID, date of symptoms/asymptomatic subtract 2 days prior to test result date or symptoms listed (this is the contact tracing date), known exposures, staff in close contact, activities/locations/shift times visited, breaks/meals contacts, outside employment, actions taken by the facility, and reviewed by the Infection Control nurse; Conduct control activities such as management of infectious wastes, terminal cleaning of the isolation room, contact tracing of exposed individuals, and monitoring for additional cases under the guidance of local health authorities, and in keeping with guidance from the CDC; and will test any resident symptomatic for the Infectious organism and will conduct additional testing of residents and staff in accordance with applicable DOH (Department of Health), CDC and CMS (Centers for Medicare & Medicaid Services) guidance. On 08/31/22 at 9:37 AM, the IP/RN provided incomplete contact tracing forms for the eight requested COVID-19 positive residents reviewed and the six COVID-19 positive staff who were reviewed. The incomplete contact tracing forms revealed the following: Resident (R) #444 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposure to residents, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #446 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, no exposure to residents, date of symptoms, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #3 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposures to residents, and reviewed by facility Infection Control Nurse. R #445 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, areas for breaks/meals, known exposure to residents, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #447 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, known exposures to residents, and reviewed by facility Infection Control Nurse. R #46 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, date of start of symptoms, known exposures to residents, and reviewed by facility Infection Control Nurse. R #76 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposures to residents, area for breaks/meals, and reviewed by facility Infection Control Nurse. R #179 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, date of positive COVID-19 test result, known exposures to residents, and reviewed by facility Infection Control Nurse. LPN #2 no: area left blank, known exposures to residents or staff noted. LPN #3 noted to be symptomatic with cough, body aches, and congestion on 08/01/22. Possible exposures were not identified from the date of symptoms back 48 hours. Administrative staff member: area left blank of names of those who were in close contact with since contact tracing date of 08/04/22. LPN #1 no: name of residents (only one set of initials noted), reviewed by facility Infection Control nurse. Food Service Worker #2: area left blank action taken by facility, contact tracing notes asymptomatic and corresponding Incident Report noted symptomatic with cough, headache, runny nose, and vomiting. Food Service Worker #1: area left blank, actions taken by facility. On 08/31/22 at 11:21 AM during an interview with the surveyor, the IP/RN stated the contact tracing forms she had provided were all filled out yesterday (08/30/22) based on memory. When asked about additional staff who may have been a close contact such as the nurses caring for the residents who tested COVID-19 positive, the IP/RN stated the nurses were not with the residents long enough to be considered a close contact. The IP/RN stated that an exposure would be traced 48 hours prior for someone within six feet for 15 minutes or more. She further stated, I know from memory that none of the nurses were (with the residents for 15 minutes or more consecutively in a 24 hour period). The IP/RN stated that the facility implemented routine broad based COVID-19 testing back in December 2021 where the staff were tested three times a week and the residents were tested on ce or twice a week. The IP/ RN stated that close contacts were not all tested when identified as exposed. The IP/ RN further stated that testing of close contacts would depend on what time a person tested positive. She stated sometimes staff would have gone home and so testing would be, as soon as possible. The IP/RN acknowledged that the forms should have been complete. On 08/31/22 at 1:12 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated they were familiar with the process of contact tracing. At 1:14 PM, the IP/RN joined the interview and stated that it was facility process for her to keep her own notes and that the facility would test everyone weekly. The IP/RN further stated that she remembers from December 2021 on that none of the nurses who cared for the COVID-19 positive residents spent over 15 minutes with the residents and that there were no treatments done either. The LNHA stated that was incorrect and the facility did require formal tracking (contact tracing). The LNHA further stated that the IP/RN should have conducted the contact tracing at the time of the exposure and not from memory. The LNHA stated that the IP RN's statement that the nurses did not spend more than 15 minutes with the residents was not fully accurate. Based on interviews and a review of pertinent documents, it was determined that the facility failed to ensure: a.) a process was followed to initiate immediate action and conduct COVID-19 testing upon the identification of a single COVID-19 positive result, b.) that staff who were exposed were COVID-19 tested prior to working at the facility, c.) Federal, State and infection control guidelines were followed, and d.) the facility Infectious Disease Outbreak Response Plan was followed to prevent exposure and mitigate the spread of COVID-19, a deadly, highly transmissible infectious disease. The facility's system wide failure to immediately conduct COVID-19 testing upon the identification of a single new case of COVID-19, posed a serious and immediate risk to the health and well-being of all staff and residents who resided at the facility and who were placed at risk for contracting a contagious infectious and potentially deadly virus. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 09/01/22 at 2:37 PM. The survey team verified the removal plan during an on-site visit conducted on 09/06/22 at 4:31 PM. The evidence was as follows: Refer to 880L On 08/16/22 at 10:24 AM, during the entrance conference held with the Administrative team. The survey team was informed that the facility was currently experiencing an outbreak of COVID-19, which began on 11/23/21. The surveyor requested contact tracing (a process to identify people who have come in contact with someone diagnosed with an infectious disease) for seven residents and four staff members. The surveyor reviewed what the facility Infection Preventionist Registered Nurse (IP/RN) provided, Resident & Staff COVID-19 Incident Reports, updated 04/21, which included but was not limited to please be as detailed as possible and type all responses, 9. Explain contact tracing that has been completed in detail, and 10. Describe action(s) taken. The review was as follows: #444 who was fully vaccinated and resided in the Old [NAME] unit, presented symptomatic with a cough and sneezing and tested positive on 12/28/21. The contact tracing section failed to list any staff or residents who may have been a close contact. #446, who was fully vaccinated and resided in the Eagle unit, presented symptomatic with a cough and tested positive on 01/4/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #445, who was fully vaccinated and resided in the Freedom unit, presented symptomatic with fever and shortness of breath and tested positive on 01/30/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #447, who was fully vaccinated and resided in the Freedom unit, presented symptomatic with a fever and shortness of breath and tested positive on 02/3/22. Resident #447 was noted to be transported to hemodialysis three days a week. The contact tracing section failed to list any facility staff, hemodialysis staff, transport staff, visitors, or residents who may have been a close contact. #46 was fully vaccinated and resided in the Freedom unit, presented symptomatic with a cough, and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #76, who was fully vaccinated and resided in the Freedom unit, was asymptomatic and tested positive on 08/11/22. The contact tracing section failed to list any staff or residents who may have been a close contact. #179, who was fully vaccinated and resided in the Freedom unit, was asymptomatic and tested positive on 08/16/22. The contact tracing section failed to list any staff or residents who may have been a close contact. Licensed Practical Nurse (LPN) #2 was asymptomatic and tested positive on 08/1/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN #3 presented symptomatic with cough, body aches, and congestion and tested positive on 08/1/22 and the last day worked at the facility was 07/28/22. An Administrative staff member presented symptomatic with nasal congestion and an itchy throat and tested positive on 08/6/22. The contact tracing section failed to list any staff or residents who may have been a close contact. LPN #1 presented symptomatic with a runny nose and tested positive on 08/7/22. The contact tracing section failed to list any staff or residents who may have been a close contact. On 08/29/22 at 8:39 AM, during an interview with the surveyor, the facility IP/RN was asked to provide contact tracing for eight residents reviewed between 12/28/21 through 08/16/22 and for six staff members reviewed from 08/01/22 through 08/16/22, all were noted on the facility line-list as have been tested COVID-19 positive. The IP/RN stated that when someone was exposed, she would do the contact tracing but would not list the staff or residents. She stated she could not provide any documentation of staff or residents who may have been exposed because she kept that information in a personal notebook. She further stated that she was alone, no secretary, no help and that she did not document the exposed people. The IP/RN stated that she also followed the facility's Outbreak Response Plan. On 08/29/22 at 9:32 AM, during an interview with the surveyor, a Licensed Practical Nurse Unit Manager (LPN/UM) in Liberty Unit stated that if a resident tested COVID-19 positive, the IP/RN would isolate the resident and do the investigation. She further stated that if a staff member tested COVID-19 positive, they would be sent home, and the IP/RN would do all the paperwork. The LPN/UM further stated that she was unsure if testing was done when someone was exposed, but she knew the facility had a team to do routine testing of the residents and staff. On 08/29/22 at 9:40 AM, during an interview with the surveyor, the RN Employee Health Nurse stated that she was only responsible for routinely testing the staff and residents and, upon return to the facility, if the resident had gone out. The RN Employee Health Nurse further stated that contact tracing was important to warn others who were exposed so they may be tested as there was a 2 to 14 day incubation period for COVID-19. On 08/29/22 at 11:27 AM, the IP/RN provided the incomplete facility, Contact Tracing Forms, for the six requested COVID-19 positive staff. The IP/RN stated there was no policy for contact tracing so she would use the Center for Disease Control and Prevention (CDC) guidance and stated she would provide that information. On 08/30/22 at 10:58 AM, during an interview with the surveyor, the IP/RN stated that the facility had enough testing supplies to perform facility wide COVID-19 testing. The IP/RN had provided the CDC guidance, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 02/02/22. The surveyor reviewed the guidance with the IP/RN and asked about the directive that asymptomatic residents with close contact to someone COVID + (positive), regardless of vaccination status, should have two viral tests. Testing is recommended immediately and if negative, in 5-7 days after the exposure. The surveyor asked the IP/RN to provide documentation of the tests and follow up tests. The IP/RN stated she would talk to the staff but did not write things down. She again stated that she had kept the information in a personal notebook and would throw out that information when the case was resolved. The IP/RN stated she was unaware of any formal documentation or form to use and retain, so she would not be able to inform the surveyor of the exposed staff or residents or their COVID-19 testing in response. The IP/RN stated that contact tracing would be used to prevent the spread of infection in the facility. A review of the facility provided, Outbreak Response Plan revised 02/22, included but was not limited to the following: Purpose - to protect our residents, families, and staff from harm resulting from an outbreak of an infectious disease organism; the IP would be responsible for conducting routine audits of Infection Control in the facility, establish and implement policies and procedures for screening for exposure, will collaborate with facility medical director, public health authorities, regarding interventions to implement responses; Contact Tracing Form - to include name of interview/contact tracer, date of interview, name of resident, history prior positive COVID, date of a + (positive) COVID, date of symptoms/asymptomatic subtract 2 days prior to test result date or symptoms listed (this is the contact tracing date), known exposures, staff in close contact, activities/locations/shift times visited, breaks/meals contacts, outside employment, actions taken by the facility, and reviewed by the Infection Control nurse; Conduct control activities such as management of infectious wastes, terminal cleaning of the isolation room, contact tracing of exposed individuals, and monitoring for additional cases under the guidance of local health authorities, and in keeping with guidance from the CDC; and will test any resident symptomatic for the Infectious organism and will conduct additional testing of residents and staff in accordance with applicable DOH (Department of Health), CDC and CMS (Centers for Medicare & Medicaid Services) guidance. On 08/31/22 at 9:37 AM, the IP/RN provided incomplete contact tracing forms for the eight requested COVID-19 positive residents reviewed and the six COVID-19 positive staff who were reviewed. The incomplete contact tracing forms revealed the following: Resident (R) #444 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposure to residents, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #446 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, no exposure to residents, date of symptoms, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #3 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposures to residents, and reviewed by facility Infection Control Nurse. R #445 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, areas for breaks/meals, known exposure to residents, and areas for breaks/meals, and reviewed by facility Infection Control Nurse. R #447 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, known exposures to residents, and reviewed by facility Infection Control Nurse. R #46 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, date of start of symptoms, known exposures to residents, and reviewed by facility Infection Control Nurse. R #76 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, known exposures to residents, area for breaks/meals, and reviewed by facility Infection Control Nurse. R #179 no: name of interviewer, no date of interview, demographic or locating information, history of prior positive COVID-19 tests results, date of collection specimen, date of positive COVID-19 test result, known exposures to residents, and reviewed by facility Infection Control Nurse. LPN #2 no: area left blank, known exposures to residents or staff noted. LPN #3 was noted to be symptomatic with cough, body aches, and congestion on 08/01/22. Possible exposures were not identified from the date of symptoms back to 48 hours. Administrative staff member: area left blank of names of those who were in close contact with since contact tracing date of 08/04/22. LPN #1 no: name of residents (only one set of initials noted), reviewed by facility Infection Control nurse. Food Service Worker #2: area left blank action taken by facility, contact tracing notes asymptomatic and corresponding Incident Report noted symptomatic with cough, headache, runny nose, and vomiting. Food Service Worker #1: area left blank, actions taken by the facility. On 08/31/22 at 11:21 AM, during an interview with the surveyor, the IP/RN stated the contact tracing forms she had provided were all filled out yesterday (08/30/22) based on memory. When asked about additional staff who may have been a close contact, such as the nurses caring for the residents who tested COVID-19 positive, the IP/RN stated the nurses were not with the residents long enough to be considered a close contact. The IP/RN stated that an exposure would be traced 48 hours prior for someone within six feet for 15 minutes or more. She further stated, I know from memory that none of the nurses were (with the residents for 15 minutes or more consecutively in a 24 hour period). The IP/RN stated that the facility implemented routine broad-based COVID-19 testing back in December 2021, where the staff were tested three times a week, and the residents were tested on ce or twice a week. The IP/ RN stated that close contacts were not all tested when identified as exposed. The IP/ RN further stated that testing of close contacts would depend on what time a person tested positive. She stated sometimes staff would have gone home and so testing would be as soon as possible. The IP/RN acknowledged that the forms should have been complete. On 08/31/22 at 1:12 PM, during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated they were familiar with the process of contact tracing. At 1:14 PM, the IP/RN joined the interview and stated that it was a facility process for her to keep her own notes and that the facility would test everyone weekly. The IP/RN further stated that she remembers from December 2021 that none of the nurses who cared for the COVID-19 positive residents spent over 15 minutes with the residents and that no treatments were done either. The LNHA stated that was incorrect, and the facility did require formal tracking (contact tracing). The LNHA further stated that the IP/RN should have conducted the contact tracing at the time of the exposure and not from memory. The LNHA stated that the IP RN's statement that the nurses did not spend more than 15 minutes with the residents was not fully accurate. On 09/01/22 at 9:22 AM, during an interview with surveyors in the conference room, the IP/RN stated that she consulted with the local health department (LHD) but did not get any guidance on testing close contacts versus broad-based testing. The IP/RN stated, the nurses (facility) I spoke to were in and out (of resident rooms); I should have kept my contact tracing personal notes; I cannot say 100% if the nurses did not stay 15 minutes or more. The surveyor requested communication information from the LHD. A review of the communication with the LHD provided by the IP/RN on 09/02/22 at 9:30 AM, revealed emails sent to the LHD as follows: 01/04/22, the IP/RN asked for a meeting, and the LHD asked for her concerns; 01/25/22 the IP/RN asking for clarification if she needed to test the roommate of a COVID-19 positive resident and would she be required to retest in 48 hours and the IP/RN added according to an attached policy (not provided), she would say no; 04/22/22 the IP RN asking about quarantining residents not up to date with COVID-19 vaccinations in response to COVID-19 positive residents on the same unit, and 07/18/22 regarding staff going on vacation and coming back COVID-19 positive if they would need to be reported. On 09/01/22 at 9:34 AM, during an interview with the surveyors, the IP/RN stated that not all the staff were tested at the facility. She stated some would go elsewhere to get tested , but they would have to let her know. The IP/RN again stated she did not keep the contact tracing or testing documentation. She stated that the documents should have been kept, but most of the contact tracing was done by her, and in December, she was getting like 10 positives (COVID-19) a day. The IP/RN could not provide any documented evidence of COVID-19 testing performed outside of the facility. On 09/02/22 at 9:47 AM, the IP/RN stated that if someone tested COVID-19 positive on a Saturday, she would wait until Monday. She stated, the nurses on the weekend would verbally tell her (who was exposed), but there was no documentation regarding the conversation. The IP/RN acknowledged that close contacts should have included visitors, physicians, and therapy staff but that she did not have documentation that they were ever included on the contact tracing forms to be tested . On 09/02/22 at 11:34 AM, during a telephone interview with the survey team, the Medical Director (MD) stated he started working at the facility

NJ Complaint #156759 Based on observation, interview, record review, and other pertinent facility documentation, it was determined that the facility failed to ensure residents were free from abuse after a resident (Resident #24) was prevented from leaving an abusive situation by Certified Nursing Aide (CNA #1) who continued to work with other residents following no investigation. This deficient practice was identified for 1 of 5 residents reviewed for abuse (Resident #24). Resident #24, who had diagnoses which included anxiety, depression, and Post Traumatic Stress Disorder (PTSD) (A mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations), reported on 07/30/22 an Agency Nurse (Licensed Practical Nurse (LPN #1) became verbally abusive with him/her when their scheduled Percocet (pain medication) and Xanax (anxiety medication) was requested. The resident reported LPN #1 closed the door to his/her room which triggered the resident's PTSD. The resident indicated that they had a history of imprisonment, which caused the feeling of entrapment with closed doors and feelings of anxiety. Resident #24 reported that when they tried to exit the unit to find help, LPN #1 prevented them from leaving by holding the handlebars of the wheelchair (w/c). He stated that CNA #1 further prevented him/her from escaping the anger that LPN #1 exhibited towards him/her, by blocking the exit doors and preventing him from leaving. The resident reported that this made them angry because all they wanted was to leave, and the resident could not understand why they were not permitted to leave the unit to find help. During a review of video surveillance footage, it was observed that the resident self-propelled in the wheelchair, and LPN #1 moved alongside the resident towards the closed exit doors of the unit. CNA #1 was seen exiting from Resident room [ROOM NUMBER] and stood in front of the resident blocking them from proceeding forward, and then stood in front of the exit door blocking the exit. A review of CNA #1's written statement regarding the incident included that she was stopping the resident from leaving the unit. The facility's failure to ensure all residents were free from abuse, including verbal, physical, restraints, and involuntary seclusion by not investigating the actions of CNA #1 after a written statement acknowledged she stopped the resident from leaving the unit as well as video footage confirming she blocked the exit door preventing the resident from leaving the unit posed a serious and immediate threat for abuse which can cause serious physical and emotional harm or impairment. This resulted in an Immediate Jeopardy (IJ) situation that began on 07/30/22 after CNA #1 blocked Resident #24 from leaving the unit and continued to work seven additional shifts until the surveyor inquiry. The facility Administration was notified of the IJ on 08/25/22 at 02:55 PM. The facility submitted an acceptable Removal Plan (RP) on 08/26/22 at 01:55 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 08/26/22. Part A On 08/18/22 at 10:38 AM, the surveyor interviewed Resident #24, who stated on 07/30/22, they received Percocet and Xanax every six hours and asked an aide to find the nurse to administer the medications. An Agency Nurse (LPN #1) entered my room and informed me that they would administer my medications and take my vital signs and proceeded to leave the room and closed the door. The resident stated that they proceeded to use the call bell and LPN #1 came back into the room to tell me to stop pushing the call bell; pulled down her mask and attempted to bite my finger as I pointed at her. The resident continued that he/she got out of bed to get away from LPN #1, LPN #1 lunged her nurse's cart at me three times and hit his/her left foot causing a wound to re-open. The resident stated that he/she was trying to get away from LPN #1 and get to the Registered Nurse Supervisor (RN Supervisor). The resident stated as they were attempting to leave the unit in the hallway, the nurse assaulted them by pulling the wheelchair (w/c) 2-3 times, which positioned the resident on only two back wheels and the two front wheels were lifted off of the floor. The resident stated that there was a (CNA #1) there, but he/she could not recall the name who tried to calm the crazy nurse down. The resident stated that the RN Supervisor escorted LPN #1 out of the building and a State Trooper came last week who viewed the surveillance footage and confirmed LPN #1 assaulted the resident. The resident stated that they had severe PTSD and that this event had triggered an episode. The surveyor reviewed Resident #24's medical record. A review of the Resident Facesheet (an admission summary) reflected that the resident was admitted to the facility in September of 2021 but did not include admitting diagnoses. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 08/10/22, reflected a brief interview of mental status (BIMS) score of 15 out of 15, which indicated the resident was fully cognitively intact. It further reflected the resident had verbal behavioral symptoms directed toward others that occurred four to six days in the last seven days of assessment. Section I Active Diagnoses included the resident had hypertension (high blood pressure), anxiety, depression, psychotic disorder, and PTSD. It further included in a seven-day look back period, the resident received daily antianxiety, antidepressant, and opioid medications. A review of the individualized comprehensive Care Plan (CP) included a problem area initiated on 04/8/22, for at risk for altercation in mood/behavior; history of major depressive disorder, anxiety, use of Seroquel (antipsychotic medication) for agitation, use of Xanax for anxiety, and Remeron for anxiety/depression/mood with interventions that included to observe for efficiency of medications; monitor for target behaviors or behaviors not easily redirected; refer to nurse if noted behaviors worsening, unable to redirect; keep the room well lit, open blinds for sunlight; and give medications Remeron, Xanax, Seroquel as ordered. A further review of the CP included a diagnosis of PTSD, however, did not include a problem area or interventions pertaining to the resident's diagnosis of PTSD. A review of the Interdisciplinary Progress Notes included a Nursing Note dated 07/30/22 at an illegible time, which reflected at around 05:10 AM; a CNA approached the writer who was on the other side of the unit to report an altercation between an Agency Nurse (LPN #1) and the resident. The writer went over to Resident #24 and brought them back to their room, and conducted a body check. The note reflected that the writer reassured Resident #24 that everything would be okay. On 08/18/22 at 11:49 AM, the surveyor requested from Administration all investigations for Resident #24 from 07/01/22 until present. On 08/18/22 at 12:48 PM, the surveyor interviewed the RN Supervisor via telephone, who stated on 07/30/22, she was called to the unit the Agency Nurse (LPN #1) and Resident #24 were having an argument, and the nurse was very aggressive. The resident had told the CNA that he/she wanted his medications, and LPN #1 came into the room to tell the resident she would get the medications. The RN Supervisor stated that ten minutes had passed and the resident had not received their medications so they pressed the call bell and LPN #1 came into the room and asked why he/she was calling her. LPN #1 then proceeded to close the door, which the resident did not like, and he/she went to call the Supervisor, but LPN #1 took the phone, so the resident could not call. LPN #1 then blocked the resident's room with her medication cart so they could not leave and then pulled the resident's w/c so the resident could not leave the unit. The RN Supervisor stated the aides told LPN #1 to stop, and RN #1, who was on the other side of the unit, called the RN Supervisor, who had LPN #1 leave the facility, and an investigation was initiated. The RN Supervisor stated the resident reported LPN #1 attempted to bite their finger but no injury was observed. There was surveillance video footage reviewed and statements were taken. The RN Supervisor stated Resident #24 gets really upset sometimes due to pain so the nurses usually responded to him/her right away. On 08/18/22 at 01:06 PM, the surveyor requested the Licensed Nursing Home Administrator (LNHA) to provide all investigations conducted for Resident #24 from 07/01/22 to present. On 08/19/22 at 11:25 AM, the surveyor interviewed the Director of Nursing (DON) who stated she had been on vacation for the past two weeks so the Assistant Director of Nursing (ADON) completed the investigation and the final report. The DON confirmed she watched the video surveillance footage which revealed LPN #1 abused Resident #24. On 08/19/22 at 11:31 AM, the surveyor interviewed the ADON who stated that she completed an investigation for the incident on 07/30/22 which she reported to the New Jersey Department of Health (NJDOH), Ombudsman, the Veteran's Affairs [NAME], Office of Inspector General, Physician, family, and later the State Police after the resident alleged LPN #1 assaulted him/her with her medication cart. The ADON stated when she reviewed video footage, it was clear LPN #1 was holding the handlebars on the back of Resident #24's wheelchair as well as a verbal altercation. On 08/19/22 at 11:59 AM, the surveyor interviewed LPN #1 via telephone who stated she was an Agency Nurse assigned to the facility that day (07/30/22) and received no information from the facility prior to the start of her shift. LPN #1 stated to a degree she understood that the resident was right, but the resident made racist remarks to her and weaponized their wheelchair rolling over her feet. LPN #1 stated that the medication cart was in front of his/her room since she was trying to administer the resident's medication and he/she started pushing the medication cart at the nurse. LPN #1 stated a nurse informed her Resident #24 had to receive their medication on time and she apologized that the medication was a few minutes late and she started to prepare the medications. The resident proceeded to press the call bell and started yelling and cursing at her to administer the medications and he/she was going to call administration. LPN #1 stated that she tried to calm the resident down but he/she started making derogatory racial remarks to her telling her that she was yelling at them. The resident then got out of bed and charged in their wheelchair at the medication cart yelling and cursing. LPN #1 stated that she told the aides to get the Supervisor. LPN #1 stated she was unaware if the resident had any behaviors and the two CNAs were telling her to stop the resident from leaving the unit and she had no idea why the resident could not leave the unit; if the unit was a lockdown unit or the resident was on COVID-19 restrictions, but she was the closest staff to the resident so she grabbed the back of the wheelchair to stop the resident. LPN #1 further stated that she did not know the two CNAs' names, but they were yelling at her to stop the resident from leaving the unit, so she grabbed the back of his/her wheelchair. On 08/19/22 at 12:52 PM, the surveyor in the presence of the DON, Employee Relations/Legal Specialist, and survey team observed the surveillance video from 07/30/22 and observed the following: At approximately 05:13 AM, Resident #24 was observed self-propelling in a wheelchair alongside of LPN #1 and proceeded up the hallway in the direction of the closed exit doors; LPN #1 was observed at some point holding her left arm up with their left hand positioned upward in a motion to stop that was directed towards the resident. CNA #1 was observed exiting Resident room [ROOM NUMBER] which was located on the right side directly next to the closed exit doors and proceeded to position herself directly in front of the resident. There was no audio, but it could be determined that there was a verbal exchange between the resident and staff. LPN #1 then grabbed the back of the handlebars of Resident #24's wheelchair, which changed the resident's direction from facing forward towards the exit doors to now facing towards Resident room [ROOM NUMBER]. The resident was trying to get away but was being restrained by LPN #1, who was still holding onto the back of the wheelchair, which caused the front wheels to lift off the ground, causing the resident to recline in the w/c. CNA #1 then stood in front of the exit door and blocked the resident from having access to exit. CNA #2 was observed walking up the hallway towards LPN #1, CNA #1, and the resident and it can be observed CNA #2 was engaging in the conversation. Then, CNA #3 came through the closed exit door and proceeded to wheel the resident away from LPN #1 and CNA #1. RN #1 was seen walking up the hallway towards the resident and CNA #3 and it appeared that they were attempting to calm the resident as they were bringing the resident towards their room. On 08/19/22 at 1:23 PM, the surveyor interviewed CNA #1 via telephone who stated she could not recall the incident but she had provided a statement, so the surveyor should read their statement. On 08/19/22 at 1:31 PM, the surveyor attempted to interview CNA #2 via telephone about the incident, and CNA #2 would only repeat the word yes in response to interview questions and offered nothing further. On 08/22/22 at 10:00 AM, the surveyor reviewed the facility provided an investigation report for Resident #24's incident which occurred on 07/30/22. A review of the staff statements included a statement provided by CNA #2, which detailed that they were taking care of a resident when they heard a noise in the hallway and came out into the hallway and saw Resident #24 trying to leave the floor. She stated that, I stopped him/her from leaving the floor. CNA #2 stated that both she and another CNA called the charge nurse, but I did not know what was going on. CNA #2's statement appeared to be what the surveyor witnessed CNA #1 do in the surveillance video. There was no statement included from CNA #1 in the investigation report provided. On 08/22/22 at 10:31 AM, the surveyor reviewed the surveillance video with the Assistant Licensed Nursing Home Administrator (ALNHA) #1, Employee Relations/Legal Specialist, and another surveyor, and the Employee Relations/Legal Specialist confirmed CNA #1 was the aide who was blocking the door and CNA #2 was the aide observed later walking up the hallway towards LPN #1, CNA #1, and the resident during the altercation. At this time, the surveyor reviewed the investigation packet with ALNHA #1 who confirmed there should have been a statement from CNA #1 included in the investigation report. On 08/22/22 at 11:28 AM, the surveyor asked the DON if there was any surveillance video footage from the camera by the nurse's station from the incident and the DON reported that the camera was not working during the incident. The surveyor also informed the DON that they attempted to interview the CNAs and was told to read their statements, but there was no statement provided for CNA #1. On 08/23/22 at 10:59 AM, the DON provided the surveyor with CNA #1's statement dated 07/30/22 which was the exact same statement provided by CNA #2. At this time, the surveyor asked the DON to read both CNA #1 and CNA #2's statements, and she confirmed that both statements were the same but was signed by the corresponding CNA. At this time, the surveyor requested to watch the video footage again with the DON. On 08/23/22 at 11:10 AM, the surveyor with the DON, Employee Relations/Legal Specialist, and another surveyor viewed the video footage. The surveyor asked the DON, when comparing the surveillance footage with the statements if the statements clearly reflect what had happened. The DON reported that she completed a three-page reportable to the New Jersey Department of Health (NJDOH) and told RN #1 to watch the video to see if anything should be added to her statement, and then the DON reported she left for vacation. The DON stated that the ADON had watched the video with RN #1 who did not want to change her statement. The DON stated the purpose of an investigation was to determine a root cause analysis and confirmed these statements were not clear. The DON stated when she returned from vacation, the investigation was completed by the ADON and she did not review it even though she was responsible for oversight of all aspects of nursing. The DON confirmed the resident had the right to leave the unit and no staff, including the two CNAs should have stopped the resident from leaving the unit. The surveyor reviewed the video with the DON. The DON acknowledged CNA #1 was standing in front of the exit door blocking Resident #24 from exiting the unit, which was an issue because this was considered a restraint. The DON stated that even if the resident was confused, which Resident #24 was not, staff could not stop the resident from leaving. The DON stated staff had to ensure the resident's safety and could follow the resident from a distance, but staff could not prevent the resident from leaving the unit. The DON stated the ADON was currently on vacation but confirmed the investigation was not complete, and she had to re-open the investigation to clarify the statements and determine why CNA #1 stood in front of the door. On 08/23/22 at 11:50 AM, the surveyor requested from the LNHA all nursing schedules from 07/31/22 until present. On 08/23/22 at 12:09 PM, the surveyor reviewed the education for CNA #1 and CNA #2, which revealed both aides received abuse training prior to the event on 04/11/22 and 12/20/21 respectively. On 08/23/22 at 01:14 PM, the surveyor re-interviewed Resident #24 who stated CNA #1 was stopping LPN #1 from verbally abusing him/her, but confirmed CNA #1 was preventing him/her from leaving the unit and told them they were not allowed to leave the unit. The resident stated CNA #1 could have done more since she was not letting them leave and he/she did not know why. On 08/24/22 at 10:30 AM, the surveyor reviewed the nursing schedules since 07/31/22, which revealed CNA #1 worked seven shifts at the facility after the incident. On 08/24/22 at 11:35 AM, the surveyor interviewed the DON regarding the process for investigating abuse. The DON stated that for abuse, you take the person off the floor immediately and get their statement. When asked why you removed them from the floor, the DON responded that you have to remove them from the floor because it was a concern of abuse, you would not leave the residents with that person until you determined it was not abuse. When asked what constitutes abuse, the DON stated there were different types of abuse including physical, verbal, monetary, emotional, sexual, seclusion, and restraining against ones will. The DON stated she called CNA #1 yesterday and spoke to her over the phone regarding her statement that she stopped the resident from leaving, and CNA #1 stated after everything was done, the RN Supervisor gave an in-service that if a resident wanted to leave, they cannot stop anyone from leaving the floor, and they can follow them from afar. The DON stated that the situation was looked at initially that CNA #1 was trying to calm the resident down and not by the statement which the video confirmed that CNA #1 was trying to prevent the resident from leaving the unit. An additional review of the investigation report included an in-service/education attendance sheet dated 07/31/22, the day after the incident, with a program topic of the resident should be allowed to leave the unit if [they] wish. Do not stop the resident from leaving the unit by holding [their] chair, re-direct verbally. If they insist on going leaving the unit allow them to leave, and can follow behind to make sure the resident is safe. The in-service was presented by RN Supervisor to four staff members CNA #1, CNA #3, LPN #2, and RN #2. The in-service was not given to CNA #2 or RN #1, who were both present at the incident. Further review of the investigation report included in the Final Investigation dated 08/11/22, for actions taken: staff intervened separating the Agency Nurse (LPN #1) from [resident]; provided emotional support and notified Nursing Supervisor (RN Supervisor) immediately of their observations and [resident's] allegations; Agency Nurse was removed from the nursing unit and asked to provide a statement. She was subsequently dismissed from the remainder of her shift; [Agency] was notified of incident and request was made for the staff member not to return to facility; MD (Physician) was notified with order for body check every shift for five days and vital signs every shift for five days; [resident] reported that the nurse did not make physical contact with [his/her] person, only restricted [him/her] by holding [his/her] wheelchair; Social Worker will continue to provide emotional support. The summary included: the ADON reviewed the footage, which showed [Resident #24] was near the end of the door of the unit, the Agency staff was holding [their] wheelchair handle preventing [them] from leaving the unit. It was apparent on the video that staff members intervened and came to diffuse the situation. Hand gestures were made by Charge Nurse noted to put her hand up in a stop motion to Agency Nurse (LPN #1) as she appeared to follow [Resident #24] up the hall making verbalizations. Conclusion: evidence of verbal abuse and intent to involuntarily seclude a resident was consistent in staff members' statements and observations made by the ADON on the video footage. Verbal abuse and attempt to involuntarily seclude were substantiated. The Final Investigation summary did not include that CNA #1 involuntarily secluded the resident or that any action was taken towards CNA #1. On 08/24/22 at 12:33 PM, the DON informed the survey team that in light of CNA #1 blocking door, she was reporting it to the NJDOH. On 08/25/22 at 09:51 AM, the surveyor interviewed Resident #24 who stated he/she was imprisoned for twenty months and preferred the door to their room remain open because the closed door triggered their PTSD causing anxiety. The resident stated on 07/30/22, they were waiting for LPN #1 to administer their routine Percocet and Xanax medication so they could go back to sleep. LPN #1 closed his/her room door and then started yelling at him/her, and the resident reported they just wanted to escape LPN #1 who grabbed their wheelchair almost tipping the chair over. Resident #24 stated that he/she remembered the aide (CNA #1) saying their name and that he/she knew her and he/she could not leave but Resident #24 stated they could not determine who the aide was at the time. Resident #24 stated they just wanted the RN Supervisor, which made them feel angry because they were being prevented from escaping from LPN #1, and CNA #1 was not helping the situation. CNA #1 could have opened the door to let me leave but she would not let me leave which made me mad. The resident stated he/she had never been prevented from leaving the unit before so they could not understand why that was happening. The facility's failure to ensure all residents were free from abuse, including verbal, physical, restraints, and involuntary seclusion by not investigating the actions of CNA #1 after a written statement acknowledged she stopped the resident from leaving the unit as well as video footage confirming she blocked the exit door preventing the resident from leaving the unit posed a serious and immediate threat for abuse which can cause serious physical and emotional harm or impairment. This resulted in an Immediate Jeopardy situation. The IJ was identified on 08/25/22, and the LNHA, ALNHA #1, ALNHA #2, DON, and Director of Veterans Health Care Services were notified of the IJ at 02:55 PM. A written Removal Plan was accepted and verified on-site on 08/26/22, which included staff members will be immediately relieved from their duties; to ensure safety of the residents a comprehensive investigation will commence at the time of the event to ensure a thorough and complete review of all contributing factors have been conducted; all staff in-serviced on the Abuse and Neglect Policy. On 08/26/22 at 10:34 AM, the surveyor interviewed the DON who confirmed that the investigation regarding CNA #1 should have started upon review of the CNA's statement and video footage. The DON stated that after surveyor inquiry, she had called on the telephone both CNA #1 and CNA #2 to clarify their identical written statements. The DON stated CNA #1 had better English than CNA #2 so CNA #2 copied CNA #1's statement. The DON acknowledged that CNA #2 should not have copied CNA #1's statement and CNA #2 provided the DON with a new written statement and the DON received a verbal statement over the phone from CNA #1. On 08/26/22 at 11:00 AM, the DON provided the surveyor with a copy of the Statement of Clarification dated 08/23/22. A review of this statement included a revised statement of CNA #1 given via telephone to the DON and the MDS Coordinator. The statement indicated CNA #1 was taking care of a resident in room [ROOM NUMBER] when she heard Resident #24 and the nurse's voices in the hallway. When she came out, she observed the nurse holding the resident's wheelchair while he/she was trying to leave the floor. I stayed in front of the door, and tried to talk to him/her and said, You cannot leave the floor so we are going to get the charge nurse for you. This statement contradicts video footage of LPN #1 grabbing the back of the resident's wheelchair after CNA #1 had exited Resident room [ROOM NUMBER]. On 09/06/22 at 02:35 PM, the surveyor conducted an interview via telephone with the DON. The surveyor asked the DON to review the Statement of Clarification dated 08/23/22. The DON read the statement and the surveyor asked if the statement confirmed what the video footage revealed. The DON stated she watched the video three times with the surveyor and the video confirmed that CNA #1 was blocking the door preventing the resident from leaving which was the part she was focused on. When asked if LPN #1 grabbed the back of Resident #24's wheelchair before CNA #1 exited Resident room [ROOM NUMBER] or after, and the DON stated she could not speak to that. The DON confirmed she did not review the video again after receiving the statement because it was the CNA's statement and she admitted to blocking the resident from leaving the room. When asked if it was important to verify the written statement matched the video footage, the DON confirmed yes. On 09/06/22 at 02:50 PM, the DON, in the presence of two surveyors, watched the video surveillance footage which showed CNA #1 stepped out of Resident room [ROOM NUMBER] before LPN #1 and Resident #24 reached the closed exit doors, and CNA #1 stood in front of the exit doors. The video then revealed after CNA #1 was in front of the doors, LPN #1 grabbed the back of Resident #24's wheelchair in the presence of CNA #1. This contradicted CNA #1's revised statement that she walked out of Resident room [ROOM NUMBER] and observed LPN #1 was holding the back of Resident #24's wheelchair at that time. On 09/06/22 at 03:15 PM, the DON followed-up with the surveyor via telephone and confirmed that she watched the video footage again. The DON confirmed that the video footage showed that LPN #1 did not grab the back of Resident #24's wheelchair until after CNA #1 was outside of Resident room [ROOM NUMBER] in front of the door which contradicted the CNA's statement. The DON continued the statement taken was what CNA #1 informed her of what had happened. A review of the facility's Resident Safety Policy and Procedure Resident Abuse Certification dated 06/08/22, included it is policy to promote and maintain a work and living environment that is professional and free from threat, and/or occurrences of harassment, mistreatment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property .Residents must not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals . Procedure . identify, correct and intervene in situations in which mistreatment, abuse, neglect and/or misappropriation of resident property [in] more likely to occur. This shall include but is not limited to: the supervision of staff to identify inappropriate behaviors such as using derogatory language, rough handling, ignoring residents while giving care, speaking to a resident in a scolding manner, etc. A review of the facility's Abuse Investigation policy, includes the facility will investigate all alleged and/or suspected events, occurrences, patterns, or trends that may constitute abuse. An investigative report of the findings, disposition of the victim, conclusions, and subsequent administrative actions filed as a matter of record . Procedure . Investigations pertaining to employee to resident . incidents involving employees shall require the employee be assigned to another work area or released from duty with pay pending on the outcome of the investigation. The employee shall not have contact with the resident throughout the course of the Administrative Investigation . NJAC 4.1(a)(5) F600 remains a deficiency at a scope and severity level of a D based on the following: Part B Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure an Agency Nurse received abuse training according to facility policy prior to working in the facility. This was identified for 1 of 3 staff members (LPN #1) reviewed for an abuse investigation of 1 of 5 residents (Resident #24) and was evidenced by the following: On 08/18/22 at 10:38 AM, the surveyor interviewed Resident #24 who stated on 07/30/22, he/she received Percocet (pain management medication) and Xanax (anxiety medication) every six hours and asked an aide to find the nurse to administer the medications. An Agency Nurse (Licensed Practical Nurse (LPN #1)) entered my room and informed me that they would administer my medications and take my vital signs and proceeded to leave the room and closed the door. The resident stated that he/she proceeded to use the callbell and LPN #1 came back into the room, to tell me to stop pushing the callbell; pulled down her mask and attempted to bite my finger as I pointed at her. The resident continued that they got out of bed to get away from her and LPN #1 lunged her nurse's cart at me three times and hit my left foot that reopened a wound. The resident stated that he/she was trying to get away from LPN #1 and get to the Registered Nurse Supervisor (RN Supervisor). The resident stated as he/she was attempting to leave the unit in the hallway, the nurse assaulted me by pulling my wheelchair 2-3 times which caused my wheelchair's (w/c) two front wheels to be in the air which positioned me only on the two back wheels. The resident stated that there was a Certified Nursing Aide (CNA #1) there but he/she cannot recall their name who tried to calm the crazy nurse down. The resident stated that the RN Supervisor escorted LPN #1 out of the building and a State Trooper came last week who viewed the surveillance footage and confirmed LPN #1 assaulted me. The resident stated that he/she had severe Post Traumatic Stress Disorder (PTSD) and this event had triggered an episode. The surveyor reviewed the medical record for Resident #24. A review of the Resident Facesheet (an admission summary) reflected that the resident was admitted to the facility in September of 2021 but the document did not include admitting diagnoses. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 08/10/22, refl [TRUNCATED]

Complaint #NJ156886 Based on interview, record review, and review of other facility documents, it was determined that the facility failed to ensure a resident who sustained a fall with a possible fractured arm received a timely recommended medical follow-up by failing to: a.) thoroughly review the After Visit Summary (discharge hospital summary) and communicate the recommendations to the physician, and b.) thoroughly review an X-Ray report received on 07/13/22, and alert the physician of the recommended follow-up with more films to confirm the possible fracture detected on the X-Ray. This deficient practice occurred for 1 of 47 sampled residents reviewed (Resident #44) who sustained a fall with a hematoma (collection of blood outside of blood vessels) on the forehead on 07/12/22. There was a 12 day delay from 07/13/22 to 07/25/22. The recommended follow-up was as soon as possible for a visit in 2 days (around 07/14/22), and was evidenced by the following: Reference: New Jersey Statutes, 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 wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: On 08/16/22 at 10:52 AM, during the initial tour of the facility, the surveyor observed Resident #44, who had a yellow cast on the right forearm. The resident was sitting in a chair in the room close to the nursing station and did not respond to the surveyor's greetings. On 08/17/22 at 1:16 PM, the surveyor observed Resident #44 in the room eating lunch. Resident #44 consumed approximately twenty-five percent of the lunch tray. On 08/18/22 at 1:28 PM, the surveyor observed Resident #44 sitting quietly in the resident's room and wearing non-skid socks on both feet. The yellow cast was observed on the right forearm. On 08/19/22 at 8:51 AM, Resident #44 was observed sitting in the room eating breakfast. The yellow cast was observed on the right forearm. On 08/23/22 at 9:22 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for Resident #44. The CNA stated that Resident #44 was totally dependent upon staff for care but was able to feed themself after set-up. The CNA stated that Resident #44 could be combative with care. However, she had developed a trusting relationship with the resident, and the resident was not very combative with her during care. The CNA also stated that the family was very involved. The surveyor reviewed Resident #44's medical record on 08/17/22. According to the Admission Face Sheet, Resident #44 was admitted to the facility with diagnoses which included, but were not limited to: hypertension (high blood pressure), pernicious anemia (a condition in which not enough red blood cells are produced due to deficiency of vitamin B12 in the body) and Dementia (a group of symptoms that affects memory, thinking and interfered with daily life) with behavioral disturbances. The quarterly Minimum Data Set Assessment (MDS ), an assessment tool used by the facility to prioritize care, dated 05/22/22 and 08/22/22, revealed that Resident #44 was severely cognitively impaired. Resident #44 scored 99 on the Brief Interview for mental status (Normal score 8-15). Further review of the MDS revealed that Resident #44 was unable to make their needs known. A Care Plan (CP) dated 10/29/20 revealed the following problems: Cognitive- Resident #44 was impaired in decision making ability related to Depression, Dementia, and anxiety as evidenced by difficulty making decisions in new situations, poor decision ability, and needs cues and supervision. The fall care plan dated 12/27/17, last revised 07/28/22 included the following: Keep my surroundings safe and free from clutter. Keep my bed at the lowest safe position. Apply non-skid strips on the floor. Assist me to wear non-skid socks when I am not wearing shoes . A Progress Note dated 07/12/22 revealed that Resident #44 sustained a fall with injury. Resident #44 was observed lying on the floor in the room with a hematoma (collection of blood) on the forehead measuring 3.5 centimeters (cm) x 3.5 cm. Resident #44 was transferred to the Emergency Department (ED ) for evaluation and treatment. CT Scan (Computed Tomography) of the spine and head performed at the hospital was negative for fracture. The nurse documented upon return to the facility the following: Scalp hematoma still persists, no signs and symptoms of distress noted. The recommendations to follow up as soon as possible for a visit in 2 days was not depicted on the After Visit Summary dated 07/12/22. The following entries were documented in the clinical record: On 07/13/22 - 07:00 AM. Received resident in bed sleeping, hematoma still persists on right forehead slept in the night. Neuro checks (assess an individual's neurological functions, motor and sensory response, and level of consciousness) within normal limits . will continue to monitor. On 07/13/22, the surveyor reviewed the medical record which lacked evidence of a post fall nursing assessment completed for the 7:00 AM - 3:00 PM shift. On 07/13/22 at 4:00 PM, the resident (referring t Resident #44) received in bed, sleeping, and the patient spit out Tylenol offered. Upon assessment, swelling was noted on the right wrist. When assessing the right hip, the resident was guarding. MD (Medical Doctor) made aware and ordered stat X-Ray of the right side of the upper body, forearm, femur, right pelvis, right humerus, right tibia/ fibula. The resident remained in bed. Will continue to monitor. On 07/14/22, there was no evidence of a documented post fall assessment for the 7:00 AM - 3:00 PM shift. On 07/14/22, 11:00 PM - 7:00 AM shift, revealed that Resident #44 refused vital signs, all care rendered, no delayed injury noted from past fall. On 07/14/22 at 5:40 PM, the following entries were noted, Received resident in bed, X-Ray of the body was done. No fracture noted. Meals and meds well tolerated. No delayed injury. The surveyor reviewed the X-Ray result, dated 07/13/22, timed 5:38:22 PM, and observed the word Alert was stamped on the X-Ray result. Under the section Forearm AP [(Antero Posterior) and lateral, Right. The following were documented: The study is significantly limited. No fracture or bone destruction are seen in the forearm. However, there is a possible subtle nondisplaced fracture in the right distal right radius. No soft tissue masses are seen. Conclusion: Limited study. There is a possible nondisplaced fracture in the distal right radius. Follow-up more complete wrist films are recommended along with clinical correlation. The above recommendations were not communicated to the physician/Nurse Practitioner in charge of Resident #44's care. On 08/29/22 at 9:20 AM, the surveyor interviewed the Registered Nurse (RN ) who received the X-Ray report on 07/13/22. The RN stated that she reviewed the X-Ray result along with the Unit Manager and did not see the recommendations. The surveyor inquired about the word Alert observed on the report. The RN stated, alert means abnormal The RN further stated that she reviewed the first page only and did not see the second page with the recommendation. The RN stated it was only on 07/25/22 that she was made aware of the second page. The RN confirmed that she did not contact the nurse practitioner or physician with the recommendations documented on the X-Ray report that the resident had a right wrist fracture. The RN stated that she met with the Director of Nursing (DON), and the DON had not informed her that she had to provide a statement pertaining to this incident. The RN stated she was not provided with any education either. The RN elaborated that on 07/25/22, a change of condition was reported by the CNA who cared for Resident #44, and the nurse then assessed the resident. At that time, it was noted that Resident #44 was limping, guarding the right side, and appeared to have pain in the right arm. The physician was called and ordered an X-Ray of the right side of the body. The X-Ray report dated 07/25/22 timed 11:46:33 PM, confirmed the fracture identified on the report dated 07/13/22 and indicated the following: Comparison is dated 07/13/22. As was suspected on the previous examination (07/13/22), there is a nondisplaced distal radius fracture without significant interval healing. No additional fractures are observed. There is no destructive bony process. The surrounding soft tissues have a normal appearance. The NP gave an order to transfer Resident #44 to the hospital for evaluation and treatment. Imaging Tests[X-Ray forearm two views Right] confirmed a closed fracture of the distal end of the right radius with delayed healing. During the second ED visit dated 07/26/22, a second X-Ray confirmed the fracture detected since 07/13/22. Resident #44 returned with a splint to the right arm. On 08/10/22, during a visit to the orthopedist, Resident #44 had a cast applied to the right hand to facilitate healing of the fracture. The cast was removed on 08/23/22. The Nurse Practitioner signed the X-Ray report on 07/19/22 and missed the recommendations on the X-Ray report. On 08/29/22 at 10:05 AM, an interview with the Director of Nursing (DON) in the presence of another surveyor revealed that during the investigation, she noted that the nurse failed to pick up on the recommendations both on the After Visit Summary and on the X-Ray report; therefore, there was a delay in treatment. The DON stated, When a consult comes in, there should be a follow-up. The DON confirmed that the recommendations were not detected during the 24 hours chart check. The DON added, There is going to be a write-up for the nurses and the supervisors as well. An entry dated 07/26/22, timed 10:15 AM, revealed that the son was made aware of the fracture on 07/26/22. He indicated, I still want my (Resident #44) to go to the hospital in case she fell and sustained an injury or serious medical condition. The family was not informed of the fracture on 07/13/22. On 08/29/22 at 10:33 AM, an interview with the Registered Nurse/Unit Manager (RN/UM) revealed that she was unaware of the follow-up required as documented on the After Visit Summary until 07/25/22. The RN/UM confirmed that she reviewed the X-Ray report also and missed the recommendations. On 08/30/22 at 09:30 AM, the surveyor requested all investigative reports for Resident #44 from the DON. The facility provided a Reportable Incident dated 07/25/22. The report revealed the final investigation indicated that Resident #44 was observed with swelling. X-Ray done, result was positive for fracture of the right distal radius. MD (physician) notified of result and ordered for Resident #44 to be transferred to the hospital for further evaluation and treatment. Resident #44 returned from the hospital with a splint to the right arm. On 08/30/22 at 12:13 PM, conducted a second interview with the regularly assigned CNA assigned to Resident #44. The CNA stated that the bruises had been present since last week. The CNA stated that she did not report it to the nurse because the bruise had been there since the fall, and she thought the nurse knew about it. Conclusion: Resident (referring to resident #44) was noted with swelling of the right wrist region on 07/29/22. resident did have an X-Ray of the same area on 07/12/12, which the radiologist reported as inconclusive for fracture. However, based on clinical record provided by the facility and reviewed on site, Resident #44 was noted with swelling of the right wrist on 07/13/22. An X-ray was ordered and carried out on that same day, 07/13/22. The X-Ray report dated 07/13/22 came with an Alert as there was a possible nondisplaced fracture seen, and the facility was to order more films to correlate. The facility missed the recommendations. The physician or the nurse practitioner was not made aware until 07/25/22, when a change of condition was reported. On 08/31/22 at 10:09 AM, during a second interview with the DON, she indicated that the Nursing Supervisor informed her on 07/25/22 that she needed to schedule an orthopedic appointment that had been missed on 07/12/22. She did not have any prior knowledge of the incident. On 08/31/22 at 11:18 AM, the surveyor observed Resident #44 sitting in the room with the left hand holding the right wrist. On 08/31/22 at 12:30 PM, an interview with the Physical Therapy (PT) Director revealed that Resident #44 was not referred to PT immediately after the fall. He received a referral on 07/29/22. On 08/31/22 at 1:43 PM, an interview was conducted with the NP in charge of Resident #44's care. The NP was asked if she was aware of the fracture when she signed the report on 07/19/22. She stated that she did not know exactly what she did. When asked to elaborate on the process if a fracture was detected on the X-Ray report, she said she would usually follow up immediately and notify the family right away. The NP stated, I could not remember. I don't know. There was no documented evidence that the fracture was detected and discussed with the family on 07/13/22. The RN who reviewed the report did not inform the NP. On 09/01/22 at 8:55 AM, the surveyor conducted a second interview with the RN. The RN stated that she had been aware of the After Visit Summary recommendations. She added that she had discussed the recommendations with the NP, and the NP then informed the son, and the NP indicated that there was no need to follow up. On 09/01/22 at 11:21 AM, during a second interview with the RN/UM, she confirmed that she reviewed the X-Ray result with the Charge Nurse. The UM stated, We both saw the word Alert, and we don't know how we missed it. When asked if the radiology department was called to clarify the Alert, the RN/UM stated that she did not contact radiology to clarify the Alert. On 09/01/22 at 11:21 AM, during a third interview with the RN, who initially received the X-Ray report, she maintained that she did not review the whole report. She stated, If I was aware, I would call the MD/NP immediately., and we did not follow up with the care that needed to be provided. The RN stated, This is a delay in treatment. I learned my lesson and need to review the whole report to the end. The RN further stated that she had not received any education yet regarding the incident. The surveyor then asked the RN to elaborate on the facility's documentation post-fall. The RN stated that the staff was to perform a daily head-to-toe assessment for 5 days after a fall. When asked if body check was done or the protocol was being followed, she replied that Resident #44 was always combative with care. There was no documented evidence that assessment was carried out post fall on all three shifts for five days. On 09/01/22 at 9:07 AM, the surveyor observed Resident #44 in bed. Resident #44 was not dressed. On 09/01/22 at 2:13 PM, an interview with the Nursing Supervisor on duty that day revealed that she did not review the After Visit Summary or the X-Ray result. The nurse told her there was no fracture. She did not assess the resident as the resident returned the same day. She was not aware of the recommendations. She added that the Nursing Supervisor on the day shift was to follow on the next day. On 09/02/22 at 9:37 AM, the regular CNA assigned to Resident #44 retired. Throughout the survey until 09/01/22, the surveyor would observe Resident #44 sitting in the room eating breakfast early in the morning. On 09/02/22 at 9:37 AM, the surveyor observed Resident #44 in bed. The side rails were elevated on both sides. The breakfast tray was untouched. On 09/02/22 at 10:20 AM, an interview with the Charge Nurse revealed that the breakfast tray was served around 7:30-08:00 AM. Care was not provided to Resident #44 until the surveyor inquired about the breakfast tray at 10:30 AM. The nurse stated that the resident was left in bed due to a cardiologist visit. There was no rationale provided for the breakfast tray left at the bedside with the side rails up and the breakfast tray, not within the resident's reach. The Charge Nurse also acknowledged that since the fall, the resident had not been able to ambulate and confirmed that Resident #44 could not reach the breakfast tray. That same day the Charge Nurse had to use a transport chair to transfer Resident #44 from the room to the hallway to be weighed. No weight loss was noted. On 09/02/22 at 10:25 AM, an interview with the CNA who cared for the resident that day revealed that he worked the 3:00-11:00 PM shift and was unfamiliar with Resident #44's routine. He was aware that Resident #44 was combative with care. The CNA added that he did not provide care yet to Resident #44. Resident #44 was a high risk for falls. Resident #44 received a score of 16 on the Fall Risk Assessment. A care plan to prevent falls was in place prior to the fall. After the fall, dated 07/12/22, the care plan was revised to include non-skid strips on the fall care plan. However, the facility did not follow up with: a) recommendations on the After Visit Summary. b) recommendations on the X-Ray report, which came with an Alert. Resident #44's clinical record lacked evidence that the physician or nurse practitioner was consulted with all the recommendations dated 07/12/22 and 07/13/22 and that a head to toe assessment was done on all three shifts following the fall. The clinical record lacked evidence of any steps taken to address Resident #44's health status in a timely manner. The facility lacked evidence of a system to ensure that all recommendations and consults were thoroughly reviewed, documented, and communicated to the physician or the nurse practitioner in a timely manner. Although the nurse practitioner confirmed that she signed the X-Ray report on 07/19/22, the clinical record lacked evidence that she was aware of the possible fracture, acted upon the recommendations, and consulted with Resident #44's family before 07/26/22. An undated facility policy entitled Guidelines for Charting and Documentation included: The purpose of charting and documentation is to provide : 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, and the progress of the resident's care. 2. Guidance to the physician in prescribing appropriate medications and treatments. 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. The above findings were reviewed with the facility administrative staff on 09/01/22 and again during the Exit Conference. No further information was provided. NJAC 8:39-27.1 (a)

Based on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 08/16/22 from 10:29 AM to 12:43 PM, the surveyor toured the kitchen in the presence of the Assistant Food Service Director (AFSD) and observed the following: 1. In refrigerator #2, there was a wheeled metal cart that was covered with an unlabeled and undated clear plastic bag, that the AFSD identified as the breakfast cart, which contained: On the top shelf was one metal 4 inch half pan that was covered with clear plastic wrap, that contained a solid yellow substance with black specks, that the cook identified as garlic butter, with no label and no use by date. The AFSD acknowledged that the garlic butter should have been dated. On the second shelf was one metal 4 inch half pan that was covered with clear plastic wrap, that the AFSD identified as pieces of lettuce, sliced tomato, and sliced turkey, with no label and no use by dates. On the third shelf was one metal 4-inch pan that was covered with clear plastic wrap, that contained six circular light brown patties, that the AFSD identified as pancakes, with no label and no use by dates. On the fourth shelf was one metal tray containing 43 circular tan patties, that the AFSD identified as 2- ounce sausage patties, with no covering, no label and no use by dates. On the fifth shelf was one metal tray containing 60 circular tan patties, that the AFSD identified as 2-ounce sausage patties, with no covering, no label and no use by dates. The AFSD acknowledged there was no covering or label on the sausage patties and stated that they should have been covered with plastic then labeled and dated so everyone would know exactly what the food was and when the food was prepared. The AFSD discarded the patties. 2. On the bottom shelf of a metal rack there was an unlabeled metal roasting pan which contained four sealed, defrosted, five pound individual packages marked mechanically separated turkey, which were resting in a large amount of red liquid. One package was marked with a sticker that stated, dated pull 08/08, thaw 08/08, use by 08/18, one package was marked with a sticker that stated PM, with no pull or use by date, and two packages were not marked with pull or use by dates. The AFSD acknowledged there were no dates on three of the packages of turkey and discarded the meat. The AFSD stated all of the meat should have been marked with the date so that everyone would know it was not bad. 3. In refrigerator #3, on a wheeled metal cart, was a one quarter half inch pan covered with clear plastic wrap and foil that contained several circular slices of pink meat, that the AFSD identified as 3-4 pounds of sliced pork roll, with no label or use by dates. The AFSD acknowledged that the pork roll should have been labeled and should have had a use by date. The AFSD discarded the meat. 4. In freezer #1 there was one tied, clear bag containing four tan rectangular meat patties, that the AFSD identified as breaded fish, with an opening in the bottom of the bag with the meat exposed to air, with no label and no use by date. The AFSD acknowledged that the fish should have been labeled and stored in the original box and he discarded the bag. There was one tied, clear bag marked breaded scallops with no open or use by date. The AFSD acknowledged that the scallops should have been dated and discarded the bag. There was one box marked salmon patty that contained an unsealed white plastic bag with the meat exposed, with a manufacturer sticker dated 07/07/22, with no open or use by dates. The AFSD acknowledged the bag should have been closed and discarded the salmon. There was one sealed clear bag containing small tan squares, that the AFSD identified as tater tots, with no label or use by dates. The AFSD stated there should have been a label and the tater tots should have been stored in the original box. There was one sealed four pound package marked liverwurst with a manufacturer stamp marked sell by [DATE] with no use by date. On a rolling metal cart, there was a metal tray covered with clear plastic wrap marked roast beef and dated 07/31, with the side of the tray uncovered with the meat exposed. There was white frost observed on all three pieces of meat. The AFSD acknowledged that the meat was not sealed correctly and discarded the meat. There was one metal tray marked pancakes that was dated 08/12, that was partially covered with clear plastic wrap with the pancakes exposed to air. The AFSD acknowledged the pancakes were not sealed correctly. On the bottom shelf of a metal rack there was one sealed 10 pound package of ground beef with manufacturer stamp marked best before or freeze by 08/08/22, with no received or use by date. The AFSD acknowledged there was no received date and stated that the meat should have had a sticker with the date it was received. The AFSD then discarded the meat. On the top shelf of a rolling metal cart, there was a metal tray with five, unwrapped, red oblong shaped pieces of meat wrapped in dough with no label or dates. The AFSD identified them as pigs in a blanket and discarded the meat. On the second shelf there was one metal tray marked pigs in blanket, dated [DATE], that was partially covered with clear plastic wrap, the meat was exposed to air, and white crystals were observed on the meat. The AFSD stated that the meat was freezer burnt and discarded it. On a metal tray was one brown piece of meat marked filet [NAME] that was dated 05/21/22, with the clear plastic wrap partially covering the meat and the end of the meat exposed. The AFSD acknowledged the meat was exposed and stated that the meat should have been covered then discarded the meat. There was one metal tray marked breaded eggplant that was dated 08/11/22, that was partially covered with clear plastic wrap with the side of the tray open and the eggplant exposed. The AFSD acknowledged the opening in the covering then discarded the food. 5. In the dry storage room, there was one sealed plastic container labeled orzo with no open or use by date. The AFSD acknowledged he did not know how old the orzo was and stated it should have had a dated sticker on it. On a metal rack was one 111 ounce can of three bean salad with a large dent, one 106 ounce can of tomato puree with a large dent, one 106 ounce can of fruit cocktail with a large dent, one 6 pound 10 ounce can of mandarin oranges with a large dent, and one 6 pound 10 ounce can of cut yams with a large dent. The AFSD acknowledged the dented cans and discarded them in the trash. The AFSD stated that all of the employees were inserviced and know to remove dented cans to the milk crate for them to be discarded. During an interview at that time, the AFSD stated that it was important to not serve food from dented cans because the food could be compromised. The AFSD further stated that if the residents ate compromised food from a dented can, or food that was old, undated or uncovered, that the residents could get sick or die. 6. There was one large free standing white covered bin containing a white powder, marked flour, with no open or use by date. There was one large free standing white covered bin containing white granules, marked sugar, with no open or use by date. The AFSD stated the bins have never been dated. There was a large black hair resting on the sugar. The AFSD acknowledged the hair and stated it should not have been there. The AFSD removed the bin and instructed the cook to dump the sugar and clean the bin. 7. On the top convection oven, there was a brown greasy residue on the inside of the doors and black debris on the oven floor. On the bottom convection oven, there was a brown greasy residue on the inside of the doors and black debris on the oven floor. The AFSD acknowledged they were dirty and stated they were cleaned biweekly. 8. On the spice rack, over a prep table, there was: one opened 16 ounce jar of garlic powder with no open, use by, or expiration date; one opened 1 pound jar ground sage with no open, use by, or expiration date; and two 3 ounce jars of marjoram with no open, use by or expiration dates. The AFSD acknowledged the undated spices and discarded them. The surveyor reviewed the facility's policy, Food Storage, Date of Issue/Revision 08/22/22, which revealed Procedure: 5. All food products will be identified and must show date of receipt. 6.All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 7. Any cans that are bulging, crushed, have deep or sharply pointed dents, have holes, and/or are heavily rusted must be separated from stock and discarded. Per the USDA, cans with small dents do not need to be discarded. A deep dent is one that you can lay your finger into. The surveyor reviewed the facility's policy, Labeling of Foods/Food Products, Date of Issues/Revision 08/22/22, which revealed Protocol: 3. Pull/Thaw/Use By labels are for pulling food from the freezer. Each item pulled from the freezer must be labeled, along with the received date. 4. Prep Date/Use By labels are for food that has been prepped for use. 5. White labels, dry good storage (which includes, but is not limited to such items as potato flakes, spice type products, canned items). The surveyor reviewed the facility's policy, Storage of Prepared Food Items, undated, which revealed Procedure: 1. Foods prepared and held for over 24 hours under refrigeration need to be labeled with a preparation date. 2. Once prepared, food, including sliced deli meats, is not to be held for longer than five days. 3. Any food more than five days old is to be discarded. The surveyor reviewed the facility's policy, Cleaning/Preventive Maintenance of [NAME] Ovens, Date of Issue 12 [DATE], which revealed Purpose: To maintain ovens properly. Procedure: 3. Wash interior sides, bottom and top with mild detergent and water. A stainless steel cleaner should be used for the interior. Rinse and dry. 4. Wash doors using a stainless steel cleaner. Rinse and dry. NJAC 8:39 17.2(g)

Based on interview and document review it was determined facility failed to: a.) ensure that the facility Quality Assurance Improvement Program (QAP), identified, developed and implemented Quality Assurance Improvement Plans (QAPI) to address areas related to infection prevention and control related to an ongoing COVID-19 outbreak that began on 11/23/21, b.) ensure all infections and antibiotic usage was monitored by the QAP, and c.) ensure the QAP monitored all 13 clinical areas per facility policy. The deficient practice impacted 5 of 5 currently occupied resident units and was evidenced by the following: Refer to 886L, 880L, 881F On 08/16 22 at 10:24 AM, during the entrance conference held with the facility administration, the administration informed the survey team that the facility was presently in an outbreak of COVID-19 which began on 11/23/21. On 08/31/22 at 12:53 PM, the surveyor interviewed the facility Licensed Nursing Home Administrator (LNHA) regarding the facility Quality Assurance and Improvement (QAI) process. The LNHA stated the Assistant Nursing Home Administrator (ANHA) was in charge of the QAI program, and stated as the LNHA she was present at the monthly meetings. On 09/02/22 from 9:04 AM to 9:42 AM, the surveyor interviewed the ANHA, with a QAI Nurse present. The ANHA stated she has been responsible for the facility quality assurance process on and off since 2008, and then resumed the responsibility back in 2021. The ANHA stated her role for the QAI was to work with the department heads, work with the quality indicators, and assist with the department heads to ensure what was supposed to be submitted for each department's individual QAPI plans. The surveyor asked the ANHA to list the current QAPI plans for all facility departments. The ANHA stated, in addition to monitoring falls and elopements, the current active QAPI plans for each department were as follows per the January 2022 QAPI report: Activity Department (related to low attendance at resident activities), Business Department (related to vendors and visitor incidents), Nutrition (related to resident weight loss), Food Service (related to the food, including temperature and taste), Housekeeping (related to the cleanliness of resident rooms and cleaning of wheelchairs), Infection Control (related to increasing the COVID-19 boosters and vaccination status percentage for employees), Maintenance (related to perimeter door identification), Medical Records (related to closed and discontinued charts, medical errors, medication pass compliance, restorative program audit, as needed psychotropic medication, pain with wound treatments, and reportable event monitoring. The ANHA then reviewed the July 2022 QAPI report and report and stated additional QAPI plans included from Rehabilitation (related to wound modalities), Nursing (related to medical storage), Social Services (related to ombudsman release of papers, funeral homes and grievances, Staff Development (related to mandatory educational topics). The surveyor inquired to the ANHA regarding how new topics for QAPI plans were developed and initiated. The ANHA stated when we conduct the QAPI meeting the departments would usually come up with new topics, and if the department needed to form a QAPI team then we would determine who would be on the team. The ANHA stated that the QAP process would include identifying root causes analysis regarding the problem. The ANHA stated once a root cause analysis was completed for a QAPI, it would be reviewed to identify if a system issue or a staff issue was the problem and then addressed by the group that was assigned the problem. The QAP would also review the policies, develop new policies as needed, and finalize the new policies. The ANHA stated that the LNHA has joined us in the policy revision meetings and the surveyor inquired as what role that the facility Medical Director (MD) had with the QAPI. The ANHA stated that he would be updated on the QAPI's, and right now it is on a limited basis. The surveyor asked the ANHA what the purpose of the QAP was. The ANHA stated to ensure that we have effective and efficient quality care for the residents and we want to make sure we are giving the proper care to the residents. The surveyor inquired to the ANHA regarding how the QAP would determine what QAPI plans were initiated regarding infection control. The ANHA stated that based on the past meetings that the facility Infection Preventionist RN (IP/RN) was monitoring COVID-19 boosters, and stated the IP/RN just brought up the COVID-19 boosters for a QAPI. The ANHA stated that any issues from previous surveys would be enacted into a QAPI plan also. The surveyor inquired to the ANHA regarding any infection control related concerns that were current QAPI plans, or anything related to the ongoing COVID-19 outbreak that began November 23, 2021. The ANHA stated it's not part of any QAPI's that have been brought up in the QAP meetings. The ANHA stated there was a separately held infection control (IC) meeting. The surveyor inquired to the ANHA if she attended the IC meeting and she responded no. The surveyor asked if infection control issues should be part of the QAPI program an she stated not really. The surveyor asked the ANHA to confirm if there were any additional QAPI plans related to infection control. The ANHA showed the surveyor the document that confirmed the only infection control parameter that was currently monitored by the QAP was for the COVID-19 boosters. The surveyor asked the ANHA if the QAP had been aware of the concerns regarding the lack of contact tracing, and COVID-19 testing that was identified during the current survey, and the ANHA stated no. The surveyor inquired to the ANHA if antibiotic use was tracked and reported at the QAPI meetings. The ANHA stated that antibiotic stewardship was not part of the QAPI meeting, and stated that the IC/RN was focusing on urinary tract infections only regarding the antibiotic stewardship, however, the IC/RN should be tracking all infections. The surveyor inquired if any part of the infection control meetings were carried through to the QAPI program, and she stated no they were not integrated, and the infection control meeting minutes were not part of the QAP. On 09/02/22 at 10:03 AM, the surveyor interviewed the IC/RN in the presence of the survey team. The surveyor inquired to the IC/RN regarding what current infection control QAPI plans were in place. The IC/RN stated the COVID-19 boosters were the current infection control QAPI. The surveyor asked the IC/RN what was the purpose of the infection control meeting. The IC/RN stated the purpose of the infection control meeting was to discuss infection control issues. The surveyor asked the IC/RN if information discussed at the IC meeting transferred to the QAP. The IC/RN stated she would present numbers of infections, however there was no benchmarks or QAPI plans created. The surveyor asked the IC/RN if QAPI plans were developed regarding any infection control concerns. The IC/RN stated infection control issues would not develop into a QAPI plan. The IC/RN stated I just present any issues, and stated no when asked if after numbers of infections were discussed, would then specific and measurable goals be developed. The IC/RN stated that QAPI was focused on specific issues and how we could improve things in a specific format and stated I am so backed up with work, that is something I could just present. On 09/02/22 at 10:21 AM, the surveyor interviewed the LNHA in the presence of the survey team regarding the QAPI program. The LNHA stated the ANHA was responsible for implementing the QAPI program and stated that we also have an infection control meeting. The surveyor inquired to the LNHA if the infection control meeting was integrated into the QAPI program and she stated yes, it was part of the QAPI. The surveyor inquired if the QAPI plans should be specific and measurable and the LNHA stated yes, it is not running the way I would like it to run. The LNHA stated that minimally there should be a status update for the clinical care areas, and stated she was aware that the clinical care areas were not being monitored. The LNHA stated I am ultimately responsible for everything that happens in the building, to ensure appropriate management for each of the departments and to monitor goals and outcome of the other assistant administrators. The surveyor asked the LNHA what the purpose of the QAP was. The LNHA stated to identify areas needed for improvement, measure progress and set goals. A review of the facility Quality Assurance Improvement Plan, Approved 05/02/2022 by the LNHA. Revealed the following: Purpose: .strive to consistently provide the highest quality resident-centered long term care, through efforts to continuously improve services, care and treatment through professional collaboration, innovation and dedication in a setting that promotes dignity and independence. The QAPI program will systematically monitor all services provided by the facility and implement appropriate interventions to promote continual improvement in quality of care, quality of life, resident choice, person-centered care and services provided; Components of the QAPI Plan: The QAPI program will incorporate the following components in the implementation of the QA plan, Maintain a Quality Assurance Committee which is responsible for the implementation of the QAPI plan. The QA committee will identify, define, and measure performance improvement concerns and establish goals in order to provide optimal care and services, Identify and prioritize problems and opportunities for improvement, Incorporates the following Five Elements essential base for the Performance Improvement program which includes: 1. Design and Scope: the QAPI program will be ongoing and comprehensive to include all departments and services provided, 2. Leadership: administration supports and develops a culture of striving for continual improvement in order to provide excellence in all areas of service and care. Encourages input from residents, families and caregivers to identify problems. Will ensure provision necessary resources to address areas of concern, 3. Feedback, Data Systems and Monitoring: draws data from multiple sources. Monitors and tracks care, services and project outcomes, 4. Performance Improvement Projects (PIPS): implements and monitors specific projects to address identified concerns, 5. Systematic Analysis and Action: utilizes Root Cause Analysis to thoroughly examine the cause or exacerbation of an identified problem; QAPI Leadership: Administrator will be responsible for oversight of the QAPI program ., .will ensure regular reports of the QAPI program and activities; Quality Assurance Coordinator (QA) is responsible for implementation of the QAPI program. The QA Coordinator will work with administration and staff to ensue collection and analysis of data from all identified sources. QA Committee meetings, led by the QA Coordinator, will meet at least quarterly to review collected data, identify problems and prioritize areas of concern for potential intervention projects; The QA Leadership Committee will be responsible to review and analyze collected data, investigate root causes of problems identified, and assist with decisions on actions to implement that will address the underlying cause of the problem. Quality Improvement Program Areas of Assessment and Monitoring: The Quality Assurance Improvement program will monitor the following clinical care areas: Clinical Care: 1. Pressure ulcers and skin breakdown, 2. Psychoactive drug use, 3. hospitalization s and re-hospitalization s, 4. Medication errors, 5. Catheter rates and care, 6. Weight loss, 7. Infections, Antibiotic use, 9. Restraint use, 10. Bowel Impactions, 11. Falls/fall resulting in injury, 12. Incidents of potential abuse, neglect or misappropriation, 13. Other identified care areas. NJAC 8:39-33.1(a)(b); 8:39-33.2 (a)(b)(c)7

Complaint # NJ 129 B. Based on interviews, and record review, it was determined that the facility failed to ensure that care plan interventions were being followed and that direct care staff were consistently following the person-centered care plan. This deficient practice was identified for Resident #29 one of 2 residents reviewed for abuse and was evidenced by the following: On 08/16/22 at 11:45 AM the surveyor observed Resident #29 in bed. The head of the bed was elevated, Resident #29 was alert and able to answer some simple questions. On 08/19/22 at 11:00 AM, the surveyor conducted an interview with the Certified Nursing Assistant ( CNA ) assigned to Resident # 29. The CNA stated that Resident #29 was a total care, does not get out of the bed by choice, had behavior of being accusatory toward staff. She further stated that Resident #29 must have two staff in the room at all times to provide care. The CNA showed the daily assignment to the surveyor. The surveyor reviewed Resident #29's medical record on 08/19/22. The Admission Face sheet revealed that Resident #29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set ( MDS ) an assessment tool to prioritize care dated 08/01/22 revealed that Resident #29 was able to make his needs/ her needs known. Resident #29 scored 11 on the Brief Interview for Mental Status ( BIMS.) normal score 15. A care plan dated 05/10/21 last revised 08/24/22, identified the following problem :I have a habit of accusing others of misconduct towards me The Goal was for Resident #29 to not accusing others of misconduct for the next 90 days. The intervention implemented was for two staff to care for Resident #29 at all times. On 08/23/22 at 12:30 PM an interview was conducted with the Director of Nursing. The surveyor requested all investigative reports for Resident #29. The DON provided a reportable incident dated 08/10/29 regarding an allegation of abuse. 08/24/22 02:30 PM, the surveyor conducted an interview with the (Registered Nurse Unit Manager ) RNUM. The RNUM confirmed that Resident # 29 had behavior of being accusatory toward staff, and the behavior was addressed in the care plan. The surveyor reviewed the care plan with the RNUM and noted that the behavior was not addressed on the current care plan. However the behavior was addressed on the CNA's daily assignment. The CNA daily assignment read, two staff members during care at all times. The surveyor reviewed the incident provided and noted that on 08/10/22 Resident #29 reported an allegation of verbal abuse to the Nursing Supervisor. The facility suspended the CNA pending investigation. 08/25/22 at 11:48 AM, the surveyor entered the room with the RNUM . Resident #29 in the presence of the RNUM agreed to an interview. The resident stated that he had been residing at the facility for 5 years and had a supportive family. Resident #29 stated that something happened and he/she reported it to the Social worker. ( SW ) Resident #29 stated a female CNA referring to him/her as a black bastard, when he/she inquired about what was going to be served for dinner. Resident #29 stated, I did not like it, I reported it. On 08/25/22 at 12:45 PM, an interview with the RNUM confirmed that 2 staff were to care for Resident #29 at all times. The RNUM stated that a prior allegation of abuse prompted the facility to revise the care plan and implemented that two staff would care for and answer Resident #29's call light all times. On 08/25/22 at 1:30 PM, the surveyor requested all investigative reports regarding Resident #29 for review. The following documentation were provided: 03/31/21 12:18 PM, Resident #29 stated that S staff member was verbally abusive. 04/06/21 4:08 PM, Resident #29 alleged verbal abuse from a staff member. 05/03/21 4:36 PM, reported alleged physical abuse. Resident #29 reported that an aid slapped him in the face. 05/10/21 1:48 PM, alleged verbal and physical abuse. 11/24/21 2:06 PM, Resident #29 stated that a Certified Nursing Assistant ( CNA ) called him a damn pig 11/24/21 The intervention implemented again for 2 CNAs to be present when entering Resident #29's room. 2 staff will be present when care was rendered. 08/10/22 at 23:08 PM Resident stated that the staff who provided care was verbally abusive. The CNA was suspended, pending an investigation. The surveyor obtained the CNA's file. The CNA received in-service education on abuse and neglect on 09/24/21. The CNA had been working at the facility since 2015. There was no disciplinary action or written warning on the file. On 08/25/22 at 12:06 PM, the surveyor interviewed the Licensed Social Worker (SW ) who confirmed that Resident #29 reported the alleged abuse. The SW stated that she met with Resident #29 and completed the investigation. Resident #29 was able to describe the time and described the staff involved. The resident indicated that he/she was not afraid and felt comfortable. On 08/30/22 at 09:30 AM, the DON provided the incident report pertaining to the above allegation. There was statement from one staff only. On 08/30/22 at 10:58 AM, two surveyors conducted a telephone interview with the CNA who provided care to Resident #29 on 08/10/22. The CNA stated, that she was aware of the plan of care, she could not find any staff to assist. She stated, that night the facility was short handed. One of the CNA on duty that could assist her,was not allowed to enter Resident #29's room due a prior allegation of abuse. On 08/30/22 at 12:30 PM, the surveyor conducted an interview with the DON. The surveyor reviewed the Care Plan with the DON, the DON stated that the CNA did not follow the plan of care. The surveyor reviewed the Interdisciplinary Progress Notes dated 08/10/22, with the RNUM, the RNUM stated, that she was told that only documentation of clinical relevance should be entered in the medical record. The RN stated that Resident #29 made appropriate remarks . The appropriate remark was not entered in the medical record. NJ Complaint # 9 Based on observation, interviews, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan for a resident who had known triggers for Post-Traumatic Stress Disorder ([CONDITION(S)]). This deficient practice was identified for 1 of 47 residents sampled for comprehensive care plans (Resident #24). This deficient practice was based on the following: Refer to F600 J On 08/18/22 at 10:28 AM, the surveyor observed Resident #24 seated in a wheelchair at the bedside. When interviewed, the resident informed the surveyor that on 07/30/22, he/she pressed the call light to request scheduled pain and anxiety medications and the call light was answered by the Certified Nursing Assistant (CNA) who reportedly informed the resident's assigned nurse. The resident stated the nurse walked in the room and stated that she would obtain the resident's vital signs and medications simultaneously and then proceeded to walk out of the resident's room and closed the door behind her. The resident reportedly pressed the call light in an effort to call the nurse back to the room. The resident stated that the nurse walked back into the room and yelled at the resident to, Stop buzzing. The resident stated that a verbal exchange ensued between the two and when the resident pointed his/her finger into the nurse's face, she pulled down her mask and attempted to bite the resident's finger. The resident stated the nurse continued to scream and the resident got out of bed at that point and attempted to get away from her. The resident alleged that the nurse lunged the medication cart towards him/her three times and hit the resident's left foot. The resident reportedly tried to call for a nursing supervisor and the nurse pulled the wheelchair two or three times and caused the resident to do a wheelie in the wheelchair and the nurse continued along side the resident as the resident attempted to leave the nursing unit. The resident confirmed that the nurse was an agency nurse who had never provided care to him/her before and was not permitted to return to the facility. The resident further stated that the nursing supervisor responded and escorted the crazy nurse off of the unit, and the resident was assured that the nurse was not permitted to return to the facility. The resident further stated that he/she had severe [CONDITION(S)] and was visibly upset during the recount of the event. A review of the resident's medical record reflected the following: Review of Resident #24's Resident Facesheet revealed that the resident was admitted to the facility in September of 2021, with a single diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 08/10/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was fully cognitively intact. Further review of the MDS indicated that the resident was independent with bed mobility, required limited assistance of one person for transfers, required set up for meals and required extensive assistance of one person for toileting and personal hygiene. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's Plan of Care (POC) revealed that a single diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the POC revealed that there was an entry dated 07/30/22, which confirmed the resident's account of the incident that occurred between the resident and the agency nurse. The problem identified that the resident had an altercation with a nurse, reported that the agency nurse yelled at the resident, pointed her finger at the resident, and blocked the resident with the medication cart in his/her room. Goals included that were effective on 08/11/22, included that the resident would feel safe and would be allowed to move freely around the facility. Interventions included: Staff to treat resident with dignity, respect, not raise their voices or yell at the resident, staff to allow the resident to leave his/her room as long as environment was safe, encourage resident to engage in care, staff to encourage resident to move about the facility at will, if resident asserts themselves verbally, staff to actively listen, validate, and respond to resident in an intentionally calm or low voice and lastly, staff to engage with resident and provide support. Further review POC revealed that there was no entry related to the resident's primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/01/22 at 9:04 AM, the surveyor interviewed the Supervisor of Nursing/MDS Coordinator (SON/MDSC), who stated that each unit was assigned it's own MDS Nurse. She stated that she bore the responsibility to sign that the MDS was completed prior to submission. The SON/MDSC stated that the facility held Interdisciplinary Team Meetings/Care Planning MDS meetings. She remarked that it was identified in meetings that Resident #24 had a lot of pain. When the surveyor asked if she would expect to see a POC entry related to [CONDITION(S)], she stated, Yes, especially with some of the resident's behaviors that I have heard about. The SON/MDS described the resident behaviors which included: yelling at staff, dressing change refusal and room mate refusal. She stated that a [CONDITION(S)] POC should have been there in the POC with specific triggers which may provoke the resident's behaviors. On 09/02/22 at 9:52 AM the surveyor interviewed the 7 AM - 3 PM Supervisor, who reportedly worked on another unit. The surveyor asked her to review Resident #24's Care Plan which was kept in a binder on the counter at the nurse's station with the surveyor. The 7 AM - 3 PM Supervisor stated that the MDS Nurse who was assigned to the unit was responsible to generate and update the resident's POC. The 7 AM - 3 PM Supervisor stated that the resident's POC should have included a [CONDITION(S)] entry and how to handle the resident's behaviors when they come up. The 7 AM - 3 PM Supervisor stated, Like what just happened now. The 7 AM - 3 PM Supervisor stated that the Unit Clerk phoned her unit and requested that she come over and address a concern with Resident #24. The 7 AM - 3 PM Supervisor stated that the resident complained that he/she requested a topical medication to treat foot pain that was no longer ordered and the resident hollered at the the nurse to, Do it now! The 7 AM - 3 PM Supervisor stated that she phoned the doctor and obtained an order and the doctor advised her to send the resident to the hospital if no relief. The 7 AM - 3 PM Supervisor stated, The POC was very important and that was why it was left on the desk. That is why it is here. On 09/02/22 at 10:02 AM, the surveyor interviewed Resident #24's assigned MDS nurse who stated that she was unsure if she initiated the resident's POC. She stated that the resident had behaviors, but not [CONDITION(S)]. She stated that the POC was generalized with behaviors, not specifically [CONDITION(S)]. She further stated that maybe we have not connected the behaviors and the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/02/22 at 9:31 AM the surveyor interviewed the Social Worker (SW), who stated that Resident #24 had spoken to her about their diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The SW stated that we suggested that we kept the resident's door closed a little bit, and the resident informed her that the resident did not want the door closed, because it was the resident's preference to keep the door open. The SW stated that the resident also referred to stuff that happened during war time. The SW further stated that, The POC should have addressed the resident's [CONDITION(S)] and included interventions and goals to include triggers such as loud noises and closing the door. On 09/02/22 at 12:13 PM the surveyor interview the Director of Nursing (DON), who stated that she would review Resident #24's POC because [CONDITION(S)] was the big problem. She stated she would have expected that the POC would have included an entry for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further stated that if staff were aware that the resident had [CONDITION(S)], it should have been care planned to help alleviate the resident's behaviors. Review of the facility policy titled, Care Plans-Comprehensive (undated) revealed the following: Purpose: An individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident's comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's conditions change. Each resident's comprehensive care plan is designed to: Incorporate identified problem areas, Incorporate risk factors associated with identified problems, Build on the resident's strengths, Reflect the resident's expressed wishes regarding care and treatment goals, Reflect treatment goals, timetables and objectives in measurable outcomes, Identify the professional services that are responsible for each element of care, Aid in preventing or reducing declines in the resident's functional status and/or functional levels, .Reflect currently recognized standards of practice for problem areas and conditions . The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: When there has been a significant change in the resident's condition, When the desired outcome is not met, When the resident has been readmitted to the facility from a hospital stay; and at least quarterly . NJAC 8:39-11.2 (e)(1)(2)

Based on observation, interviews, and record review, it was determined that the facility failed to a.) ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. b.) Ensure all residents were seen by the physician or nurse practitioner every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 14 of 47 residents (Resident #8, #24, #50, #59, #64, #83, #84, #78, #87, #92, #106, #122, #125 and #187) reviewed. Reference: Centers for Medicare and Medicaid Services (CMS) memo QSO-,d+[DATE]-NH & NTC & LSC, dated [DATE], Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers indicated the Emergency Declaration Blanket Waivers Ending for SNF/NFs 30 Days from Publication of this Memorandum including Physician Visits-42 CFR 483.30 (c ) (3): CMS waived the requirements that all required physician visits (not already exempted in 483.30 (C) (4) and (f) must be made by the physician personally. The waiver modified this provision to permit physicians to delegate any required physician visit to a nurse practitioner, physician assistant, or clinical nurse specialist who is not an employee of the facility, who is working in collaboration with a physician, and who is licensed by the State and performing within the state's scope-of-practice laws. This deficient practice was evidenced by the following: 1. On [DATE] at 9:39 AM, a review of Resident #64's chart by Surveyor # 1 revealed the Primary Physician 30 Day Assessment and Medical Plan of Care forms were signed by Nurse Practitioner (NP) #1 for [DATE], [DATE], and [DATE]. Surveyor #1 was unable to locate a June visit by the PCP or NP at that time. On [DATE] 9:38 AM, Registered Nurse/Unit Manager (RN/UM #1) reviewed Resident #64's chart with the surveyor. He was unable to show documentation for when the resident was last seen by the Primary Care Physician (PCP). He asked the unit clerk to review Resident #64's thinned chart records for PCP documentation. At 09:42 AM, the RN/UM #1 stated that they were unable to find documentation that Resident #64's PCP #2 had conducted a face-to-face visit. He stated that PCP #1, PCP #2 and NP#1 were from the same medical practice. He then stated that the PCP would do the assessments after an admission for 3 months and then the NPs would take over the resident's care. On [DATE] at 10:08 AM, a review of Resident #187's chart by Surveyor #1 revealed the Primary Physician 30 Day Assessment and Medical Plan of Care forms were signed by NP #1 for [DATE] and [DATE]. The Annual/Readmit Examination & Plan of Care form dated [DATE] was signed by NP #1. Further review of the chart revealed that Resident #187 was hospitalized in July and was readmitted to the facility [DATE]. On [DATE] at 10:16 AM, Surveyor # 1 interviewed Registered Nurse Supervisor (RNS) #1 who stated that the PCP and the NP should alternate seeing the resident every other month, but the PCP would see a new admission for the first 3 months. RNS #1 reviewed Resident #187's chart with the surveyor and was unable to find documentation that the PCP had seen the resident since [DATE]. On [DATE] at 10:23 AM, Surveyor #1 interviewed Unit Clerk (UC)#1 who stated that the PCP should see the resident for the first 3 months after admission and then the NP would take over the care. On [DATE] at 10:13 AM, during an interview with the survey team, Assistant Nursing Home Administrator (ANHA #1) stated that the PCP should see the residents at least every other month, but there was an executive order in place which allowed the NPs to continue to see the residents each month instead of the PCP. He further stated, he was not sure if the waiver had expired. On [DATE] at 12:00 PM, ANHA #1 provided the survey team with a copy of the QSO-,d+[DATE]-NH & NTC & LSC memo, dated [DATE]. He confirmed that the PCP waiver expired as of [DATE], which meant that the physician should have seen the resident at least once since May. On [DATE] at 09:03 AM, Surveyor #1 requested documentation that the PCP or NP had seen Resident #64 for [DATE] and Resident #187 for [DATE] from ANHA #1. On [DATE] at 12:48 PM, ANHA #1 confirmed that they were unable to provide documentation that the PCP or NP had seen Resident #64 in [DATE] or Resident # 187 for [DATE]. On [DATE] at 11:37 AM, during a phone interview with the survey team the Medical Director (MD) stated that the long-term residents should be seen once a month by the PCP and NP. They could alternate monthly visits, but the PCP must see the resident at least every other month. He further stated that the PCP would see a new admission for the first 3 months and then NP can alternate with the PCP. On [DATE] at 11:21 AM, in the presence of the surveyor and ANHA#2, the Director of Nursing (DON) reviewed the Interdisciplinary Progress Notes and confirmed that there was not documentation that the PCP or NP had seen Resident # 187 for [DATE]. The DON stated the PCP should have seen Resident #187 within 48 hours of readmission in [DATE] and then again in [DATE]. At 11:58 AM, ANHA #2 confirmed that they were unable to find documentation that the PCP had seen the resident since readmission to the facility. 43308 2. On [DATE] at 11:43 AM, Surveyor #2 interviewed RN/UM #1 who stated the PCPs came to the facility based on the need of the residents. He stated that they came monthly to complete their assessments and for all new admissions they came within 72 hours to complete the admission assessment. He further stated the PCPs came for the first three (3) months then the NP came to visit the residents three to four times a week. The RN/UM #1 stated PCP #3 had not been to the facility, but that PCP #4 worked with PCP #3, and she came to the facility often. A review of the Primary Physician 30-day Assessment and Medical Plan Care for Residents #8, #50, #87 and #122 reflected the physician's NPs had completed the monthly physician visits as followed: NP #1 completed and signed the form for Residents #8, #50 and #122 on [DATE], [DATE], and [DATE]. NP #2 completed and signed the form for Resident #87 on [DATE], [DATE] and [DATE]. On [DATE] at 10:08 AM, Registered Nurse/Charge Nurse (RN/CN #1) stated NP #2 came to the facility every day and PCP #4 came to the facility twice a week. She stated to be honest she was unsure of the last time PCP #1 and #3 came to the facility. She further stated PCP #2 came on admission and followed the residents for three (3) months and PCP #2 also came into the facility for any cardiology consults. On [DATE] at 10:08 AM, ANHA #1 stated the [DATE] monthly physician visits for Residents #8, #50 and #122 were not done yet but the residents would be seen by NP #1 today ([DATE]) or tomorrow ([DATE]). The ANHA #1 further stated the physicians normally sees the residents at admission, the first three (3) months, and then every other month. He stated there was an executive order in place which allowed the NPs to continue to see the residents each month instead of the PCP, but he was not sure if the waiver had expired. On [DATE] at 10:44 AM, Surveyor #2 observed PCP #4 on the Eagle unit and interviewed her regarding the physician visits. PCP #4 stated she came to the facility twice a week but decreased it to once a week since May of 2022 but emphasized that NP #2 came to the facility every day. She stated each week she visits a set number of residents which included any residents that staff mentioned had recent changes. PCP #4 stated that there was a certain criteria which warranted a physician visit. She explained the criteria included all new admissions/readmissions and the first three (3) months after an admission. She further stated the NP would take over the monthly physician visits as long as the resident was stable and had no issues. PCP #4 stated if the resident wasn't stable then the PCP would visit the resident. On [DATE] at 12:09 PM, NP #1 stated in the presence of Surveyors #1 and #2 that she came into the facility twice a week on Tuesdays and Wednesdays and sometimes on Thursdays for a few hours. She further stated she was not sure of how often the PCPs came as sometimes they preferred to complete their rounds on the residents at night. NP #1 stated her role was to see residents and complete their assessments and confirmed she was at the facility today ([DATE]) to complete the monthly assessments for Residents #8, #50, and #122. She stated the requirements for the physician visits were once a month unless they are sick. NP #1 explained it was either herself or PCPs #1 or #2 that were to complete the monthly physician assessments. When asked was the PCPs and NPs required to alternate the monthly physician visits, NP #1 stated they were supposed to alternate each month but acknowledged that does not happen. AHNA #1 provided the Primary Physician 30 Day Assessment and Medical Plan of Care for August of 2022 which reflected that NP #1 completed the form on [DATE] for Residents #8, #50, and #122. 44605 3. On [DATE] at 9:30 AM, during record review for Resident # 59, the surveyor observed the Primary Physician 30 Day Assessment and medical Plan of Care forms were not signed by the Physician for May, June, July of 2022. [DATE] form was not available. The forms were signed by Nurse Practitioner (NP #1). On [DATE] at 10:50 AM, during record review of Resident # 24's chart, the surveyor observed the Primary Physician 30 Day Assessment and Medical Plan of Care was not signed by the Physician for May, June, July and August of 2022. The forms were signed by NP #2. 43307 4. A review of the Annual/Readmit Examination and Plan of Care for Resident #84 reflected the physician's NP #1 had completed and signed the form on [DATE]. A review of the Primary Physician 30-day Assessment and Medical Plan of Care for Resident #84 reflected the physician's NP #1 had completed and signed the monthly physician visits form on [DATE]. A review of the Primary Physician 30-day Assessment and Medical Plan of Care for Resident #78 reflected the physician's NP #2 had completed and signed the monthly physician visits form on [DATE], [DATE], and [DATE]. On [DATE] at 09:22 AM, Surveyor #4 interviewed Licensed Practical Nurse (LPN #1) who stated she was unsure which doctor visited the facility because NP #1 was the staff member she saw on the unit and the staff member she called for the residents. LPN #1 further stated she did not know how often the doctor was supposed to visit the residents and that NP #1 covers for the doctor. On [DATE] at 11:17 AM, Surveyor #4 interviewed Resident #78 who stated PCP #3 was his/her doctor and that he/she only saw him by request and that he does not come in regularly. On [DATE] at 10:34 AM, Surveyor #4 requested from ANHA #1 the physician notes for the last four months on Residents #84 and #78. On [DATE] at 01:33 PM, ANHA #2 provided Resident #78's Primary Physician 30-day Assessment and Medical Plan of Care dated [DATE], [DATE], and [DATE] which revealed to have all been completed and signed by NP #2. On [DATE] at 01:50 PM, ANHA #1 provided Resident #84's Annual/Readmit Examination and Plan of Care dated [DATE] that was completed and signed by NP #1, and Primary Physician 30-Day Assessment and Medical Plan of Care dated [DATE] that was completed and signed by NP #1. ANHA #1 stated that they were the only two notes available. 39460 5. On [DATE] at 12:27 PM, the surveyor interviewed the Registered Nurse/Charge Nurse (RN/CN #2) for Freedom Unit who stated the residents were usually assessed monthly by the NP #1 who comes to the facility nearly every day. The RN/CN #2 was not sure how often the physician made rounds or came to the facility to assess the residents, that she mostly saw the NP. A review of the Primary Physician 30-Day Assessment and Medical Plan of Care forms for Residents #106, and #125 reflected NP #1 had conducted the monthly physician's assessment as followed: NP #1 completed and signed the form for Resident #106 on [DATE], [DATE], and [DATE]. NP #1 completed and signed the form for Resident #125 on [DATE], [DATE], and [DATE]. On [DATE] at 11:30 AM, The surveyor interviewed the ANHA #1 who stated he was unable to locate a Primary Physician 30 Day Assessment and Medical Plan of Care form for [DATE] for Resident #106. The facility was unable to provide documentation that a physician responsible for supervising the care of residents conducted face to face visits, wrote and signed progress notes at least every 60 days. 39885 6. On [DATE] at 12:29 PM, during record review for Resident #92, Surveyor #6 observed that the physician visit dated [DATE] was documented on a Primary Physician 30 Day Assessment and medical Plan of Care form and was not signed by the Physician. The form was signed by NP #1. The surveyor observed that the physician visits dated [DATE] and [DATE] were documented on an Annual/Readmit Examination & Plan of Care form and were not signed by the Physician. The form was signed by NP #1. Surveyor #6 did not observe a physician visit for [DATE]. On [DATE] at 10:20 AM, the surveyor requested information from the ANHA #1 if a physician visit was done in July. The facility did not provide documentation that a physician visit was done during [DATE] by either a physician or NP. The facility did not provide documentation that a physician responsible for supervising the care of residents conducted face to face visits, wrote and signed progress notes at least every 60 days. 36419 7. On [DATE] at 9:45 AM, Surveyor #7 reviewed Resident #83's hybrid chart which revealed Resident #83 was admitted to the facility on ,d+[DATE]. A further review reflected the Primary Physician 30 Day Assessment and Medical Plan of Care form was not completed or signed by PCP #1 for ,d+[DATE] or ,d+[DATE]. Surveyor #7 was not able to locate any documentation that PCP #1 had conducted a face-to-face visit with Resident #83. On [DATE] at 10:23 AM, Surveyor #7 interviewed UC #2 who stated that the attending physician should see the resident for the first 3 months after admission, and then the NP could see the resident after the initial 3 months. Unit Clerk #2 further stated that Resident #83 must not have been seen by PCP #1 since the Primary Physician 30 Day Assessment and Medical Plan of Care Form was not filled out. On [DATE] at 10:31 AM, Surveyor #7 interviewed RNS #1 who stated that the Primary Care Physician should see the resident on admission, readmission, and then every ,d+[DATE] months. Surveyor #7 asked RNS #1 for the documentation that Resident #83 had been seen by PCP #1. RNS #1 replied, it should be in the chart. The RNS #1 was unable to provide Surveyor #7 with documentation that Resident #83 had been seen by PCP #1. On [DATE] at 11:03 AM, Surveyor #7 interviewed Resident #83 who stated that he/she would like to see their physician but had not seen him since they were admitted . A review of the facility's undated policy Physician Services revealed Interpretation and Implementation: 5. Physician visits .are provided in accordance with current OBRA regulations. The regulation states that the physician (or his/her delegate) must visit the resident at least every 30 to 60 days. Physician will visit resident for 3 months following admission and every other month to alternate with NP/PA if applicable. NJAC 8:,d+[DATE].2 (D)

Complaint #NJ156516 Based on interviews and review of pertinent facility documentation, it was determined that the facility failed to ensure that licensed nursing staff had the specific competency and education on the removal of a resident's (Resident #179) indwelling urinary catheter. This deficient practice was identified for 1 of 1 Registered Nurse (RN) reviewed and was evidenced by the following: Refer to F658 L The clinical record of Resident #179 was reviewed on [DATE]. According to the Admission Face Sheet, Resident #179 was readmitted to the facility on [DATE] following hospitalization for urinary retention. Review of Resident #179's care plan updated on [DATE] and [DATE], revealed that Resident #179 was at risk for infection due to urinary retention. The care plan goal was for Resident #179 not to have a Urinary Tract Infection and to receive the care needed to maintain his/her current functional status. The Annual Minimum Data Set Assessment (MDS) an assessment tool used by the facility to prioritize care dated [DATE], revealed in section H which addressed Bladder and Bowel, that Resident #179 had an indwelling urinary catheter in the bladder. A review of the Interdisciplinary Progress Notes (IDPN) dated [DATE] at 3:00 PM, revealed that the Registered Nurse (RN) caring for Resident #179 had used an improper procedure in attempts to remove the indwelling urinary catheter which caused part of the catheter to retract into the resident's bladder. It was noted that the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Nurse Practitioner (NP) were made aware. Orders were given to transfer Resident #179 to the emergency room for retracted indwelling urinary catheter removal. Resident #179 was transferred via 911. On [DATE] at 11:52 AM, the surveyor interviewed the RN Unit Manager (RN/UM) regarding the IDPN dated [DATE]. The RN/UM revealed that the RN caring for Resident #179 had cut the indwelling urinary catheter. The RN/UM stated reportedly the RN had never removed an indwelling urinary catheter before, so the RN cut the catheter with a pair of scissors instead of using a syringe to remove the water to deflate the balloon. The remaining portion of the catheter retracted into the bladder. On [DATE] at 9:23 AM, the surveyor interviewed a RN assigned to the 200 unit regarding resource materials available on the floor. The RN directed the surveyor to the binder located outside the Nursing Station that contained all the facility policies and procedures. A review of the facility policy, # 4:035 B titled, Indwelling Catheter Replacement dated [DATE] revealed: Indwelling Catheter replacement must have a physician order indicating size and schedule. Indwelling catheter replacement must be done by a registered nurse whose clinical skill has been checked by the instructor of nursing. If the physician and/or registered nurse, who has demonstrated clinical competence for this procedure is not available, send Resident to the emergency room for indwelling Catheter. The binder and the policy did not include the procedure for the removal of an indwelling urinary catheter. On [DATE] at 11:00 AM, the surveyor conducted a telephone interview with the RN. The RN stated that she had not received any in-service or education on how to remove an indwelling urinary catheter at the facility. The RN stated that after being hired by the facility and during orientation, she was able to demonstrate and be evaluated on the skill sets of inserting an indwelling urinary catheter but was not evaluated on the removal of an indwelling urinary catheter. The surveyor then asked the RN if there were any resource materials on the nursing unit that she could have referenced prior to removal of the indwelling urinary catheter. The RN stated that she did not review any procedure on indwelling urinary catheters but that she was provided with a form titled, [redacted -out of state form] Nursing Skills 21.13 Checklist for [redacted] (indwelling urinary catheter) Removal from a facility representative on [DATE]. A review of the RN's orientation file provided by the Nurse Educator (NE) confirmed that the RN received in-service education on how to insert an indwelling urinary catheter on [DATE] during orientation. On [DATE] at 11:15 AM, the surveyor reviewed the Facility assessment dated [DATE]. According to the documentation provided, the facility had to identify and analyze the resident population that must be considered when determining staffing and resources needed to care for the residents. Under staff training it is noted, Licensed nursing staff receive training and demonstrate competencies in areas of responsibility related to providing skilled nursing care to residents of the facility. Nurses receive updated and additional training as necessary to meet the changing needs of our residents. Training and competencies include, but were not limited to: Licensed nurse training and/ or competencies. Oxygen set up Oxygen masks . Nasal cannula / Non-Rebreather /Simple face mask Wound care / Dressing Change Suctioning skill/ Tracheostomy care Glucometer Medication Pass Indwelling catheter replacement Cardiopulmonary resuscitation (CPR) The Facility's policy for Indwelling Catheter Replacement did not cover indwelling urinary catheter removal. On [DATE] at 12:03 PM, the surveyor interviewed the NE in charge of orientation and staff competencies. The surveyor inquired about specific competencies and skill sets necessary to care for resident's needs. The NE provided the surveyor with the orientation package used by the facility. A review of the orientation package confirmed that indwelling urinary catheter removal was not included in the competency. The RN had not received any in-service training for indwelling urinary catheter removal. The NE stated that licensed staff had to go to general orientation classes for 2 days, then they had to work with a mentor on the nursing unit for 14 days. The NE stated mandatory training was scheduled yearly and skill sets for competencies every two years. Based on the orientation package provided, the facility staff did not receive competency training for indwelling urinary catheter removal. The NE stated that he was aware of the adverse outcome with the attempted indwelling urinary catheter removal on [DATE] and that Resident #179 had to endure emergency care because the indwelling urinary catheter was improperly removed. The surveyor requested in-service or education training that was provided after the incident, none was provided. A review of the facility provided policy revealed it had not been revised to include indwelling urinary catheter removal. When asked how licensed staff competency education was being tracked, the NE added he would be informed by the DON of any needed in-services or educational training. The facility could not provide the rationale for licensed staff not being trained or provided competency on how to remove an indwelling urinary catheter. NJAC 8:,d+[DATE].3(a), 27.1(a)

COMPLAINT # NJ 9 CENSUS: 168 SAMPLE SIZE: 3 Based on observations, interviews, review of the Medical Records (MR), and review of other pertinent facility documents on 8/31/20, and 9/1/20, it was determined that the facility staff failed to ensure a resident with severe cognitive impairment, who was at risk for elopement, and had a known history of wandering and exit seeking behavior, was appropriately monitored and supervised to prevent elopement or exiting the building when on 7/8/20, the CNA for Resident #2 left the unit on an unscheduled break, without giving report to someone, or asking someone to monitor her residents. The facility also failed to follow their Elopement/Possible Elopement/Missing Resident Policy, for 1 of 3 residents (Resident #2) reviewed for elopement. On 7/8/20 at 7:30 p.m., Resident #2 was able to exit the building by the stairwell without the knowledge of the staff, triggered the door alarm, and 2 housekeeping staff heard the alarm and failed to follow the Facility Policy to search for residents. Resident #2 was able to exit the building and wandered down to the driveway and fell sustaining fractures to the maxilla and the humerus of the left arm. This deficient practice placed Resident #2, as well as all other residents with cognitive impairment who were at risk for or had a known history of wandering and/or elopement in an Immediate Jeopardy (IJ) situation. The IJ was identified on 9/1/20 at 2:25 p.m., when the Facility's Administrator (Admin), Assistant Chief Executive Officers #1 and #2 (ACEO), and the Director of Nursing (DON) were notified of the IJ and were provided the IJ template. The Immediate Jeopardy was past Non-Compliance (PNC) for 7/8/20, the day of the elopement. The facility removed the immediacy on 7/8/20, when staff was placed at the exit to monitor 24/7 and staff inservicing was started immediately. The facility was in compliance the day of the survey. This deficient practice was further evidenced by the following: 1. According to the Medical Record (MR), Resident #2 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Dementia without behavior disturbances, [CONDITION(S)], Depression and Type 2 Diabetes. According to the Minimum Data Set (MDS), an assessment tool dated 4/1/20 and 6/25/20, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 04/15, indicating the resident had severe cognitive impairment. The MDS dated [DATE] and 6/25/20, also indicated that Resident #2 had one fall since admission. Review of the Care Plan dated 1/10/20, listed that Resident #2 was at risk for falls related to a history of falls, an unsteady gait and not using a walker. The goals included; that the resident will not have any injuries from a fall. Interventions included; a safe environment, remind resident to call for assistance, encourage use of walker for ambulation, and the bed in a low position. Review of the Care Plan (CP) dated 3/23/20, revealed Resident #2 had a potential to wander related to forgetfulness and confusion. The goals included; that the resident will remain safe in the environment and will not wander to other units or go outside the facility unattended. Interventions included; redirection from the staff if noted wandering, visual observations, and a wanderguard to the ankle and check for placement and function. Review of the Fall Risk Evaluation on admitted d 9/30/19, revealed a score of 11 which indicated Resident #2 was a high risk for falls (10 or above represents a High Risk). Review of the Fall Risk Evaluation dated 6/25/20, revealed a score of 20 which indicated Resident #2 was a high risk for falls secondary to a history of falls, mental status, poor vision, medications, and predisposing diseases. Review of the Facility's Elopement Risk Assessment (ERA) tool dated 6/27/20, revealed Resident #2 had scored 8 on the ERA, which indicated the resident was not a high risk for elopement, a score of 10 or greater is considered a high risk. Under Clinical Condition - History of Elopement Episodes the nurse documented zero points, indicating No known attempts of elopement over the last 6 months. However, review of the progress notes showed documentation by the nursing staff indicating elopement and exit seeking behavior, prior to the assessment, which would have scored Resident #2 as a high risk for elopement. The following interventions were recommended on the ERA form for residents at a high risk: Score of 10 or higher = Elopement Risk Monitoring, Care Plan, wanderguard, and placed on a Secured Unit. The progress notes showed the following: On 6/4/20 at 8:00 p.m., the progress notes documented resident with wandering episodes. Exiting unit, wanderguard intact. On 6/13/20, Resident was seen by staff member going through the exit door at about 9:40 p.m., Resident was redirected to the unit. Resident stated, 'I'm going home.' Resident remains stable. Further review of the progress notes showed Resident #2 continued wandering on 7/2/20 at 7:15 p.m., the nurse documented in the progress notes that Resident #2 was wandering on another unit and required the staff to escort the resident back to the unit. Review of the Facility's Treatment Administration Record (TAR), dated July 2020, revealed an order dated 1/9/20, indicating that Resident #2 had a wanderguard to the ankle, the TAR also showed an order dated 1/9/20, for 1:1 monitoring for elopement risk. There was no evidence to show 1:1 monitoring was in place. Review of the Reportable Event Record/Report (FRE) with an event date of 7/8/20, and a time of event of 8:40 p.m., revealed an Elopement incident reported to the New Jersey Department of Health (NJDOH) on 7/10/20, regarding Resident #2. The Director of Nursing (DON) reported that on 7/8/20 around 7:40 p.m., two staff members had observed Resident #2 outside of the facility. Before the staff could reach the resident, he/she fell . The staff members alerted the unit and the charge nurse responded immediately. Upon assessment a bruise was observed to the left cheek. An investigation into the incident was initiated. The charge nurse assessed the resident and called 911. The resident was sent out to the hospital for an evaluation/treatment and upon return to the facility the CP will be reviewed, revised and updated. Review of the Incident Report dated 7/8/20 at 7:40 p.m., revealed documentation by the Registered Nurse (RN #1) revealing Resident #2 had a fall outside on the facility grounds. The resident had wandered off the unit and was redirected back to the unit by the Certified Nursing Assistant (CNA #1), who then offered the resident fluids and sat the resident at the nursing station. The resident then got up and walked around but was found later outside the building walking and fell before the staff could intervene. The resident was observed lying on his/her back with a bruise on the left cheek, alert, and responsive, able to move all extremities, no cuts or bruises noted on the head, slight bleeding noted at the nares. Neurological status was intact. First Aid was given. Vital signs were checked, and ice was applied to left cheek. The resident was sent to the hospital via 911. The following interventions were listed on the Incident report; Staff to do rounds with resident's census at hand. Resident #2's Cognitive status was listed as alert, with severely impaired decision making. Injuries listed included: A left cheek bruise with intact skin. Review of a Facility document dated 7/8/20, titled Interviews of Involved Incident, indicated that the DON and the ACEO #1 documented an interview with the primary CNA (CNA #1) of Resident #2 on 7/8/20. The CNA stated that the resident had left the unit and was escorted back to the unit several times that evening, the last time was about 7:20 p.m., when CNA #1 brought the resident to the nurse's station and stated the resident looked tired. CNA #1 stated she gave the resident some water and asked the resident to sit down, then the CNA stated she left to go on break and get something to eat. Review of CNA #1's written statement dated 7/8/20, revealed the following: Resident went off the unit three times The resident was brought back to the unit and sat in front of the nursing station and was given a cup of water. The CNA documented she did not remember the time it occurred. The housekeeper then came to inform the nursing staff that a resident fell outside. Review of the kitchen staff employee statement, dated 7/8/20, revealed the following: Around 7:40 p.m., I was driving and saw a resident standing by the sidewalk. I told him/her to stop and he/she kept walking and fell face first. I did not see what door he/she came from. Review of a facility email dated 7/9/20 at 4:35 p.m., written by the Information Technology Support Specialist (ITSS), after reviewing the Facility's Security Video included but was not limited to the following summary: 7:20 p.m., Licensed Practical Nurse (LPN) prevents Resident #2 from going off the Unit. 7:23 p.m., Resident #2 walks back to Independence Hall low side. 7:30 p.m., Resident #2 observed at the nursing station. 7:35 p.m., Resident #2 walked to the high side of unit. 7:36 p.m., Resident #2 exits the unit by the rear doors which were open while the fire door was closed to the stairwell. Resident #2 proceeds by opening the fire door to the stairwell going down the stairs and activating the alarm. 7:37 p.m., Housekeeper (HK #1) heard the alarm and goes to the fire door and tries to reset the alarm, however, she is unable to shut the alarm off, so she returns to the Rehabilitation (Rehab) department. 7:39 p.m., HK#2 was passing by and heard the alarm, turns the alarm off then continues to the unit. 7:41 p.m., HK #2 goes into a room which faces the outside roadway and comes out seconds later and runs down the stairs to the 1st floor. He returns and runs to the nursing station. 7:42 p.m., Housekeeper #2 then goes back downstairs with the nurse. 7:44 p.m., Registered Nurse (RN) goes downstairs with the vital sign equipment. 7:48 p.m., Another nurse goes downstairs. 7:54 p.m., A nurse attempts to turn off the alarm but is unable. 7:55 p.m., HK #2 shuts off the alarm. 7:58 p.m., Nursing opens fire door and reactivates the alarm. 7:59 P.M., the supervisor arrived and goes out the exit door. 8:10 p.m., Total of 5 staff members return from the exit door. Alarm is turned off. During a staff interview on 8/31/20 at 12:45 p.m., the Director of Nursing (DON) reported that on 7/8/20 around 9:30 p.m., she reported back to the facility to investigate an incident of elopement with injury. She stated that the Certified Nursing Assistant (CNA#1) for Resident #2 reported that she had gone on break before her scheduled breaktime, and failed to notify any staff members and failed to ask anyone to watch her residents while she was gone. During that time the charge nurse had paged the CNA to toilet Resident #2. The resident required assistance to use the bathroom, however, the CNA did not return to the unit until after the resident had already eloped and had fallen. In addition, the DON reported the resident was not on a locked or secured unit even though the resident had a history of elopement and she was not sure why. Review of the Facility's document titled Final Investigation dated 7/15/20, the DON reported the following: Review of the video footage showed Resident #2 was walking around the unit at 7:30 p.m. He/she was observed on the high side of the unit near the exit at 7:36 p.m., the resident then opened the door which activated the alarm. HK #1 responded to the alarm at 7:37 p.m., then attempted to reset the alarm by typing in the code. HK #1 was unsuccessful in turning off the alarm and went back to working in the Rehab Department. HK #1 did not open the door or go down the stairs to see if there was a reason the alarm sounded. HK#1 did not go to the nursing or housekeeping supervisor to alert or ask for help for the sounding alarm on the Egress door. HK #1 failed to follow the policy and was suspended pending investigation. The DON also documented the following: At 7:39 p.m., HK #2 noticed the alarm sounding and reset it. At 7:40 p.m., HK #2 noticed through the window that a resident was outside on the grounds with 2 staff members. A staff member was driving through the driveway and saw Resident #2 and yelled stay there and don't move the resident continued to walk and stepped off the curb falling forward. HK #2 is seen in the stairwell then runs back into the building. The RN follows HK #2 with the vital signs machine, and 2 additional nurses go outside. The supervisor arrived a few minutes later. While outside the nursing staff assessed the resident and called 911. The resident remained on the ground and is monitored until the Emergency Medical Technician's (EMT) arrived. The EMTs transported the resident to the hospital where he/she was admitted . The DON also concluded the following on the Final Investigation report: Based on the above findings Resident #2 was walking around the unit, opened the door, proceeded to walk down the stairs and exited the building to the facility grounds through the fire egress door. The resident was approximately 84 feet from the door on the egress walkway, and the staff found him/her within 4 minutes of exiting the door. The DON also documented on the Final Investigation report: Based on the interviews of the assigned CNA, it was found that the CNA took an unscheduled break. The charge nurse was at the desk completing documentation, the LPN was administering treatments and neither followed up with the resident. The DON further documented under Conclusions/Recommendations that the staff members identified were suspended, will have a hearing, then be terminated. The staff was unavailable for interviews. The DON also documented on the Final Investigation report dated 7/15/20: That Resident #2 was readmitted to the facility on [DATE], with diagnoses of dizziness, fractured left distal humerus and fractured maxilla. Review of the Facility's Physician's Order Sheet (POS) upon readmission to the facility dated 7/10/20, revealed an order for a left arm immobilizer, in place all the time except during care and [MEDICATION(S)] 50 milligrams (mg) every 12 hours for 14 days for severe pain control. According to the Interdisciplinary Progress Notes dated 7/10/20, the RN documented the following assessment when Resident #2 was readmitted to the facility on [DATE]: Bruises of the left maxillary, neck, left arm. Complaints of pain. New order for [MEDICATION(S)] 50 mg every 12 hours for 14 days. During an interview on 8/31/20 at 2:20 p.m., the Facility's ACEO #1 reported that Resident #2 was able to exit the unit via the double doors to the hallway because the doors to the unit are not locked. She further stated that the resident was CP as an elopement risk and the interventions in place prior to the incident was a wanderguard, and monitoring. During an interview on 8/31/20 at 2:50 p.m., the ACEO #2 reported that a security guard is in the building 24/7 (24 hours a day 7 days a week), but prior to the incident on 7/8/20, the fire door alarms could only be heard locally when activated, but not at the security desk. After the incident the alarms were upgraded so the security guards will be alerted at the security desk that an exit door was opened. ACEO #2 also stated that all the doors and alarms in the facility were checked the night of the incident and 2 CNA's were posted at the exit doors 24/7, until the alarms upgrades were completed. During an interview on 8/31/20 at 3:40 p.m., the ACEO #1 reported that prior to the incident the wanderguard ankle bracelet would only trigger the alarm near the elevators or at the front door, they would not trigger when the resident left the unit or when the resident opened the fire door however, since the upgrade to the alarm system the alarm will trigger at the exit doors. According to the Facility document titled Post Incident report dated 7/8/20, ACEO #2 documented that all staff involved in the incident were suspended immediately. A staff member (CNA) was assigned to monitor said egress door and egress and stairwell, post incident at all times. In addition, any violation of the doors to the stairwell without entry of a bypass code will result in an alarm to wanderguard system loudly at the door, as well as at the security guard's desk. Review of the Facility's Policy titled Elopement/Possible Elopement/Missing Resident undated, indicated the following under Policy Interpretation and Implementation, section 2. If any staff member hears a door alarm (wanderguard/Code-alert or other annunciator sounding), he/she will respond by; Checking the area to ascertain if any resident in the vicinity (do not silence or reset) the area and surrounding area (including doors and stairwells) must be checked to ascertain if a resident is attempting to leave or place themselves in a potential unsafe situation. Resident #2, a cognitively impaired resident was able to exit the building without the staff's knowledge. The facility staff did not respond according to their policy when a door alarm sounded, the resident was able to leave the building by the unsecured fire door, wandered down the pathway to the driveway where the resident was observed by staff members. The staff were unable to intervene prior to the resident stepping off the curb and falling. The resident sustained injuries requiring medical attention and was transported to the hospital via 911. This deficient practice placed Resident #2 and all other residents with cognitive impairment who were at risk or who had a known history of wandering and/or elopement in an Immediate Jeopardy (IJ) situation. The Immediate Jeopardy is past Non-Compliance (PNC) for 7/8/20. Interventions to remove the immediacy were verified on 9/1/20, the second day of the survey and included, in-services, 24/7 monitoring of the exit doors, upgrade of wanderguard and door alarms, and staff involved were suspended and terminated. N.J.A.C. 8:39-27.1(a),(b)

C# NJ , NJ 1. Based on interviews and review of medical records and other facility documentation, it was determined that the facility staff failed to provide adequate supervision to Resident #6 who had a history of [REDACTED]. The care plan specified that Resident #6 was not to be left alone in the bathroom and was 2 staff assist on/off in the bathroom. On 7/19/15 Resident #6 sustained a fall when one staff member transferred the resident without assistance and left the resident unattended in the bathroom. Subsequently Resident #6 sustained a Cervical fracture. The surveyor reviewed the medical record of Resident #6 on 12/2/15/at 12:05 PM. The Resident Face Sheet revealed that Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated 11/23/15, reflected that Resident #6 had a Brief Interview for Mental Status (BIMS) score of 10, indicating that Resident #6's cognition was moderately impaired. According to the MDS, Resident #6 required extensive staff assistance with Activities of daily Living (ADL's). The surveyor reviewed Resident #6's Plan of Care dated 2/23/15 on 12/2/15. The following information was observed, in the problems column of the care plan, but was not limited to: At risk for fall, due to gait disturbance related to cognitive impairment as evidenced by non compliance with preventative equipment, history of falls. In the goals column; (Resident #6) will be free from injury related to fall. In the Interventions column, Resident not to be left alone in bathroom. According to the Resident/Family Teaching Record, dated 12/3/14, Must need assistance during transfer. Two staff to assist with resident on/off the bathroom. Resident agreed that she will wait for staff before transferring. Review of the facility Nursing Investigation documentation revealed that, Resident #6 is able to stand and pivot with one person assist into the wheelchair or recliner chair. Due to (Resident #6's) desire for total independence, resident occasionally attempts to self transfer during the night and must have an assigned caregiver stationed at the doorway. On July 19, 2015 at approximately 1:10 AM, Resident (#6) called for assistance to the bathroom. The Nursing Assistant (CNA #5 - Certified Nursing Assistant) assigned to monitor the resident entered the room as requested and transferred the resident without difficulty from the recliner into the wheelchair and into the bathroom where (Resident #6) was placed on the toilet. The CNA (#5) stated that she/he had forgotten to retrieve gloves prior to placing the resident on the toilet; turned around to get the gloves that were located outside the bathroom doorway. The CNA (#5) observed the resident sliding from the toilet and simultaneously hitting her head on the wall. The CNA (#5) called for assistance of other staff members. Resident #6 sustained a raised area on head as well as a skin tear to the left lower leg approximately 2 cm x 1.5 cm long. The resident (#6) was transferred to the hospital ER. Resident returned to the facility after a Cat Scan was performed. Resident complained of a headache with left neck pain during the next shift. Resident #6 was returned to the hospital ER and was admitted to the hospital with [REDACTED]. The facility conducted a staff interview on 7/21/15 with the assigned CNA (#5) concerning the night of the incident. The CNA (#5) was reminded that the CNA assignment states that the resident should never be left alone in the bathroom and that (CNA #5) should have had another person with him/her in the bathroom. The CNA (#5) stated, 'I didn't know, we never do that.' The CNA (#5) was asked is she/he had taken care of the Resident (#6) before and CNA #5 said 'yes'. CNA #5 responded that she/he did not read the assignment for the care of resident #6. The CNA #5 was explained the severity of not reading the assignment or following the assignment as stated, caused injury to the resident (#6). CNA #5 was suspended until notice of a final decision. The facility conclusion to their investigation was that the CNA (#5), did not follow the plan of care for Resident (#6) and unfortunately Resident (#6) struck her head on the wall as she slid from the toilet seat sustaining a cervical fracture and a skin tear. The surveyor interviewed the Director of Nursing (DON) on 12/02/15 at 3:05 PM. According to the DON, Resident (#6) became a 2 person transfer in December of 2014 secondary to fall. The CNA (#5) did not read the assignment as per (CNA #5's) own admission. The CNA was suspended since the fall. CNA (#5's) hearing will be in a couple of weeks and plan is not to rehire the CNA (#5) back. A couple of months after the 7/19/15 fall, Resident (#6) became stronger with physical therapy and now is a 1 staff with pivot for transfers. The surveyor interviewed Resident #6 on 12/2/15 at 10 AM. According to the Resident #6, one staff is transfer is all I need. There was somebody with me when I fell . I slid off the toilet and the aide (CNA #5) ran back to me but I already banged my head. The surveyor interviewed RN #2 on 12/2/15 at 1:40 PM. According to the RN #2, Resident (#6) could help herself and is now 1 staff assist. For transfers with Hoyer Lift our policy is 2 people for all transfers. For residents on stand and pivot, we do 1 staff transfers if they have no behaviors. If with behaviors, need 2 staff assist. NJAC 8:39-27.1(a) (b) 2. Based on interviews and review of medical records and other facility documentation, it was determined that the facility staff failed to assure safe transfer techniques, using a mechanical lift, for 3 out of 9 sampled Residents. (Resident #5, Resident #7, Resident #8) and 1 unsampled Resident (Resident #A). This deficient practice was evidenced by the following: Observations and interviews were conducted on 12/2/15 unless otherwise noted. A. The surveyor reviewed the medical record of Resident #5 on 12/2/15 at 1:10 PM. The Resident Face Sheet revealed that Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated 9/28/15, reflected that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #5's cognition was intact. According to the MDS, Resident #5 required extensive staff assistance with Activities of Daily Living (ADL's) and two staff assist via Hoyer Lift (a mechanical lift) for all transfers. The surveyor reviewed Resident #5's Plan of Care dated 4/6/15 on 12/2/15. The following information was observed but was not limited to: In the problems column of the care plan, Potential for fall, fall risk 13. In the goals column, (Resident #5) will not fall by the next evaluation. In the Interventions column, Use of Hoyer Lift with 2 staff assist for all transfers. The surveyor interviewed Resident #5 on 12/2/15 at 11:00 AM. According to Resident #5, the facility staff transfer Resident #5 utilizing a Hoyer Mechanical Lift and two staff assist. Resident #5 further explained that sometimes he is transferred with only 1 staff assist while utilizing the Hoyer Lift. When they call for some to assist them and no one comes they are tired of waiting and use the Hoyer Lift by themselves. They mostly transfer me with only 1 staff using the Hoyer Lift, but not always. B. The surveyor reviewed the medical record of Resident #7 on 12/25 at 12:05 PM. The Resident Face Sheet revealed that Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE], reflected that Resident #7 had a BIMS score of 15, indicating that Resident #7's cognition was intact. According to the MDS, Resident #7 required extensive staff assistance with Activities of Daily Living (ADL's) and two staff assist via Hoyer Lift (a mechanical lift) for all transfers. The surveyor reviewed Resident #7's Plan of Care original date of 2/17/2015. The following information was observed but was not limited to: In the problems column of the care plan, Potential for fall, R/T (related to) Use of Hoyer Lift for transfers, Use of antidepressant, Hx (history) of falls, and right [DIAGNOSES REDACTED]. In the goals column, (Resident #7) will not fall by the next evaluation. In the Interventions column, Hoyer Lift for all transfer with 2 staff assist. The surveyor interviewed Resident #7 on 12/2/15 at 10:27 AM. according to Resident #7, I am transferred with the Hoyer lift with mostly 2 staff and sometimes 3. But in the morning, have only 1 staff for transfers most of the time. C. The surveyor reviewed the medical record of Resident #8 on 12/3/15 at 9:30 AM. The Resident Face Sheet revealed that Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Urinary Retention, Suprapubic Catheter, Chronic Obstructive Pulmonary Disease (COPD), Severe [DIAGNOSES REDACTED], Diabetes Mellitus (DM) and Degenerative Joint Disease (DJD). A Minimum Data Set (MDS), an assessment tool dated 9/3/15, reflected that Resident #8 had a Brief Interview for Mental Status (BIMS) score of 5, indicating that Resident #8's cognition was severely impaired. According to the MDS, Resident #8 required extensive staff assistance with Activities of Daily Living (ADL's) and two staff assist via Hoyer Lift for transfers. The surveyor was not able to interview Resident #8 secondary to his/her impaired cognition. The surveyor interviewed Resident #9, who is Resident #8's spouse and roommate on 12/3/15 at 3:05 PM. According to Resident #9, CNA #1 was putting my spouse to bed. My husband's arms were going up and the CNA (#1) was pushing his arms down. The CNA (#1) used the machine (Hoyer Lift) to put my husband (Resident #8) to bed by himself. No one assisted him (with the transfer). The surveyor reviewed Resident #8's Care Plan on 12/3/15. The following information was observed but was not limited to: In the Problems/Strengths section of the care plan for Potential for fall/injury related to Alzheimer's, Dementia, Hoyer Lift. In the Goals section, will be free from injury related to fall by next evaluation date. In the Interventions section, In & (and) out transfer via Hoyer lift with two person's assist. In the Problems/ Strengths section of the Potential for altercation in mood/behaviors related to Alzheimer's Dementia, History of agitation & verbally abusive towards staff and others. In the Goals section, Episodes of mood and behaviors will minimized by next evaluation date. In the Interventions section of the care plan, Approach in a calm manner. If resident is agitated leave him alone to calm down and go back later. If the resident is combative during care, provide the care with two staff. The surveyor interviewed CNA #1 on 12/11/15 at 9:25 AM. As per CNA #1, We transfer the residents using a Hoyer Lift with assist. I can't recall if I called anyone for assistance on that day (2/13/15). But we don't do transfers by ourselves. D. The surveyor interviewed an Unsampled Resident #A on 12/2/15 at 10:48 AM. According to the Unsampled Resident #A, My aide (Certified Nursing Assistant - CNA) transfers me with the Hoyer lift and 1 staff mostly, sometimes 2 but mostly 1 (staff). The surveyor reviewed the Special Assignment sheet for the Unsampled Resident #A. According to the assignment sheet, Unsampled Resident #A is, OOB (out of bed) via Hoyer lift x 2 to motorized or manual wheelchair. According to the Unit Manager #1, Resident (Unsampled Resident #A), is non-ambulatory, utilizes a motorized wheelchair and is transferred via Hoyer lift with 2 staff assist. The surveyor interviewed RN #2 on 12/2/15 at 1:40 PM. According to RN #2, Our Hoyer Lift policy is for 2 people for all transfers. The surveyor interviewed CNA #2 on 12/2/15 at 1:53 PM. According to CNA #2, All Hoyer Lift transfers are always 2 staff. That is our policy here. If we get caught by using only 1 staff, we get reprimanded and written up. The surveyor interviewed CNA #3 on 12/2/15 at 2:15 PM. According to CNA #3, We always transfer 2 staff for hoyer transfers. I never transferred any one by myself. The surveyor interviewed CNA #4 on 12/2/15 at 2:30 PM. According to the CNA #4, we transfer using Hoyer Lift with 2 person. I never transfer anyone via Hoyer Lift by myself. The policy is 2 staff for transfers. The surveyor reviewed the facility policy on Mechanical Patient Lifter 5:006 which indicated but was not limited to : Purpose: To safely transfer a patient from one surface they are either siting or lying on to another. This device is often referred to as a Hoyer Lift regardless of brand. Equipment: Mechanical lift. Sling. Always 2 trained staff members. Points to remember: Always have at least 2 (TWO) trained staff present when using device. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to provide adequate supervision for residents identified at high risk for falls. The facility failed to follow specific fall prevention interventions for Resident #12 who had a fall and sustained a left hip fracture with pain, and which required surgery to repair. This deficient practice was observed for Resident #12, 1 of 15 residents reviewed for falls and was evidenced by the following: During the initial tour on 8/4/14 at 10:30 a.m., the Unit Manager (UM) told the surveyor that Resident #12 was cognitively impaired; used a wheelchair for mobility, and had a feeding tube. The UM also stated that Resident #12 sustained a fall which resulted in a fracture. On 8/6/14 at 9:30 a.m., the surveyor reviewed Resident #12's medical record which revealed that the resident had [DIAGNOSES REDACTED]. The surveyor reviewed the 7/2/14 annual Minimum Data Set (MDS), an assessment tool. The MDS revealed the resident's mental status was assessed using the "Brief Interview for Mental Status." The assessment indicated Resident #12 scored a 3 out of a possible 15, indicating that the resident had severe cognitive impairment. A "Fall Risk Evaluation" was completed for the resident on 12/30/13. The resident scored a 15, where a score of 10 or greater indicated that a resident was at high risk for potential falls. The medical record of Resident #12 further revealed that the resident sustained [REDACTED]. On 12/15/13 the resident slid from her/his wheelchair. The resident sustained [REDACTED]. On 3/23/14 the resident sustained [REDACTED]. According to the incident report provided to the surveyor by the Director of Nursing (DON) on 8/6/14 at 1 p.m., Resident # 12 was being showered by the Certified Nursing Assistant (CNA) in the shower room when the resident became combative during care and fell from the shower chair to the floor onto his/her left side. The CNA failed to inform the nurse immediately after the incident occurred and transferred the resident to a wheelchair and brought the resident to his/her room before notifying the nurse. Also included with the incident report provided to the surveyor was an "Assignment Sheet" provided to the CNA at the start of her shift. The assignment sheet provided specific details for the care of Resident #12. The care instructions for the resident included, "Call for assistance immediately and do not touch, move or transfer resident until further assessment/evaluation is made by nurse. Obtain help prior to showering to anticipate his/her needs based on fall precaution." On 8/7/14 at 10 a.m. the UM showed the surveyor the shower room and the shower chairs that were used by the residents. The UM stated that residents were placed in shower chairs when showered and that a seatbelt was required to be secured. She further stated that the shower rooms had call bells that were easily accessible. On 8/7/14 at 10:45 a.m. the surveyor interviewed the Director Of Nurses (DON), Assistant Chief Executive Officer (ACEO) and Chief Executive Officer (CEO). The DON stated that the seatbelt was supposed to be secured when a resident was using the chair in the shower. The DON further stated that she could not ascertain if the belt had been buckled during this particular incident because the CNA refused to answer that inquiry. The DON further stated that it was unlikely that the fall would have occurred if the belt had been buckled. The DON and ACEO agreed that the resident would not be able to release the seatbelt by his/her self. The DON also stated that when Resident #12 became agitated, the CNA should have called for help. The DON stated that the CNA was disciplined. The ACEO stated at the interview on 8/7/14 at 11 a.m. that although the facility does not have a policy, all staff knew not to move a resident after a fall because that could aggravate further injury. On 8/7/14 at 12 p.m. the ACEO provided the surveyor the education provided the staff in regards to falls which included education on not moving the resident after a fall until assessed by proper medical staff. The CNA did not follow administrative procedures, and Resident #12 sustained an injury that required surgery, and had pain. NJAC 8:39-11.2(b)

Surveyor: Garofalo, Joanne C# NJ & NJ Based on observation, interview and review of medical records and facility policy, it was determined that the facility failed to protect 1 of 4 sampled residents, Resident #1, after an incident of staff-to-resident abuse was reported. Resident #1 reported an allegation of abuse by her caregiver (Certified Nurses Aide, CNA #1). The CNA, who had prior abuse allegations by 2 other sampled residents, Residents #2 and #4, was neither suspended nor removed from the unit after the incident with Resident #1. In fact, the CNA later that same day confronted Resident #1 about the allegation. This resulted in an immediate jeopardy situation for Resident #1 and other residents who had the potential to also be abused by CNA #1. The Immediate Jeopardy was identified on 5/21/12 at 3:00PM and lifted day of survey based on an acceptable plan of correction submitted by the facility. This deficient practice is evidenced by the following: Medical records were reviewed and interviews conducted on day of survey, unless otherwise noted. A Facility Reportable Event Record/Report (AAS-45) faxed to the Department of Health and Senior Services (Department) revealed that on May 16, 2012, Resident #1 reported an allegation to the Social Worker that a CNA who assisted her in the morning was very rough and angry with her. Resident #1 stated that the CNA began to complain as she was rendering care. According to this resident, the CNA grabbed her leg and began to drag the resident very roughly and told the resident to get up. The resident indicated that she did not know who the CNA was until someone had called for the CNA over the speaker. According to the AAS-45, interventions in place identified that Resident #1 had a history of [REDACTED]. Interventions in place at the time of the incident included but were not limited to; explore Resident #1's feeling, motivators or fears that lead to the behavior, offer to talk to the resident and redirect the resident with a calm and reassuring tone, monitor and log behavior and two (2) CNAs during care. Additionally, in an interview with a Department representative on 5/18/12 with the facility staff, the Department learned that the CNA involved remained on the unit where Resident #1 resided. The staff also reported that this resident was crying and tearful. 1. According to the Minimum Data Set, an assessment tool dated 1/20/12, Resident #1 had [DIAGNOSES REDACTED]. A Brief Interview for Mental Status examination determined the resident was alert and oriented with a score of 15 out of a possible 15. Also, the resident was non-ambulatory and required assistance of staff for activities of daily living. A review of the resident's Care Plan dated 3/06/12, identified a problem with the resident accusing caregivers of giving her a hard time, talking about her and not treating her right. Identified interventions included reassuring the resident during provision of care and having additional staff present during care. A psychotherapy session note dated 5/14/12 indicated the resident is alert and oriented times three. The note went on the say that the resident presented in a calm, moderately depressed mood and expressed concern about her inability to perform activities of daily living independently. Supportive therapy was provided. In an entrance interview with the surveyor at 9:30 a.m., the Assistant Director of Nursing (ADON) stated that on 5/16/12, Resident #1 reported an allegation of abuse by her caregiver to the Social Worker. The ADON confirmed that the resident was alert and oriented. The CNA was initially moved to another wing when the allegation was made but is currently suspended. The facility investigation was completed. When asked to see the facility incident report on the allegation, the ADON stated, "There is none." The ADON was aware of no monitoring plan in place for the CNA while she was allowed to work for a day and a half after the allegation was reported. She further stated that when the CNA returns, a monitoring plan will be developed. On interview at 10:00 a.m., Resident #1's assigned Social Worker (SW) stated that on 5/16/12 around 11:40 a.m., she received a telephone call from the Unit Clerk on Eagle Unit that Resident #1 wanted to speak with her. The resident is "[AGE] years old but very alert and oriented." According to the SW, the resident stated that her caregiver that day (CNA #1) was "angry" with her this morning. The resident was "visibly upset." The resident then reported to the SW that CNA #1 told her that it was disgusting in here, referring to the resident's room. The resident asked the CNA to help her reposition and the aide responded by telling the resident couldn't she see she was busy and to just be quiet. The CNA then told the resident that everybody hated her, meaning the resident, and nobody wanted to come in and take care of her. The CNA then took her by the legs and pulled her down in the bed asking the resident if she was happy now. After this initial interview, the SW immediately reported the incident to the Director of Social Services (DSS). On a follow-up visit that same day, the resident told the SW that CNA #1 came back into her room and confronted her about her reporting the incident. The CNA told the resident that she did not know why she reported the incident but the resident needed to change her story. At that point the SW said that the resident was "tearful." On interview at 10:15 a.m., Resident #1 was observed sitting in her wheelchair in a meeting room on the unit. She was dressed appropriately and groomed and speaking with the Psychotherapist. The Psychotherapist excused himself to allow the surveyor to interview the resident. When asked if she could tell me about the incident that occurred with her caregiver, the resident reported the following: "She came in angry and took it out on me. She grabbed me like a rag doll." The caregiver wanted her to stand and the resident told her she needed help. The caregiver "had an attitude." She told the resident, "I did somebody a favor. Everybody hates you and nobody wants to take care of you." The resident then said she felt "insulted and it was very upsetting." I did not know who she (the CNA) was until they paged for her and she answered the page from my room. The surveyor then asked the resident if she saw this caregiver after she reported the incident. The resident said, "Oh, yes. She came back in my room later and asked me why I made the report and I told her I wanted to tell my side as to what happened." The resident then said that she was very upset and that she's never going to say anything again. The surveyor reinforced the importance of reporting such incidents. During Resident #1's interview, a cluster of ecchymotic bruising was observed on the left posterior mid forearm of Resident #1. When asked how she bruised her arm the resident said, "It probably happened when she (CNA #1) pulled me." On interview at 10:40 a.m., the Unit Manager (UM) on Eagle Unit stated she was not on duty the day of the reported incident. She went on to say that staff is afraid of the resident and nobody wants to go into her room because she accuses them of taking things. That is why two people are to provide care. When asked about the bruise on the resident's left arm, the UM had no knowledge of any bruising. On interview at 11:20 a.m., the Director of Social Services (DSS) said that when he found out about the allegation he immediately reported it to Administration, whose only question was whether the resident was alert and oriented. The DSS went down to see the resident. In the resident's room were the ADON, another nurse and a therapy person. The ADON was interviewing the resident. The DSS asked the nurse why the therapy person was in the room and the nurse told him that she was the Union Representative for the CNA. The DSS then said at that point he "backed the Union Representative out of the room and closed the door". At 12 noon, while the surveyor was in the facility conference room the Psychotherapist, who excused himself to allow the surveyor to interview Resident #1, came and stood at the doorway. He shrugged his shoulders and said, "She seems all right to me." This was the same Psychotherapist who wrote the previously referenced psychotherapy session note indicating the resident was alert and oriented. A review of CNA #1's personnel file and other facility documentation revealed that this most recent allegation of abuse was the third such allegation in the past three years. Additionally, over the course of her employment, CNA #1 had five other disciplinary actions involving abuse, neglect and disruptive behavior. Each time the CNA was moved to another unit within the facility. 2. A review of a facility Incident/Accident Report dated 4/29/11 indicated that another resident (sampled Resident #4) reported to the nurse that he did not want to be near CNA #1 because "she beats him up." An attached statement form documented the resident accused the CNA of hitting him on the back. He was able to describe the CNA as CNA #1 and said that he did not want her to take care of him anymore. On a tour of Freedom Unit at 4:00 p.m., Resident #4 was observed in the dayroom. On interview, the resident appeared sleepy and had no recall of the above incident. 3. A review of a facility Reportable Event Record/Report dated 5/10/10, indicated that another resident, Resident #2, had told his family that his caregiver was "smacking him around during morning care." In a follow up telephone call on 5/13/10, a Department of Health and Senior Services representative spoke with the DON who reported that CNA #1 had been suspended and was pending termination. On interview at 10:45 a.m., Resident #2 was able to recall all of the details he initially reported concerning his caregiver. He said that his caregiver (identified by the resident as CNA #1) would smack him on the top of his head. When asked how long ago this occurred, the resident stated that it happened two years ago. On interview at 3:00 p.m., the Director of Nursing (DON) denied any knowledge of Resident #1 being confronted by her caregiver or that a Union Representative was present during an investigative interview. When asked if the accused CNA was being monitored, the DON said, "She was told not to go into the room." The CNA was told to stay on the other wing. The surveyor asked the DON about the bruise on the resident's left posterior mid forearm and inquired if an incident report had been written. There was no documentation of an incident report provided by the facility. The DON immediately called the UM on Eagle Unit who confirmed that she did not know the resident's arm was bruised. The DON then said that the resident had lab work drawn that morning and maybe it happened then. The surveyor reminded the DON of the location of the bruise. The DON continued saying that the resident initially refused to have an assessment the day of the allegation. The next day an assessment was done and did not reveal any bruising. However, subsequent review of Interdisciplinary Progress Notes dated 5/17/12 8:00 a.m. documented an assessment of only the lower extremities which revealed plus three [MEDICAL CONDITION] and bilateral redness. The surveyor then discussed the facility's policy on abuse with the DON. The policy stated that if an employee is involved, the employee will be moved to another work area. The DON was asked if she felt that moving the employee to the other wing on the same unit was considered removing the CNA from the area. The DON repeated that the CNA was moved to the other wing and told not to go into the room. The surveyor then reminded the DON that the resident does come out of her room and was, in fact, observed in a meeting area on the unit that day. Also, the policy stated that depending on the nature of the incident, the employee may be suspended. The surveyor asked the DON what would constitute suspension. The DON had no reply. In an exit interview at 5:00 p.m., the DON was again asked why the CNA was not immediately suspended. The DON said that the CNA was not suspended because she (the DON) immediately completed her investigation and had concluded the same day that it was all right to move the CNA to the other wing on the unit. However, the DON had no knowledge of the resident's bruised arm, that the resident was confronted by the accused CNA on the same day the allegation was reported or that the Union Representative was present during an investigative interview. A review of the facility's policy entitled, "Resident Abuse" stated that: "All alleged/suspected victims of incidents, events, or occurrences, that may constitute abuse be protected from further harm during the course of investigations. The employee shall have no contact with the resident throughout the course of the Administrative Investigation. Employees administratively reassigned in accordance with investigative protocol shall have their performance monitored by the respective shift charge nurse". The Immediate Jeopardy was identified on 5/21/12 at 3:00PM and lifted day of survey based on an acceptable plan of correction submitted by the facility. 1. CNA #1 had been suspended. 2. All other alert and oriented residents receiving care by CNA #1 were interviewed to assure no other residents were affected by this practice. 3. All staff received in-servicing on resident rights, abuse and neglect. 4. Upon return of the CNA, the caregiver will be placed on another unit and monitored by the charge nurse on that unit. A weekly monitoring report will be submitted to the DON. 5. Social Services will follow-up with Resident #1 daily for emotional support. NJAC 8:39-4.1a(5)

C# NJ ; NJ Based on observation, interview and review of facility policy, it was determined that the facility failed to thoroughly investigate and follow their own policy on abuse after an allegation of staff-to-resident abuse was reported by 1 of 4 sampled residents, Resident #1. The accused staff person (CNA #1) was allowed to remain on the resident's unit for a day and a half with no monitoring in place. The CNA subsequently confronted the resident regarding the allegation placing the resident and others in immediate jeopardy. Additionally, the facility failed to investigate a bruise of unknown origin observed on Resident #1's arm, on day of survey. The Immediate Jeopardy was identified on 5/21/12 at 3:00PM and lifted day of survey based on an acceptable plan of correction submitted by the facility. The evidence is as follows: Medical records were reviewed and interviews conducted on day of survey, unless otherwise noted. 1. According to the Minimum Data Set, an assessment tool dated 1/20/12, Resident #1 had [DIAGNOSES REDACTED]. A Brief Interview for Mental Status examination determined the resident was alert and oriented with a score of 15 out of a possible 15. Also, the resident was non-ambulatory and required assistance of staff for activities of daily living. A review of the resident's Care Plan dated 3/06/12, identified a problem with the resident accusing caregivers of giving her a hard time, talking about her and not treating her right. Identified interventions included reassuring the resident during provision of care and having additional staff present during care. A psychotherapy session note dated 5/14/12 indicated the resident is alert and oriented times three. The note went on the say that the resident presented in a "calm, moderately depressed mood" and expressed concern about her inability to perform activities of daily living independently. Supportive therapy was provided. In an entrance interview with the surveyor at 9:30 a.m., the Assistant Director of Nursing (ADON) stated that on 5/16/12, Resident #1 reported an allegation of abuse by her caregiver to the Social Worker. The ADON confirmed that the resident was alert and oriented. The CNA was initially moved to another wing when the allegation was made but is currently suspended. The facility investigation was completed. When asked to see the facility incident report on the allegation, the ADON stated, "There is none." The ADON was aware of no monitoring plan in place for the CNA while she was allowed to work for a day and a half after the allegation was reported. She further stated that when the CNA returns, a monitoring plan will be developed. On interview at 10:00 a.m., Resident #1's assigned Social Worker (SW) stated that on 5/16/12 around 11:40 a.m., she received a telephone call from the Unit Clerk on Eagle Unit that Resident #1 wanted to speak with her. The resident is "[AGE] years old but very alert and oriented." According to the SW, the resident told her that her caregiver that day (CNA #1) was "angry" with her this morning. The resident appeared "upset." The SW stated that CNA #1 told the resident that it was disgusting in here, referring to the resident's room. The resident asked the CNA to help her reposition and the aide responded by saying to the resident that couldn't she see she was busy and to just be quiet. The caregiver then told the resident that everybody hated her, meaning the resident, and nobody wanted to come in and take care of her. The CNA then took her by the legs and pulled her down asking the resident if she was happy now. The SW immediately reported the incident to the Director of Social Services (DSS). On a follow-up visit, the resident told the SW that later on that day; the CNA came back into her room and confronted her about her reporting the incident. The CNA told the resident that she did not know why she reported the incident but the resident needed to change her story. At that point, the SW said the resident was "tearful." On interview at 10:15 a.m., Resident #1 was observed sitting in her wheelchair in a meeting room on the unit. She was dressed appropriately and groomed and speaking with the Psychotherapist. The Psychotherapist excused himself to allow the surveyor to interview the resident. When asked if she could tell me about the incident that occurred with her caregiver, the resident reported the following: "She came in angry and took it out on me. She grabbed me like a rag doll." The caregiver wanted her to stand and the resident told her she needed help. The caregiver "had an attitude." She told the resident, "I did somebody a favor. Everybody hates you and nobody wants to take care of you." The resident then said she felt "insulted and it was very upsetting." I did not know who she (the CNA) was until they paged for her and she answered the page from my room. The surveyor then asked the resident if she saw this caregiver after she reported the incident. The resident said, "Oh, yes. She came back in my room later and asked me why I made the report and I told her I wanted to tell my side as to what happened." The resident then said that she was very upset and that she's never going to say anything again. The surveyor reinforced the importance of reporting such incidents. During the interview, a cluster of ecchymotic bruising was observed on the left posterior mid forearm of Resident #1. When asked how the resident bruised her arm the resident said, "It probably happened when she (CNA #1) pulled me." On interview at 11:20 a.m., the Director of Social Services (DSS) said that when he found out about the allegation he immediately reported it to Administration, whose only question was whether the resident was alert and oriented. The DSS went down to see the resident. In the resident's room were the ADON, another nurse and a therapy person. The ADON was interviewing the resident. The DSS asked the nurse why the therapy person was in the room and the nurse told him that she was the Union Representative there on behalf of the CNA. The DSS then said at that point he "backed the Union Representative out of the room" and closed the door. A review of CNA #1's personnel file and other facility documentation revealed that this most recent allegation of abuse was the third such allegation in the past three years. Additionally, over the course of her employment, CNA #1 had five other disciplinary actions involving abuse, neglect and disruptive behavior. Each time the CNA was moved to another unit within the facility. On interview at 3:00 p.m., the Director of Nursing (DON) denied any knowledge of Resident #1 being confronted by her caregiver or that a Union Representative was present during an investigative interview. When asked if the accused CNA was being monitored, the DON said, "She was told not to go into the room." The CNA was told to stay on the other wing. The surveyor asked the DON about the bruise on the resident's left posterior mid forearm and inquired if an incident report had been written. The DON immediately called the UM on Eagle Unit who confirmed that she did not know the resident's arm was bruised. The DON then said that the resident had lab work drawn that morning and maybe it happened then. The surveyor reminded the DON of the location of the bruise. The DON continued saying that the resident initially refused to have an assessment immediately after the allegation. The next day an assessment was done and did not reveal any bruising. However, subsequent review of Interdisciplinary Progress Notes dated 5/17/12 8:00 a.m. documented an assessment of only the lower extremities which revealed plus three [MEDICAL CONDITION] and bilateral redness. The surveyor then discussed the facility's policy on abuse with the DON. The policy stated that if an employee is involved, the employee will be moved to another work area. The DON was asked if she felt that moving the employee to the other wing on the same unit was considered removing the CNA from the area. The DON repeated that the CNA was moved to the other wing and told not to go into the room. The surveyor then reminded the DON that the resident does come out of her room and was, in fact, observed in a meeting area on the unit that day. Also, the policy stated that depending on the nature of the incident, the employee may be suspended. The surveyor asked the DON what would constitute suspension. The DON had no reply. In an exit interview at 5:00 p.m., the DON was again asked why the CNA was not immediately suspended. The DON said that the CNA was not suspended because she (the DON) immediately completed her investigation and had concluded the same day that it was all right to move the CNA to the other wing on the unit. However, the DON admitted that she had no knowledge of the resident's bruised arm, that the resident was confronted by the accused CNA on the same day the allegation was reported or that the Union Representative was present during an investigative interview. A review of the facility's policy entitled, "Resident Abuse" stated that: "All alleged/suspected victims of incidents, events, or occurrences, that may constitute abuse be protected from further harm during the course of investigations. The employee shall have no contact with the resident throughout the course of the Administrative Investigation. Employees administratively reassigned in accordance with investigative protocol shall have their performance monitored by the respective shift charge nurse". The Immediate Jeopardy was identified on 5/21/12 at 3:00PM and lifted day of survey as evidenced by the following Plan of Correction: 1. CNA #1 is suspended. 2. All other alert and oriented residents receiving care by CNA #1 were interviewed to assure no other residents were affected by this practice. 3. All staff received in-servicing on resident rights, abuse and neglect. 4. Upon return of the CNA, the caregiver will be placed on another unit and monitored by the charge nurse on that unit. A weekly monitoring report will be submitted to the DON. 5. Social Services will follow-up with Resident #1 daily for emotional support. NJAC 8:39-4.1a(5)