Complaint #: NJ162242 Based on observation, interview, record review, and review of the facility's policy, the facility failed to implement their abuse policies and procedures by ensuring a resident (Resident #239) was free from verbal abuse. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #239). Resident #239, who had diagnoses of bipolar, schizoaffective disorder, and anxiety, was observed by staff at an Ear, Nose, and Throat (ENT) doctor's office appointment being verbally abused and exploited by their facility escort, Housekeeping Aide (HA #1), who recorded the resident with their cell phone while they verbally abused the resident. The ENT staff who witnessed the incident reported that HA #1 was belittling and yelling at the resident. Observation of the ENT's surveillance video showed the entrance to the ENT's office with HA #1 yelling and cursing at Resident #239 who was observed visibly upset and verbalized that they thought HA #1 was kidnapping them. HA #1 continued to record and yell at the resident; never once reassuring the resident of their safety. The ENT's office had to request that HA #1 leave their office and a new escort be brought from the facility for Resident #239. The facility's failure to implement their abuse policy to ensure all residents were free from verbal abuse and exploitation posed the likelihood of serious harm to all residents. This resulted in an Immediate Jeopardy (IJ) situation. The IJ was Past Non-Compliance (PNC). The IJ was identified from 3/7/23 at 1:38 PM, when HA #1 began verbally abusing Resident #239 and exploiting them by videotaping it. The facility's Administration were notified of the IJ on 3/6/25 at 4:50 PM. The facility submitted an acceptable Removal Plan (RP) on 3/6/25 at 10:41 PM. The facility was back in compliance when the facility addressed the situation by: HA #1 was terminated; Resident #239 received a psychosocial evaluation; and all staff were in-serviced on the facility's abuse prevention and reporting policies by the Assistant Director of Nursing (ADON). The survey team verified the completion of the RP was 3/7/23, during an on-site survey on 3/6/25 at 11:13 PM, and determined the IJ was PNC. Findings include: A review of the facility's Abuse Prevention policy initiated January 2018, included the facility will not tolerate any form of resident abuse, neglect, or exploitation by staff members, volunteers, visitor, or family members or by another resident . The surveyor reviewed the closed medical record for Resident #239. A review of the admission Record face sheet (admission summary) revealed that the resident was admitted to the facility with diagnoses which included but not limited to; bipolar disorder, schizoaffective disorder, and anxiety disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 1/27/23, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severely impaired cognition. A review of the individualized comprehensive care plan (ICCP) included a focus area initiated 1/22/23, that the resident had a cognitive deficit. Interventions included: to be able to verbalize safety rules for specific tasks; engage in appropriate social conversation with facility staff; and consistent caregivers. A review of a Social Progress Note dated 3/7/23, indicated that the Social Worker (SW) documented that they followed-up with Resident #239 upon their return from the doctor's office. The resident appeared calm and in no emotional distress. The resident reported they could not recall if there was an incident while they were at the doctors and does not know what may have happened . A review of the Individual Psychotherapy Progress Note dated 3/8/23, included that the resident was initially tense, worried, and irritated because [the resident] was going to attend a meeting with staff. [The resident] was able to speak calmly once [they] were settled and assured [they] would be alright . A review of the facility's undated Investigation included an overview that on 3/7/23, at approximately 1:40 PM, the Director of Nursing (DON) received a phone call from the ENT's office that Resident #239 was observed with their escort, HA #1, who was observed having inappropriate aggressive behaviors towards the resident which included yelling, cursing, and videotaping Resident #239. That caused Resident #239 to become more agitated, that they fear for the resident safety with staff member, that [HA #1's] were so disruptive to the office that they asked her to step out of the office. The DON advised the office to call the police, to have HA #1 removed, and the facility would immediately send a new staff member to assist the resident. The investigation further indicated that HA #1 returned to the facility, they were interviewed, and the facility reviewed HA #1's cell phone video and then had them delete the video. The facility concluded that based on their investigation, the alleged allegation of abuse was substantiated. HA #1 was witnessed yelling, cursing, and videotaping the resident; actual videos of the resident were taken without their consent. HA #1 was asked and deleted all videos, and HA #1 was terminated. On 3/4/25 at 3:10 PM, the surveyor observed the video recording taken and provided by the ENT's office on 3/7/23 at 1:38 PM. The video showed the outside entrance and reception area of the ENT's office with HA #1 yelling loudly and cursing towards Resident #239 while videotaping the resident with a cell phone. Resident #239 appeared upset and was confused and the resident stated that they believed they had been kidnapped by HA #1 who never reassured the resident of their safety, but only yelled at the resident. Further review revealed that at no time did the transport driver for the facility's contracted transportation company intervene on behalf of the resident, but instead assisted HA #1 with the videotaping of the resident on the same cell phone. During a telephone interview on 3/4/25 at 2:59 PM, ENT staff (ENT #1) stated that she was notified by her staff on 3/7/23, that HA #1 was inappropriate with Resident #239 and staff asked her to come to the reception area. ENT #1 also stated that she observed HA #1 yelling and belittling Resident #239. ENT #1 stated her staff asked HA #1 to step outside and they contacted the facility to make them aware and they requested that another staff member come to supervise Resident #239 for the remainder of the appointment. During a telephone interview on 3/4/25 at 3:05 PM, ENT #2 revealed that the aide [HA #1] was very nasty to Resident #239. ENT #2 stated HA #1 was yelling at the resident a lot and videotaping the resident who seemed agitated and confused. ENT #2 reported that Resident #239 thought they were being kidnapped, but the aide [HA #1] did not assure the resident that they were safe and just yelled at them. During an interview on 3/6/25 at 8:59 AM, the DON stated she was contacted by ENT #1 at the ENT's office on 3/7/23, who reported that she had witnessed HA #1 being abusive towards Resident #239. The DON stated HA #1 was terminated, and that the facility substantiated that abuse occurred. The DON stated when she reviewed the abuse video, she was visibly shocked and upset. The DON stated the abuse Resident #239 sustained was terrible. The acceptable Removal Plan (RR) on 3/6/25 at 10:41 PM, indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including; HA #1 was terminated, Resident #239 received a psychosocial evaluation, and all staff were in-serviced on the facility's abuse prevention and reporting policies by the ADON. The facility self-corrected the deficient practice and it was determined that the IJ was Past Non-Compliance (PNC); that the facility corrected their non-compliance on 3/7/23. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 3/6/25 at 11:13 PM. NJAC 8:39-4.1(5); 33.2(c)12

Complaint #: NJ162242 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse and exploitation by a Housekeeping Aide (HA #1) who was observed being verbally abusive and videotaping the incident. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #239). Resident #239, who had diagnoses of bipolar, schizoaffective disorder, and anxiety, was observed by staff at an Ear, Nose, and Throat (ENT) doctor's office appointment being verbally abused and exploited by their facility escort, HA #1, who recorded the resident with their cell phone while they verbally abused the resident. The ENT staff who witnessed the incident reported that HA #1 was belittling and yelling at the resident. Observation of the ENT's surveillance video showed the entrance to the ENT's office with HA #1 yelling and cursing at Resident #239 who was observed visibly upset and verbalized that they thought HA #1 was kidnapping them. HA #1 continued to record and yell at the resident; never once reassuring the resident of their safety. The ENT's office had to request that HA #1 leave their office and a new escort be brought from the facility for Resident #239. During the facility's investigation, the facility failed to thoroughly investigate by obtaining statements from all witnesses including other residents who were escorted by HA #1 to their appointments. The facility's failure to implement their abuse policy by immediately conducting a thorough investigation to ensure all residents were free from abuse posed a likelihood of serious harm to all residents. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 3/7/23 at 1:38 PM, when HA #1 began verbally abusing Resident #239 and exploiting them by videotaping it. The facility's Administration were notified of the IJ on 3/6/25 at 4:50 PM. The facility submitted an acceptable Removal Plan (RP) on 3/6/25 at 10:41 PM. The survey team verified the implementation of the RP on-site 3/6/25 at 11:13 PM. Findings include: A review of the facility's Abuse Prevention policy initiated January 2018, included all reports of alleged or suspected abuse, neglect, and injuries of unknown origin shall be promptly and thoroughly investigated by the facility's Administrator. Immediate Investigation: the Nurse Supervisor will immediately initiate and investigation and will: .interview those staff members or other persons present to determine a cause/effect relationship for the injury/incident .the person conducting the interview will: .interview all witnesses and staff in the immediate area; interview the resident when appropriate . The surveyor reviewed the closed medical record for Resident #239. A review of the admission Record face sheet (admission summary) revealed that the resident was admitted to the facility with diagnoses which included but not limited to; bipolar disorder, schizoaffective disorder, and anxiety disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 1/27/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severely impaired cognition. A review of a Social Progress Note dated 3/7/23, indicated that the Social Worker (SW) documented that they followed-up with Resident #239 upon their return from the doctor's office. The resident appeared calm and in no emotional distress. The resident reported they could not recall if there was an incident while they were at the doctors and does not know what may have happened . A review of the Individual Psychotherapy Progress Note dated 3/8/23, included that the resident was initially tense, worried, and irritated because [the resident] was going to attend a meeting with staff. [The resident] was able to speak calmly once [they] were settled and assured [they] would be alright . A review of the facility's undated Investigation signed by the Director of Nursing (DON), included an overview that on 3/7/23, at approximately 1:40 PM, the DON received a phone call from the ENT's office that Resident #239 was observed with their escort, HA #1, who was observed having inappropriate aggressive behaviors towards the resident which included yelling, cursing, and videotaping Resident #239. That caused Resident #239 to become more agitated, that they fear for the resident safety with staff member, that [HA #1's] was so disruptive to the office that they asked her to step out of the office. The DON advised the office to call the police, to have HA #1 removed, and the facility would immediately send a new staff member to assist the resident. The investigation further indicated that HA #1 returned to the facility, they were interviewed, and the facility reviewed HA #1's cell phone video and then had them delete the video. The resident returned to the facility and a skin assessment was conducted with no injuries found. The facility concluded that based on their investigation, the alleged allegation of abuse was substantiated. HA #1 was witnessed yelling, cursing, and videotaping the resident; actual videos of the resident were taken without their consent. HA #1 was asked and deleted all videos, and HA #1 was terminated. The statements obtained were from the Unit Manager, DON, and HA #1. There were no interviews with the driver of the contracted transportation company, the ENT staff, HA #1's supervisor, Resident #239, or other residents. There was no evidence during the course of the facility's investigation if any other residents were identified and interviewed who had been escorted to appointments by HA #1. On 3/4/25 at 3:10 PM, the surveyor observed the video recording taken provided by the ENT's office on 3/7/23 at 1:38 PM. The video showed the outside entrance and reception area of the ENT's office with HA #1 yelling loudly and cursing towards Resident #239 while videotaping the resident with a cell phone. Resident #239 appeared upset and was confused and the resident stated that they believed they had been kidnapped by HA #1 who never reassured the resident of their safety, but only yelled at the resident. Further review revealed that at no time did the transport driver for the facility's contracted transportation company intervene on behalf of the resident, but instead, he took HA #1's cell phone and continued to record the resident. During a telephone interview on 3/4/25 at 2:59 PM, ENT staff (ENT #1) stated that she reported the incident to the facility; however, there were no follow-up interviews conducted with her by the facility. During a telephone interview on 3/4/25 at 3:05 PM, ENT #2 stated that she was not interviewed by anyone from the facility about the incident. During an interview on 3/6/25 at 8:35 AM, the Social Services Director (SSD) stated during an abuse investigation, she interviewed the resident involved and other residents. The SSD stated during that investigation, she did not interview any residents. During an interview on 3/6/25 at 8:59 AM, the DON stated the ENT staff did not make her aware of the driver being involved in the incident, but she did not ask. The DON also stated that she did not interview all the ENT staff who witnessed the incident; she did not know that she could. The DON further stated that she did not interview the Scheduling Coordinator at that time or attempt to identify and interview other residents who had been escorted by HA #1 during appointments. The acceptable Removal Plan (RR) on 3/6/25 at 10:41 PM, indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including; a complete investigation was initiated; the Licensed Nursing Home Administrator (LNHA) and DON were educated by the Regional Administrator on the facility's abuse policy, customer service, professionalism, and complete and thorough investigations; the SSD was in-serviced on proper investigation of abuse including interviews of other residents; and all staff were in-serviced on abuse. The survey team verified the implementation of the Removal Plan on-site on 3/6/25 at 11:13 PM. NJAC 8:39-4.1(a)5