Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure: a) a resident assessment was completed to rule out injury, and the physician was immediately notified when staff witnessed a resident who banged finger hard on a door frame and yelled ouch. This resulted in a delay in treatment for one and a half hours, and the resident experienced pain and was subsequently diagnosed with a fracture of the third finger left hand, and b) appropriate incontinence care and related services were provided for two residents dependent on staff for care. The deficient practice was identified for 1 of 2 residents reviewed (Resident #52) for accidents and 2 of 6 residents who were dependent on care and reviewed for provision of incontince care (Resident #13 who did not have a sacral pressure ulcer prior to not being providedd with incontinence care for 15 hours which then resulted in a facility acquired pressure ulcer, and Resident #14 who had not been provided with incontinence care for over 12 hours and was left saturated with urine and embedded feces and had a Stage IV Pressure Ulcer. and Resident #14) and was evidenced by the following: a.) On 10/18/23 at 9:46 AM, the surveyor observed Resident #52 in his/her room. The resident looked at the surveyor but did not speak to the surveyor. The resident had one shoe on and was wearing a non-skin sock on the other foot. On 10/19/23 at 11:07 AM, the surveyor observed Resident #52 wearing non-skid socks and ambulating around the nurse's station with staff holding his/her arm for assistance. Resident #52 was easily redirected. On 10/20/23 at 7:54 AM, the surveyor observed the resident in a wheelchair in front of the nurse's station. A review of the EMR revealed that Resident #52 had diagnoses which included but were not limited to; other symptoms and signs involving the musculoskeletal system, history of falling, vascular dementia, and muscle weakness. A review of the most recent quarterly Minimum Data Set (MDS) an assessment tool used to facilitate a resident's treatment, dated 07/01/23, included but was not limited to; was rarely or never understood so a Brief Interview for Mental Status (BIMS) could not be conducted, severely impaired cognition, continuous behaviors of inattention and disorganized thinking, wandering daily, required limited assistance of at least one staff member when ambulating in the hallway, and as having had a fall with injury since admission or readmission. A review of the Order Summary Report included a physician's order dated 02/02/23, for Tylenol (used for pain) 325 milligrams (mg) give two tablets by mouth every 6 hours as needed for pain. An order dated 08/20/23, to refer the resident to a hand surgeon for a fracture of the third finger left hand. A review of the August 2023, Medication Administration Record (MAR) included but was not limited to; the Tylenol 325 mg order to administer two tablets every 6 hours for pain. There was no documentation on 08/20/23, that Tylenol had been administered for pain. A review of the person-centered comprehensive Care Plan (CP) included but was not limited to; a focus area of being at risk for falls with actual falls on 08/31/23 and 09/23/23. Interventions included but were not limited to; ensure the resident is wearing appropriate footwear, review information on past falls and attempt to determine cause of falls .pain management. A focus area of having a potential for pain. Interventions included but were not limited to; monitoring/record pain characteristics, monitor/record/report any s/sx (signs and symptoms) of non-verbal pain (grunting, moaning, yelling out). On 10/26/23 at 12:00 PM, during an interview with Surveyor #1, the Licensed Practical Nurse (LPN) #1 stated he was familiar with Resident #52 and remembered the incident on 8/20/23. LPN #1 stated he saw the resident getting up and hit his/her left hand pretty hard on the door frame. LPN #1 stated he had not documented what happened in the electronic medical record (EMR), and stated I went to get [him/her] and I assisted [him/her] to the a chair and stated Resident #52 yelled ouch when the resident hit [his/her] hand on the door frame. LPN #1 stated, I sat him/her back in his/her chair and took his/her vital signs. LPN #1 then stated, It was an hour and a half later that the resident's finger was discolored and the resident was in pain. When the surveyor inquired if an assessment was immediately conducted upon observing the resident hit [his/her] hand or any care that had been provided to Resident #52, the LPN stated, I don't have the documentation of assessing the resident's hand. LPN #1 stated he only placed Resident #52 in a chair. LPN #1 confirmed that he had not contacted the physician at the time the resident hit [his/her] hand and stated he should have maybe done something. When inquired to LPN #1 what should be done when a resident has a potential injury, the LPN stated further the process would have been to assess the resident, call the nursing supervisor or Director of Nursing (DON), call the physician, and notify the family. LPN #1 stated that an assessment should have been completed and documented, and confirmed it had not been completed. A review of the Progress Notes (PN) revealed documentation by the LPN #1 dated 08/20/23 at 9:50 AM, revealed Resident c/o [complaint of] pain about middle finger of left arm, noted discolored, cold to touch, painful at touch. Vitals stable, called placed to md [medical doctor], new order for x ray of the middle finger of the left hand for c/o pain and discoloration. On 10/26/23 at 12:30 PM, the Medical Director (MD) during a telephone interview with the surveyors, stated that she was Resident #52's physician. The MD stated she was aware Resident #52 had falls but could not remember everything about the 08/20/23 incident. The MD stated her expectations would be that if a resident fell, the staff should tend to the resident, call the physician, and describe the injury so she would know the course of action. The MD further stated that if a staff member witnessed the resident hit their hand, she would expect a call immediately. She accessed her EMR and informed the surveyors that she was informed the finger was fractured on 08/23/23, three days ago and the staff was not sure how the injury occurred. On 10/27/23 at 10:46 AM, the above concern was addressed with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations, and the Regional Clinical Nurse (RCN). On 10/31/23 at 8:21 AM, during an interview with the surveyor, LPN #2 stated if she witnessed a resident fall into something or injury themselves, she would assess their whole body, write an incident report, but give first aid immediately in case the resident had pain and next call the doctor. On 10/31/23 at 8:22 AM, LPN #3 stated if she witnessed a resident injury themselves, she would immediately assess the resident and provide first aid and inform the doctor. She stated she would provide first aid definitely right away to protect the resident. On 10/31/23 at 10:24 AM, the Regional Clinical Nurse (RCN) stated LPN #1 should have called the doctor, used ice and pain management immediately given the resident yelled ouch. She stated the expectation would have been to assess for pain and administer the already ordered Tylenol for pain. The facility had no additional documentation or policies to provide. b. 1.) On 10/18/23 at 10:35 AM, Surveyor #2 toured the Noble Unit (High side), and observed Resident #13 in bed. Their eyes were open and the resident was able to communicate with the surveyor. A care tour was completed with the Certified Nursing Assistant (CNA) assigned to the unit and revealed the following: Resident #13 was unshaven, the skin on the face was covered with flakes. The lower extremities extended to the toes had areas that were covered with callus type skin areas with dry skin flakes which were noted on the bed also. The adult incontinent brief that the resident was wearing, was secured properly and was not soiled. The skin on the back and buttocks was intact and there were no open areas. No redness was noted. There was no documentation that Resident #13 had been non-compliant with care. An interview with the CNA revealed that the resident required extensive assistance of two staff for bed mobility and transfer. The CNA added that the resident remained in bed and would refuse to get out of the bed. When the surveyor inquired about the dryness noted on the face and the lower extremities, the CNA stated, There is a skin remedy that could be applied. On 10/19/23 at 8:45 AM, Surveyor #2 observed the resident in bed. The resident was unshaven and the skin was dry. An interview with the Registered Nurse Unit Manager (RN/UM) revealed that the podiatrist visited the resident on 10/18/23, and there were no new orders. On 10/20/23 at 7:45 AM, Surveyor #2 observed the resident in bed, their eyes were closed, and the side-rails were elevated. The surveyor returned during lunch and observed the resident was in bed, unshaven, and large number of flakes and dry calluses were noted on the bed. On 10/23/23 at 9:00 AM, Surveyor #2 returned to the unit and observed Resident #13 in bed. A CNA was at the bedside assisting Resident #13 with the breakfast meal. The resident was unshaven, and their face was covered with white flakes. The surveyor asked the resident if he/she would consider getting out of the bed today. The resident replied, Not really. I am itchy. I would like to get washed. On 10/23/23 at 9:30 AM, after breakfast Surveyor #2 asked two CNAs to assist with a care tour. The surveyor observed that Resident #13 was wearing two incontinent briefs which were both saturated with urine. The gown that the resident was wearing was brown and stained. The pulled sheet was also brown and stained. Resident #13 was noted with scratch marks and redness to the sacrum and buttock areas. The Registered Nurse Unit Manager (RN/UM) was not available on the Noble Unit. The surveyor summoned another surveyor to the room along with the Director of Nursing (DON). On 10/23/23 at 9:52 AM, the DON in the presence of Surveyor #2 verified that incontinence care had not been provided on the prior shift. (11:00 PM-07:00 AM shift). Surveyor #2 left the room and reviewed the 11:00 PM-7:00 AM staffing. The Census was 52, and only 1 CNA had been assigned to care for 52 residents. On 10/26/23 at 11:00 AM, Surveyor #2 conducted a telephone interview with the CNA who worked the prior 3:00 PM-11:00 PM shift. The CNA revealed that she provided care to Resident #13 on 10/22/23 at 6:30 PM and applied two adult incontinent briefs on the resident. The CNA stated that at 6:30 PM, she had to change the sheets including the gown, as Resident #13 was saturated with urine. The CNA confirmed that she applied two adult incontinent briefs prior to finishing her shift. She informed the surveyor that she clocked out at 7:00 PM. On 10/26/23 at 12:53 PM, Surveyor #2 conducted a telephone interview with the 3:00 PM -11:00 PM Registered Nurse (RN) who worked on the Noble Unit. The RN stated that two CNAs left at 7:00 PM, and the other CNA on the unit did not ask for assistance with care. He stated that staffing was lacking but he would assist if requested. He could not elaborate on whether incontinence care had been provided. On 10/27/23 at 9:25 AM, Surveyor #2 checked Resident #13 again and observed the sacral redness was still present. A small open area to the left buttock was observed and there was no documentation regarding the newly open area which was not measured or provided a treatment. On 10/27/23 at 9:32 AM, Surveyor #2 asked the RN/UM to measure the affected area. The sacrum measured: 9 centimeter (cm) x 8.5 cm. The left buttock measured 6.5 cm x 1.5 cm. On 10/27/23 at 9:49 AM, Surveyor #2 conducted an interview with the RN/UM regarding the process to ensure that the residents were being cared for. The RN/UM stated that in the morning, she would get a verbal report from the 11:00 PM-7:00 AM shift and would follow up on anything important. She stated she would assign nurses and gave report to CNAs. The CNAs should check the residents as soon as they received their report. Residents' dependent on staff for care should be checked at minimum every two hours and as needed. The RN/UM further stated that she was not aware that some of the residents did not receive care during the 11:00 PM-7:00 AM shift. In the morning during report, she was informed that adequate staffing was an issue, and the night nurse did not elaborate further. She went on to state, if she was made aware of residents not having received care, she would have asked the CNAs to check and change the residents that were not changed during the prior shift immediately. On 10/27/23 at 7:50 AM, Surveyor #2 conducted a face-to-face interview with the Licensed Practical Nurse (LPN) who worked the 11:00 PM-7:00 AM shift on 10/22/23. The LPN informed the surveyor that staffing had been an issue at the facility for the last 5 years. The LPN made it clear that on 10/22/23 during the night, they provided safety and answered call lights. When inquired regarding if she aided the CNAs to change and turn some of the residents, she stated, No, I was busy also. We provided safety that is all we could do. When asked if the administrative staff was aware of the staffing issue, she stated, yes. On 10/27/23 at 8:40 AM, Surveyor #2 conducted a telephone interview with the CNA who cared for the resident during the 11:00 PM -7:00 AM shift on 10/22/23. The CNA confirmed that he did not provide incontinence care to the resident during the shift (8 hours). The CNA told the surveyor he was overwhelmed and could not get to the resident. He stated that for that shift he provided care for 30 residents. The CNA stated he provided safety and ensured the call lights were being answered. On 10/27/23 at 10:55 AM, the DON revealed she was not aware that the facility had one CNA working for the 11:00 PM- 7:00 AM shift. She further stated, if she had been made aware, she would have call to get more staff. She added that she was not aware that incontinence care had not been provided. Her expectations were that all residents looked cleaned and received the care they deserve. A statement from the LPN assigned to the 7:00 AM-3:00 PM shift indicated that she was informed by the CNA that Resident #13 was heavily saturated with urine and had 2 adult briefs on. She informed the DON and applied periguard cream to the skin. She rechecked the resident in the afternoon after care was provided and there was no skin breakdown observed. On 10/27/23 Surveyor #2 reviewed Resident #13's EMR. The admission Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; Quadriplegia, Parkinsonism, unspecified, contracture left elbow, psoriasis and unspecified Dementia. Review of R 13's most recent annual MDS with an Assessment Reference Date (ARD) of 07/18/23, reflected that Resident #13 had moderate cognitive impairment. Resident #13 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS). Section V. Care Area Assessment (CAA) Summary, Section V 02000. CAA and Care Plan (CP) decision, documented cognitive loss, urinary incontinence, Activities of daily living, nutritional status, pressure ulcer, psychosocial well-being, and psychotropic drug use were triggered and identified to develop a care plan. Record Review (RR) of Resident #13 revealed that R #13 did not have a pressure sore. Section M which addressed skin condition, coded Resident #13 to be at risk. Surveyor #2 reviewed Resident #13's Care Plan (CP), last reviewed/revised on 07/17/23. The CP had a focus area for impaired skin integrity related to healing Stage 4 Sacrum, incontinence and impaired mobility and chronic circulatory insufficiencies. The goal was for Resident #13 to develop no new areas of skin breakdown. The interventions included, keep skin clean and dry. Apply lotion on dry skin. Turn and reposition at frequent intervals while in bed. The care plan did not reflect that Resident #13 had a pressure injury to the sacrum extended to the buttocks areas. A review of an interdisciplinary (IDCP) meeting conducted by the facility on 10/24/23, timed 15:44 (3:44) PM, reflected the following: IDCP met to review Quarterly plan of care. Resident had not had a significant change(s) in condition. Resident is compliant with care and takes his/her meds. Skin is intact at present . Despite the observed skin injury verified by the facility staff on 10/23/23, there was no documentation that the physician or the Resident Representative (RR) was informed of the issue with incontinence care resulting in skin injury. The care plan was not revised. On 10/31/23 at 9:30 AM, the RN/UM informed Surveyor #2 that the resident was seen by the wound team and provided the following progress notes dated 10/30/23 timed 13:06 (1:06) PM. Resident was seen on wound round. Left buttocks redness resolved. Right buttock redness measuring 9 centimeter (cm) x 6.5 cm. Skin is intact. Treatment, Antifungal cream. Sacrococcyx MASD (Moisture Associated Skin Damage) measuring 0.3 cm x 0.5 cm x 0.1 cm. 100% epithelization tissue present. Scant serous drainage present. Treatment with Silvadene twice daily. b. 2.) On 10/23/23 at 11:00, Surveyor #2 entered Resident #14's room with two CNAs for a care tour. The surveyor observed that Resident #14 was not provided with incontinence care. Large amount of secretions was noted on the sheet. Strong feces odor was noted in the room. During the care tour at 11:15 AM, the surveyor along with facility's staff observed Resident #14's sacrum and bottom which were covered with feces. Resident #14 had a stage 4 pressure ulcer that was covered with feces. The gauze covering the dressing was noted in the incontinent brief covered with feces exposing the open areas of skin that were also covered with feces. On 10/23/23 at 12:30 PM, Surveyor #2 interviewed the CNA assigned to Resident #14. The CNA confirmed that she had not checked or changed the resident prior to go on break at 11:00 AM. On 10/27/23 at 8:40 AM, Surveyor #2 conducted a telephone interview with the 11:00 PM-7:00 AM CNA. The CNA informed the surveyor that he checked the resident possibly at 6:00 AM and the resident was not soiled. When inquired about who assisted him with the resident, he stated, I did it alone. (Resident #14 required extensive assist of two persons for bed mobility. The surveyor then asked the CNA what he observed on the resident backside area, he stated there was nothing in place. Resident #14 had a wound and a protective dressing was to be in place but was missing per the CNA. On 10/27/23 the 11:00 PM- 7:00 AM CNA provided the following statement, I was the only CNA on the unit last night. I did rounds, offered water to the residents but did not provide incontinent care. I was alone and it was difficult. I did not ask for assistance from the nurse. It just escaped my mind. I must be honest, I made rounds, offered water but I did not change or check the residents. A telephone statement from the LPN dated 10/25/23, indicated the following: I was the only nurse and he was the only CNA. I helped the CNA with residents that he could not change alone. I have one CNA who could not do the entire floor. The LPN stated that at 6:00 AM, she observed that Resident #14 was in bed, appeared to be comfortable and he/she was covered. I did not noticed any odor during my rounds. The surveyor reviewed Resident #14's clinical record. The admission Face Sheet reflected that Resident #14 was admitted to the facility with diagnoses which included but were not limited to; Quadriplegia, heart failure, right and left hand contracture, pressure ulcer of sacral region, stage 4, dependence on supplemental oxygen. The Quarterly Minimum Data set (MDS) an assessment tool used by the facility to prioritize care dated 09/08/23, revealed that the resident was non verbal and totally dependent on staff for all Activities of Daily Living (ADLs). All needs must be anticipated. Resident #14 required two persons physical assist for bed mobility and toilet use. Resident #14's Comprehensive Care Plan dated 02/07/18, with a revision date of 03/09/21, reflected a focus for ADL Self Care Performance Deficit and is totally dependent on staff for all ADLS related to impaired mobility and cognition. The goal was for staff to anticipate and meets all Resident #14's needs with Target date of 09/21/2023. The interventions included: for personal hygiene: Resident #14 required total assistance with personal hygiene. Resident #14 also had a focus for impairment to skin integrity on sacrum related to stage 4, incontinence, immobility. The goal was for the wound to show sign and symptoms of healing through the review date of 09/21/23. Interventions included: Daily skin checks with care initiated 02/07/18. Follow facility protocols for treatment of injury. Identify causative factors and eliminate/resolve where possible. keep skin clean and dry revision date 02/07/18. Air mattress to relieve pressure to pressure points. (02/07/18). Turn and reposition every 2 hours. Weekly skin assessments by licensed nurse with a revision date of 02/07/18. On 10/20/23 at 11:15 AM, Surveyor #2 conducted a face to face interview with Resident #14's Representative (RR). The RR revealed concerns with the care delivery. The RR stated that the facility did not have enough staff to care for the residents. The RR went on to state that during visits, the RR would observe the resident soiled and laying in bed with a soiled brief for long periods of time and could not find any available staff to change the resident. The RR stated this had been discussed with the RN/UM and the prior Director of Nursing. On 10/23/23 at 11:00 AM, Surveyor #2 conducted a care tour with two CNAs assigned to Noble Unit (high side). On 10/23/23 at 11:15 AM, in the presence of the LPN assigned to the unit and two CNAs, Surveyor #2 observed that Resident #14 was heavily soiled with feces. The adult brief and the pads were covered with feces. The CNA assigned to the resident was on break and could not be interviewed. On 10/23/23 at 12:30 PM, the surveyor interviewed the CNA assigned to the 7:00 AM- 3:00 PM. The CNA revealed that she reported to work at 6:50 AM, and had not yet checked the resident during the shift. Statements from the CNA who worked the 11:00 PM-7:00 AM shift indicated that incontinence care was not provided during the prior shift because he was the only CNA. Resident #14 was totally dependent on staff for care. Resident #14 was not provided incontinence care for over 12 hours. During wound care on 10/23/23 at 11:30 AM, a new open area of skin was noted on the right buttock which was not measured by the nurse. The nurse dressed the wound with Periguard and secured the wound with the adult brief. A review of the indication for Periguard (skin barrier) indicated the following: Do not use on open and punctured wound. The LPN did not have an order to apply Periguard to the open wound. On 10/23/23 at 12:40 PM, during an interview with the Director of Nursing, she stated that the nurse should have applied a wet to dry saline dressing until she got an order from the physician. Review of the skin evaluation dated 10/23/23, provided by the facility, revealed that the resident had a stage 4 pressure ulcer to the sacral area. The pressure injury to the left buttock was identified on 10/23/23, during care and wound treatment. Review of the Physician Order Sheet (POS) dated 10/01/23, reflected an order to cleanse the sacral wound with saline and pat dry. Apply Calcium Arginate Silver to wound, cover with gauze and dry dressing daily. Silvadene 1% (Silver Sulfadiazine) was to be applied to the right buttock. There was no order to apply Periguard to the left and right buttocks. A Progress Notes dated 10/23/23 timed 6:20 PM, revealed the following: Left buttock MASD measuring 9.0 centimeter (cm) 4 cm x 0.1 cm. Right buttock MASD superior MASD measuring 1.0 cm x 0.5 cm x 0.1 cm. Right buttock inferior MASD measuring 1.0 cm x 0.5 cm x 0.1 cm. Treatment ordered with Silvadene. The facility provided, Skin Evaluation dated 10/23/23, indicated that a new issue was identified: Noted with stage 4 sacrum, MASD to left buttock and reopening of MASD to right buttock. A review of the Comprehensive Care Plan did not include documentation of the skin injury identified on 10/23/23. The rationale for not revising the care plan after the pressure injury was identified was not provided. The above concerns were discussed with the administrative staff during the survey and again on 10/30/23, during the pre-exit conference. The DON added that she started the investigation and would provide the investigation on 10/31/23. The DON provided the investigation on 10/31/23. All staff involved with Resident #13's and #14 care on 10/22/23 and 10/23/23, were interviewed. The 3:00 PM-11:00 PM shift confirmed she provided care to Resident #13 at 6:30 PM, and applied 2 adult briefs on the resident. The 11:00 PM-7:00 AM CNA provided a statement which reflected that he did not provide incontinence care to the residents. Resident #13 and #14 did not receive care according to their plan of care. The resident (#13)was last changed at 6:30 PM on 10/22/23. On 10/31/23 at 11:30 AM, in the presence of the survey team, the DON acknowledged that based on the investigation and her observation specifically for Resident #13, incontinence care was not provided. The DON further stated that all residents dependent on staff for care should have been checked and changed every 2 hours and as needed. A review of the facility provided, Abuse, Neglect and Explotation, policy revised 09/2022, included but was not limited to; Policy: to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Neglect is defined as the failure of the facility to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the facility provided, Abuse, Neglect and Mistreatment of the Elderly Policy, undated, included but was not limited to; B. Prevention: 4. adequate staffing levels are maintained at all times so that the needs of residents are met. D. Identification: 2. examples of neglect may include: a. pressure sores, b. poor personal hygiene, e. dirty, soiled bed, fecal or urine odor. A review of the facility provided, Certified Nurse Aide position summary, undated, included but was not limited to; Responsibilities: handles and attends to residents in a manner conductive to their safety and comfort; bathes the resident cleans and cuts fingernails and gives shampoos; and reports changes in resident's condition to the charge nurse or supervisor. A review of the facility provided, Licensed Practical Nurse position summary, undated, included but was not limited to; Responsibilities: takes an active role in direct resident assessment and care; assesses each resident daily and implements a change in the course of action as needed; maintains accurate resident care records and documents pertinent data; ensure that residents receive the highest quality of service .promoting dignity and respect; A review of the facility provided, Registered Nurse, position summary, undated, included but was not limited to; takes an active role in direct resident assessment and care; must have the ability to recognize and identify symptoms and to make decisions quickly in emergencies; assess each resident daily and implements a change in the course of action as needed; ensures that residents and families receive the highest quality of service .promoting dignity and respect. A review of the facility provided, Director of Nursing Services, position summary, undated, included but was not limited to; monitors nursing care to assure that all residents are treated fairly, with kindness, dignity and respect; completes daily rounds on the unit to observe residents and determine if nursing needs are being met; reviews nursing progress notes to ensure they are informative and descriptive of the nursing care provided; and provides direction to the nursing staff. NJAC 8:39-27.1 (a), 27.2 (c)(d)(g)(h)(j)