Complaint # 2587610 Based on interviews and review of pertinent facility documents on 08/19/25, it was determined that the facility failed to implement their abuse prevention policy to protect a cognitively impaired resident (Resident #1) from physical abuse when Resident #1's Representative (RR #1) reported to the facility's Social Worker (SW) an allegation of abuse. This deficient practice was identified for 1 of 3 residents reviewed (Resident #1). On 8/4/25, RR #1 reported to the SW that they were on the phone with Resident #1 while the Certified Nursing Aide (CNA #1) was providing care, and the resident was screaming. RR #1 stated that they spoke to CNA #1 through the phone who was not receptive or admitting any wrongdoing. On 8/5/25, RR #1 escalated the concern alleging that CNA #1 bent the resident's fingers/hand back and poured liquid on the resident. The SW immediately reported the allegation to the Registered Nurse Unit Manager (RNUM #1) who went to Resident #1's room to complete a body assessment. CNA #1 continued to work and was not suspended until 8/8/25, three days after the allegation of physical abuse was made, and they worked six shifts on multiple resident care assignments. An interview with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) on 8/19/25, revealed that the facility initiated an investigation into the allegation on 8/5/25, but confirmed that CNA #1 was not suspended until 8/8/25. The facility's failure to implement their abuse policy including protecting all residents from abuse during an investigation, placed all residents at risk for abuse. This posed the likelihood of serious physical and emotional harm, or impairment which resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/5/25, after RR #1 alleged CNA #1 physically abused Resident #1. The facility's Administration was notified of the IJ on 8/19/25 at 6:00 PM. The facility submitted an acceptable Removal Plan on 8/20/25 at 2:00 PM. The surveyor verified the implementation of the Removal Plan during an on-site visit survey on 8/21/25. The deficient practice was evidenced as follows: A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy initialed by the LNHA with a handwritten date of 8/7/2025, included Policy Statement: All reports of abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation are [.] thoroughly investigated by facility management.Reporting Allegations to the Administrator and Authorities.6. Upon receiving any allegation of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for protection of residents.Investigating Allegations .6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. A review of the Facility Reportable Event (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 8/11/25, included the date and time of event: 8/4/25 at 10:00 AM. The FRE further included under Narrative that on 8/4/25, [RR #1] reported concern to facility's SW that [RR #1] was on the phone with [the] resident while care being rendered by [CNA #1]. [RR #1] stated resident was yelling through the phone. [RR #1] stated [they] spoke to [CNA #1] through the telephone and [CNA #1] was not admitting to wrongdoing. Nursing unit manager made aware and responded immediately to resident room for body assessment and interview. On 8/7/25, [RR #1's] concern escalated to accusations requesting investigation of [RR #1's] concern and on 8/8/25, [an Interdisciplinary Care Plan (IDCP)] team held over the phone with [RR #1] and updated [RR #1] with good result. Another escalated email followed. Doctor informed, police notified, and [CNA #1] suspended pending investigation. A review of the facility's Investigation Report (IR) with date of incident 8/4/25, and date of investigation 8/8/25, included the following: Summary of Alleged Incident: On 8/4/25, [RR #1] reported a concern to SW [that they were] on the phone with resident while care being rendered. [RR #1] stated that the resident was yelling through the phone, [RR #1] states [they] spoke to [CNA #1] on the phone and [CNA #1] was not receptive nor admitting to wrongdoing. Concern was concluded with [RR #1's] satisfaction. On 8/5/25, [RR #1] escalated the initial concern and alleged [CNA #1] bent fingers/hand back and poured liquid on [the] resident. SW made nursing unit manager aware and responded immediately to resident room for body assessment and interview following report. No redness, no swelling, no bruising noted, skin intact, resident declined pain. Resident did not recollect account of an incident in room or bed on this date but stated in [a house of worship] over the weekend they jumped on top of [the resident], bent [the resident's] hands back, pulled [the resident's] hair, and poured liquid on [the resident]. Interview with [CNA #1] stated she was washing resident body and was assisting [the resident] to turn to the other side by reaching for [the resident's] hands which were on the edge of bed, no intention to cause harm to resident. While assisting resident to the other side, resident began to yell out and [CNA #1] stopped. [CNA #1] was able to complete care and transferred resident into [wheelchair]. Call placed [to RR #1] for discussion of alleged incident by unit manager with good result and agreeable to take [CNA #1] from resident assignment due to [RR #1's] negative perception of [CNA #1's] response when on the phone. On 8/7/25, at approximately 2:45 PM, [RR #1] sent an email regarding care concern requesting updates. On 8/8/25 at 11:35 AM, [RR #1] sent another email awaiting another response. [RR #1] began to escalate [CNA #1] allegations. On 8/8/25 at 2:22 PM, another email escalating care concern was received with allegation of [CNA #1]. Allegation was reported. Police were called. [CNA #1] was suspended until investigation was completed. A review of CNA #1's statement dated 8/5/25 at 1:30 PM, for the incident dated 8/4/25, included that I went to provide care for [Resident #1], who was refusing, but [RR #1] was on the phone and encouraged to finish care. While providing care I asked [Resident #1] to roll to other side and [the resident] refused. I reached out my hands to assist to roll over since resident was grabbing edge of bed. While assisting to the other side, the resident began to yell out and I stopped. [RR #1] began to yell through the phone asking what I was doing to the patient. I responded that I was cleaning resident and did not do anything to [the resident]. I finished dressing resident and transferred to [wheelchair] and resident thanked me. I would not cause harm to any resident. The surveyor reviewed the medical record for Resident #1. A review of the admission Record face sheet (an admission summary), revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to: metabolic encephalopathy (a condition where the brain's function is impaired due to underlying metabolic disturbance), cerebral infarction (stroke), hypotension (low blood pressure), insomnia (sleep disorder), obesity, muscle weakness, and type 2 diabetes mellitus without complications. A review of the Minimum Data Set (MDS), an assessment tool dated 6/2/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs). A review of the resident's individual comprehensive care plan (ICCP) included a focus area initiated 1/3/25, that the resident was resistive/noncompliant with treatment/care refusing ADL, nails, [laboratory work], and medications related to belief that treatment was not needed/working. Interventions included to allow flexibility in ADL routine to accommodate mood, preferences, and customary routine; and if resists care, leave (if safe to do so) and return later. According to CNA #1's statement, the resident was refusing care, and CNA #1 continued, which was not what the intervention instructed to do. On 8/19/25 at 11:38 AM, the surveyor interviewed RNUM #1, who stated that on 8/5/25, Tuesday morning, RR #1 called the SW and said, I know that I said that, but I slept on it and felt like something happened. The SW then told RNUM #1 and the DON about RR #1's phone call and their conversation with RR #1 from the previous day. RNUM #1 stated then she went upstairs with the DON and interviewed Resident #1, who stated, yes something happened in the [house of worship]. RNUM #1 stated they then did an immediate body assessment of the resident, assessed them for pain, removed CNA #1 from the resident's care assignment, and she did the incident report with the DON. RNUM #1 further stated that with the DON, they called and spoke to RR #1 and informed them that they did a body and pain assessment right away when they found out and started an investigation. RNUM #1 stated that RR #1 was satisfied that CNA #1 was taken off the resident's care. RNUM #1 stated on that same day, they took statements from other residents and Resident #1's roommate. RNUM #1 said that the roommate stated they did not hear anything, and the police came later in the week after the LNHA and DON received an email from RR #1 regarding the investigation. On 8/19/25 at 12:21 PM, the surveyor requested CNA #1's timecard and resident care assignments for the month of August 2025. A review of the timecard provided by the facility revealed that CNA #1 worked on the following days: -8/4/25 - CNA #1 punched in at 6:48 AM and out at 3:14 PM.-8/5/25 - CNA #1 punched in at 6:48 AM and out at 11:05 PM.-8/6/25 - CNA #1 punched in at 6:48 AM and out at 3:19 PM.-8/7/25 - CNA #1 punched in at 6:48 AM and out at 3:13 PM, and -8/8/25 - CNA #1 punched in at 6:48 AM and out at 5:37 PM. A review of the documents provided by the facility for CNA #1's resident care assignments according to Unit assignments were as follows: -8/4/25 - Unit 2, 7:00 AM to 3:00 PM (7-3) shift, CNA #1 was assigned to Post 4 with 9 room assignments. Resident #1 was in CNA #1's assignment. -8/5/25 - Unit 2, 7-3 shift, CNA #1 was assigned to Post 6 with 10 room assignments.-8/5/25 - Unit 2, 3:00 PM to 11:00 PM (3-11) shift, CNA #1 was assigned to Post 5 with 12 room assignments.-8/6/25 - Unit 1, 7-3 shift, CNA #1 was assigned to Post 3 with 11 room assignments.-8/7/25 - Unit 1, 7-3 shift, CNA #1 was assigned to Post 5 with 9 room assignments, and-8/8/25 - Unit 2, 7-3 and 3-11 shifts, CNA #1 was assigned to Post 5 with 10 room assignments. On 8/19/25 at 12:59 PM, the surveyor interviewed the SW, who stated that on 8/4/25, RR #1 called them around 10:00 AM during morning meeting. RR #1 asked the SW if they could run upstairs and check on [the resident] because they did not sound right when RR #1 was talking to the resident on the phone. The SW stated they went upstairs and saw the resident in their room in their wheelchair and eating their lunch. The SW stated that they asked the resident how they were, and the resident stated they could not remember the SW's name and said they were ok. The SW further stated the resident was pleasant and appeared to be in no distress, so the SW called RR #1 while they were in the resident's room and gave them updates on the resident. The SW said the RR #1 frequently called them and asked to check on [the resident]. The SW stated at that time, RR #1 reported they had a concern with CNA #1 splashing liquid on the resident. The SW stated they told RR #1 that the resident was sitting in their wheelchair and eating lunch and there was no liquid anywhere else in the room. The SW stated they then asked RR #1 if they were referring to when CNA #1 was washing or bathing the resident? The SW reported that at the end of the conversation, RR #1 was ok after the SW explained the splashing could have been during care. The SW stated they did not report that conversation with RR #1 to any of the nursing staff until 8/5/25, when RR #1 called again and said after sleeping on it, I felt like it was more than the splashing of liquid and [RR #1] further said that [CNA #1] was bending the resident's hand back, pulled [the resident's] hair, and hit [the resident] with a chair. The SW stated they then reported RR #1's concerns to RNUM #1 and the DON, who went upstairs and spoke to the resident and CNA #1. On 8/19/25 at 1:21 PM, the surveyor interviewed the LNHA and the DON. The LNHA and the DON stated that when they knew of RR #1's concerns on 8/5/25, they started the investigation; RNUM #1 did a body assessment on the resident, they interviewed and gathered witness statements, and conducted a customer service in-service. They further stated they removed CNA #1 from the resident's care and assigned a two-person assistance for [the resident's] care. They stated that they started the investigation, but did not suspend CNA #1 from other residents' care assignments because at the end of the day on 8/5/25, when they spoke to RR #1, RR #1 was agreeable with the result of their report. The LNHA and DON stated they suspended CNA #1 and called police on 8/8/25, when RR #1 emailed and escalated their concerns. An acceptable Removal Plan (RP) was received on 8/20/25 at 2:00 PM, indicating 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: on 8/19/25, CNA #1 remained suspended; all residents who received care by CNA #1 were assessed for pain, skin, and social services with no concerns; past three months of grievances were reviewed with no concerns for abuse; Regional staff in-serviced the LNHA and DON on the facility's abuse and abuse reporting policies; the DON or designee began in-servicing all staff on abuse and abuse reporting; and the DON or designee will quiz all staff on abuse.The survey team verified the implementation of the RP on-site on 8/21/25. N.J.A.C. 8:39-4.1(a)5