**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer F 835 Based on interviews and a review of pertinent facility documents, it was determined that the facility failed to ensure that a.) a non-certified Nursing Aide (NA#1) received the required training and competencies needed prior to receiving their own assignment and rendering resident care which included but not limited to; bathing, toileting, transferring, feeding, personal hygiene, and grooming and b.) NAs did not work past 120 days without being certified as a nursing aide. This deficient practice was identified for 2 of 3 NAs reviewed (NA#1 and NA#2) who provided direct care to residents on 4 of 4 nursing units. NA#1 was hired on 9/16/24, to provide care to the residents. NA#1 began independent resident care assignments on 9/27/24, and was not enrolled in a state approved Nurse Aide in Long-Term Care Facilities Training and Competency Evaluation Program (NATCEP) until 1/13/25. NA#1 worked 68 shifts with no evidence of completing the required modules/Skill Competency and NATCEP program prior to providing independent resident care and worked past 120 days (1/13/25) in the facility without being certified as a nursing aide. The facility's failure to ensure all NAs were trained with the appropriate competencies and skills required prior to receiving an independent resident care assignment posed a likelihood that serious injury, harm, impairment, or death could occur to residents since untrained staff were providing resident care. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 9/27/24, after NA #1 was assigned an independent resident care assignment. The facility Administration was notified of the IJ on 5/28/25 at 2:38 PM. The facility submitted an acceptable Removal Plan (RP) on 5/28/25 at 5:40 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 5/29/25 at 11:46 AM. The evidence was as follows: Part A A review of the undated facility provided Position Title: Nursing Assistant (NA) In Training job description included; assist residents with daily dental and mouth care .assist residents with bath functions .assists residents with dressing .assist with bowel and bladder functions .assist with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc .Must posses a Nursing Assistant Student Certificate from a state-approved NATCEP Training Program. Specific Requirements: Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served A review of the undated facility provided Caring Partner Job Description included; the primary purpose of job position is to provide non-clinical assistance to the patients/residents at the direction of supervisors . Duties and responsibilities include bedmaking, tidying rooms and personal spaces, placement of call bells/bed controls in reach of patients, [NAME] pass, linen retrieval, meal tray pass, resident companionship and activities assistance/room visits/resident video conferencing . On 5/22/25 at 9:49 AM, during the entrance conference with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Clinical Services (RDoCS), Surveyor #1 (S#1) asked if the facility utilized non-certified Nurse Aides (NAs), and the LNHA responded yes. The surveyor also asked if the NAs were providing direct care to residents, and the LNHA stated that the NAs, which included NA#1, were providing direct care under the direction of the Certified Nursing Aide (CNA) and nurse, and that the NAs were in school preparing to take their written examinations. The surveyor requested the NAs' employee files for review. On 5/22/25 at 1:40 PM, the LNHA provided Surveyor #2 (S#2) with a list of NAs who worked at the facility. NA#1 was included on the list with a date of hire (doh) of 9/16/24. On 5/27/25 at 12:32 PM, S#2 reviewed NA#1's employee file which revealed the following: -Nursing Assistant in Training: doh 9/16/24. Position: Nursing Assistant in Training, shift assigned 3:00 PM to 11:00 PM (3-11), signed by NA#1 and the previous DON. -Job Description, Position Title: Caring Partner, doh 9/16/24, signed by NA#1 on 9/16/24, shift assigned was blank, and signature of the Hiring Manager was blank. Duties and responsibilities did not include direct care. -Payroll Related Information: effective date 9/16/24, full time, five shifts per week . -School letter dated 9/11/24: This letter is to certify [NA#1] has been enrolled in the CNA Program at [name of school redacted] start date September 16th, 2024 to October 17th, 2024, Monday through Friday from 9:00 AM to 3:00 PM. Signed by the Administrative Assistant. -Student CNA Status Change Form: date of completion of first 16 hours of CNA class dated 9/18/24. The form included, You must submit this form with supporting documentation from the CNA class instructor for proof of completion of the first 16 hours of the CNA class, signed by Human Resource (HR) Manager on 9/18/24. Further review of NA#1's employee file did not include documented evidence that NA#1 completed the 16 hours or 90 hours of required education, training, and competencies in order to provide direct care to residents. A review of NA#1's time sheets provided by the RDoCS revealed NA#1 worked the following: -From 9/27/24 to 5/26/25, NA#1 worked the 3-11 shift Monday through Friday. In addition, NA#1 worked 3-11 PM and 7:00 AM-3:00 PM (7-3) shift double shifts on 9/21/24, 9/22/24, 9/28/24, 10/5/25, 10/7/24, 10/12/24, 10/13/24, 10/14/24, 10/19/24, 10/20/24, 10/21/24, 10/27/24, 10/28/24, 11/1/24, 11/2/24, 11/3/24, 11/9/24, 11/10/24, 11/14/24, 11/16/24, 11/17/24, 11/24/24, 11/30/24, 12/1/24, 12/7/24, 12/8/24, 12/21/24, 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/12/25, 1/23/25, 1/24/25, 1/30/25, 1/31/25, 2/6/25, 2/7/25, 2/13/25, 2/14/25, 2/21/25, 2/22/25, 2/27/25, 3/2/25, 3/6/25, 3/8/25, 3/13/25, 3/14/25, 3/16/25, 3/20/25, 3/22/25, 3/23/25, 3/27/25, 3/29/25, 3/30/25, 4/1/25, 4/4/25, 4/5/25, 4/6/25, 4/8/25, 4/10/25, 4/11/25, 4/12/25, 4/13/25, 4/16/25, 4/19/25, 4/20/25, 4/22/25, 4/26/25, 4/27/25, 4/30/25, 5/2/25, 5/3/25, 5/6/25, 5/7/25, 5/9/25, 5/10/25, 5/15/25, 5/17/25, 5/18/25, 5/20/25, 5/25/25, and 5/26/25. A review of the corresponding CNA assignments sheets provided revealed the following: On the 9/27/24's 3-11 shift, NA#1 was independently assigned to Assignment #2, which included 14 residents in total, showers for two residents (rooms: 117 W and 122 P), and one resident for feeding assistance and hoyer lift transfer (transfer using a mechanical lift) (room [ROOM NUMBER] P). Further review of the CNA assignment sheets provided revealed that NA#1 worked as an NA for total of 68 shifts and provided independent resident care that included bathing, feeding, transferring, toileting, and hygiene from 9/27/24 through 1/12/25, without any evidence of completing the modules/Skill Competency. A review of the additional CNA assignment sheets confirmed NA#1 worked on all four nursing units with independent resident care assignments that corresponded with their timesheets. According to NA#1's school letter, NA#1 was attending the CNA school Monday through Friday from 9:00 AM to 3:00 PM, beginning 9/16/24 through 10/17/24. According to the facility's CNA assignment sheets and NA#1's timecard, NA#1 was working at the facility providing resident care during the same dates and times NA#1 was supposed to be attending school. On 5/27/25 at 2:10 PM, Surveyor #3 (S#3) attempted to conduct a telephone interview with NA#1, there was no answer, and a message was left to call back. On 5/27/25 at 2:23 PM, S#2 interviewed the Regional Human Resources Director (RHRD), who stated that the previous HR staff of the facility left, and she was the covering HR of the facility for two weeks now. The RHRD further stated that the facility's protocol with hiring NAs was to; ensure that the NAs were enrolled in school, get the test done before 120 days before transferring their title to a CNA, provide direct care after training and competencies were done, and all required certificates, including the completion of 16 hours of training should be in the NAs files. At that time, the facility was unable to provide documentation that NA#1 completed their competency skills. The RHRD did not respond to the surveyor inquiry how the facility would know NA#1 completed their competency skills with no documentation. On 5/27/25 at 2:35 PM, S#3 called NA#1's school and spoke to the Receptionist, who stated that NA #1 started school on 1/13/25, and finished on 2/13/25. The Receptionist further stated that the school administrator was on vacation, and the Receptionist had no further information to provide. On 5/27/25 at 2:55 PM, NA#1 called back and was interviewed by S#3. NA#1 informed S#3 that his job title was NA, he went to CNA school in January 2025, and he was unable to provide the exact dates. NA#1 acknowledged he was in school back in 2024, and he could not say how many times he was enrolled in the NATCEP program prior to his January 2025 enrollment. NA#1 stated that he took care of residents in his assignments. When S#3 further asked NA#1 to explain what were the tasks and their assignments, NA#1 hung up the phone and did not answer his phone for a follow-up interview. On 5/28/25 at 9:39 AM, the LNHA, RDoCS, and [NAME] President of Operations (VPO) met with the survey team. The LNHA informed the surveyors that the facility management acknowledged the concerns of the surveyors that the NAs were hired at the facility, including NA#1, who the facility did not have documented evidence of completing the modules/Skill Competency prior to providing independent care to residents that included hygiene, toileting, bathing, transferring, and feeding. The LNHA further stated that she was aware of the 16 hours requirement as part of the regulation before their date of hire. (The regulation requires prior to the NA rendering independent resident care to complete the 16 hours.) On that same date and time, the LNHA confirmed that NA#1 had floor orientation that was done from 9/18/24 through 9/23/24, and that NA#1 did hand in hand direct care with residents, i.e. toileting, bathing, feeding, transferring, and hygiene. The LNHA further stated that NA#1 was off the schedule on 1/13/25, re-enrolled in school on 1/13/25, and completed the 16 hours on 1/16/25. The LNHA confirmed that the last day NA#1 worked was on 5/26/25, after surveyor's inquiry. The LNHA also stated that NA#1 was loved by residents and there were no reported incidents/accidents or grievance that involved NA#1. On 5/28/25 at 10:48 AM, S#2 interviewed a CNA, who stated that she remembered NA#1, and had worked with NA#1. The CNA informed S#2 that NA#1 was paired up in the beginning for two to three weeks, then NA#1 had their own assignments. The CNA further stated that NA#1 had to give showers, bathing, toileting, feeding if residents needed to be fed, dressed, and transferred. The CNA also stated that NA#1 worked on different shifts and different units. On 5/28/25 at 1:02 PM, S#2 interviewed the LNHA, who stated that she was aware who would be hired at the facility, and what positions were open. The LNHA informed the surveyor that it was the responsibility of the HR staff to follow the facility's policy and protocol for hiring a NA which included what documents were required prior to rendering direct resident care. The LNHA stated that she relied on the verbal confirmation of the HR staff that all requirements for NAs were completed. The LNHA also stated that she did not review the NAs files. At that same time, the LNHA stated that she was familiar the with requirement that the NA should be enrolled in school, but she had no knowledge of NATCEP. The LNHA confirmed that NA#1 provided direct care that included; toileting, bathing, feeding, transferring, and hygiene without evidence that the modules/Skill Competency was completed on 1/16/25, when the school had provided the certificate after surveyor's inquiry. Furthermore, the LNHA stated that the facility did not have a policy for NAs and Caring Partners; that the facility followed their job descriptions and titles. On 5/28/25 at 1:20 PM, S#2 interviewed the DON, who stated that she was responsible for interviewing the NAs. The DON further stated that she was not involved in checking the paperwork for the NAs, and that was the responsibility of the HR staff. The DON confirmed that she was unaware about the 16 hours and modules/Skill Competency certificates because she did not check them. An acceptable Removal Plan was received on 5/28/25 at 5:40 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; NA#1 was taken off the schedule on 5/26/25, and will not return to the resident care until obtaining CNA certification. No NAs are currently assigned to resident care. Any newly hired NAs will have completed: 16-hour introductory NATCEP training, required modules and competency checklist, enrollment in a state-approved NATCEP program, and no other staff were found to be noncompliant. Documentation of all NA competencies and NATCEP progress will be maintained in a centralized digital tracker and paper file in HR and will require the LNHA, DON, HRD, and Staff Educator's signatures prior to hiring. The LNHA, DON, HRD, and Staffing Coordinator (SC) were re-educated by the governing body (Vice President of HR) on the regulations, and clear accountability structure was implemented that included; HR will confirm NATCEP enrollment, the LNHA will confirm completion of Module one and Module two of the NATCEP course with written documentation, the DON will verify clinical competencies were completed prior to the NA providing direct resident care, and the SC will ensure no assignment without full clearance. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 5/29/25 at 11:46 AM. NJAC 8:39-43.1(a)(2,3); 43.2(a)(1,3)(b) PART B On 5/22/25 at 9:49 AM, during the entrance conference with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Clinical Services (RDoCS), Surveyor #1 (S#1) asked if the facility utilized non-certified Nurse Aides (NAs), and the LNHA responded yes. The surveyor also asked if the NAs were providing direct care to residents, and the LNHA stated that the NAs, which included NA#1, were providing direct care under the direction of the Certified Nursing Aide (CNA) and nurse, and that the NAs were in school preparing to take their written examinations. The surveyor requested the NAs' employee files for review. On 5/22/25 at 1:40 PM, the LNHA provided Surveyor #2 (S#2) with a list of NAs who worked at the facility. NA#2 was included on the list with a date of hire (doh) of 5/20/24. On 5/27/25 at 12:32 PM, S#2 reviewed NA#2's employee file which revealed the following: -Nursing Assistant in Training: doh 5/20/24. Position: Nursing Assistant in Training, shift assigned 3:00 PM to 11:00 PM (3-11), and signed by NA#2. -Payroll Related Information: effective date 5/20/24, full time, five shifts per week . -School Certification: Certified Nurses Aide Program Certification was completed on 12/19/22. The certification was signed by the school's Assistant Director. -NA#2 passed the skills test on 12/26/22. NA#2 was required to take and pass the written test to get the CNA license. A further review of NA#2's employee file did not include documentation that NA #2 passed the written test. There was no evidence that NA#2 received his CNA license. A review of NA#2's timesheets provided by the RDoCS revealed NA#2 worked from 6/1/24 through 5/25/25, as a NA. A review of the corresponding CNA assignments sheets provided revealed the following: On the 6/1/24's 7:00 AM to 3:00 PM (7-3) shift and 3:00 PM to 11:00 PM (3-11) shift, NA#2 was assigned as a NA on the nursing Unit 2D. On 5/27/25 at 2:09 PM, Surveyor #3 (S#3) attempted to conduct a telephone interview with NA#2, there was no answer, and a message was left to call back. On 5/27/25 at 2:23 PM, S#2 interviewed the Regional Human Resource Director (RHRD), who stated that the previous Human Resource (HR) staff of the facility left, and she was the covering HR of the facility for two weeks now. The RHRD further stated that the facility's protocol with hiring NAs was to; ensure that the NAs were enrolled in school, get the test done before 120 days before transferring their title to a CNA, provide direct care after training and competencies were done, and all required certificates, including the completion of 16 hours of training should be in the NA's files. On that same date and time, the RHRD confirmed that NA#2 was hired on 5/20/24, and did not receive his CNA license. NA#2's last day of work at the facility was on 5/25/25. On 5/28/25 at 9:39 AM, the LNHA, Regional Director of Clinical Services (RDoCS), Regional Director of Operations (RDO), and [NAME] President of Operations (VPO) met with the survey team. The LNHA stated that NA#2 previously completed the Nurse Aide in Long-Term Care Facilities Training and Competency Evaluation Program (NATCEP) program in December 2022, and failed the written test. The LNHA confirmed that NA#2 was not enrolled in school at the time he was hired on 5/20/24. The LNHA further stated that NA#2's 120 days should have been 10/10/24. The LNHA confirmed that NA#2's last day of work was on 5/25/25. NJAC 8:39-43.1(a)(2,3); 43.2(a)(1,3)(b)

Refer to F 728 Based on interview and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as herself, implemented the facility's policies and procedures including a.) the hiring and utilization of non-certified Nursing Assistants (NAs) to ensure NAs were trained with the appropriate competencies and completed modules prior to receiving their own independent resident care assignment and b.) NAs did not work past 120 days without being certified as a nursing aide. This deficient practice was identified for 1 of 3 NAs (NA#1) reviewed, who worked on 4 of 4 nursing units. Interviews on 5/28/25, with staff and the LNHA, revealed that NA#1 was hired on 9/16/24, to provide care to the residents and worked past 120 days (1/13/25) without being certified as a nursing aide. NA#1 began performing independent resident care on 9/27/24, and worked 68 shifts rendering independent resident care with no evidence of being enrolled in a State approved Nurse Aide in Long-Term Care Facilities Training and Competency Evaluation Program (NATCEP), or completed the required modules and skills competencies. The facility's failure to ensure all staff, including the LNHA, implemented the facility's policies and procedures to ensure all staff completed the appropriate modules and skills competencies prior to rendering independent resident care posed the likelihood that serious injury, harm, impairment, or death could occur to residents from untrained staff. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 9/27/24, after NA#1 was assigned an independent resident care assignment. The facility Administration was notified of the IJ on 5/28/25 at 2:38 PM. The facility submitted an acceptable Removal Plan (RP) on 5/28/25 at 5:40 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 5/29/25 at 11:46 AM. The evidence was as follows: A review of the Administrator Job Description, signed on 4/24/23, by the LNHA revealed: The Administrator was responsible to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing centers to assure that the highest degree of quality of care can be provided to the residents at all times . Duties and Responsibilities: Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the facility's programs activities. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility .Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice . Personnel Functions: Assist in the recruitment and selection of competent department directors, supervisors, facility non-licensed staff, consultants, etc. Ensure that appropriate employment identification and work documents are presented prior to the employment of personnel and that appropriate documentation is filed in the employee's personnel record in accordance with current regulations mandating such documentation .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .Review and check competence of work force and make necessary adjustments/corrections as required or that may become necessary . A review of the facility's undated Staffing, Sufficient and Competent Nursing Policy, reflected that the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment . Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully . On 5/22/25 at 9:49 AM, the surveyor met with the LNHA and the Director of Nursing (DON) during an entrance conference, and the LNHA stated that currently there were three NAs working at the facility. The LNHA further stated that the three NAs were currently in school, working under direction of a Certified Nursing Assistant (CNA) and nurse, and that they were in the process of taking the exams. The surveyor requested from the LNHA and DON for the NAs' employee files. A review of the three NAs' employee files revealed that NA#1 was hired on 9/16/24. NA#1 was enrolled in a NATCEP program from 1/13/25 through 2/13/25, and completed their modules and skills competencies on 1/16/25. NA#1 had an independent resident care assignment on 4 of 4 nursing units from 9/27/24 to 1/12/25, for a total of 68 shifts with no evidence of completing their required modules or skills. NA #1 also worked past 120 days (1/13/25) without being certified as a nursing aide. On 5/28/25 at 9:39 AM, the LNHA, in the presence of the Regional Director of Clinical Services (RDoCS), Regional Director of Operations (RDO), and [NAME] President of Operations (VPO), confirmed that NA#1 rendered resident care which included but not limited to; bathing, toileting, transferring, feeding, personal hygiene, and grooming independently without evidence of completing modules/Skill Competency. On that same date and time, the RDoCS informed the surveyors that on July 2024, the team did a Quality Assurance and Performance Improvement (QAPI) and reviewed the process for the required NA documentation that included the 16 hours modules/Skill Competency completion prior to the NA receiving their own assignment and rendering resident care. On 5/28/25 at 1:02 PM, the surveyor interviewed the LNHA, who informed the surveyor that she was not used to hiring NAs. The LNHA stated that she does not always review employee files and relied on the Human Resource Director (HRD) that everything was done or completed accordingly. She stated that she was unsure what NATCEP was, and what modules were to be completed. The LNHA further stated that as part of the requirements of the NAs was that they should be in a program. On that same date and time, the LNHA informed the surveyor that it was the responsibility of the HRD to check if the NAs were in school and the continued communication of the NAs' progress. The LNHA further stated that it was her responsibility as the administrator to do a verbal follow-up with the HRD. The LNHA also stated that it was not until July 2024, that she became aware that the NAs were required 16 hours of modules prior to the NAs being able to provide direct resident care. The LNHA acknowledged that the facility's process and policies should have been followed and it was part of her responsibility to oversee the onboarding process. On 5/28/25 at 1:20 PM, the survey team interviewed the DON, who informed the surveyor that she was responsible for interviewing the NAs. The DON stated that it was the responsibility of the HRD and Staffing Coordinator (SC) to ensure that the requirements of the NAs were completed before they worked on the nursing units independently. The DON further stated that she was unaware of the modules/Skill Competency because she did not deal with the NAs' files. An acceptable Removal Plan (RP) was received on 5/28/25 at 5:40 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; the LNHA, DON, HRD, and SC were re-educated by the governing body (Vice President of HR) on the regulation requirements specifically regarding administration oversight and enforcement of facility policies and procedures related to hiring, training, and assignment of NAs. The facility's policies related to the training, onboarding, and assignment of NAs were reviewed and reissued to all leadership employees in the nursing department. Policies include; requirement of 16 hour NATCEP training prior to any resident care, confirmation of module completion and competency prior to independent assignment. The LNHA will sign-off confirming the completed documentation prior to scheduling. A clear oversight structure has been put into place. The LNHA holds final accountability and will confirm file completion prior to assignment. The survey team verified the implementation of the RP during the continuation of the on-site survey on 5/29/25 at 11:46 AM. NJAC 8:39-9.2(a); 9.3(a)(1,2,3,4); 13.1(a),(b); 14.2