**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, physician interview, medical record review and review of other pertinent documents, it was determined that the facility failed to a.) recognize and assess the risk factors that placed a resident at risk for serious harm from drug overdose. b.) evaluate a resident's repeated symptoms of opioid intoxication that often occurred after the resident's return from treatment at a methadone clinic from [DATE] to [DATE]. c.) Evaluate the resident's non-compliance and how it may impact other residents. This deficient practice was identified for Resident #101, 1 of 24 residents reviewed for the quality of care provided to the facility residents and was evidenced by the following: Resident #101 experienced repeated significant changes in mental and physical condition that included stupor, altered mental status and collapse following visits to outside physicians and the methadone clinic . The facility could not provide any evidence that they attempted to determine the reason for repeated sudden drastic declines in the resident's mental and physical condition. Nor was there any evidence the facility communicated with the methadone clinic the resident's episodic stuporus condition upon return to the facility from the methadone clinic or possible misuse of the Methadone given to the resident for the days he/she did not go to the clinic. This failure to determine and address the cause of these episodes and other episodes of noncompliance posed a serious threat to the safety and well being of Resident #101 and other resident's at the facility. This resulted in an Immediate Jeopardy situation that began on [DATE] at 2:30 PM when Resident #101 experienced a sudden change in condition involving lethargy, disorientation and difficulty to rouse upon return to the facility from a post-operative surgical visit. The Licensed Nursing Home Administrator (LNHA) was notified of the IJ on [DATE] at 4:30 PM. The lack of monitoring of Resident #101 who left the facility three times a week (Monday, Wednesday and Friday ) for treatment at a Methadone clinic and the repeated nature of Resident # 101's sudden change in condition upon return from the Methadone clinic and other follow up medical appointments constituted Immediate Jeopardy due to the potential for injury or death to the resident. The Team Coordinator provided the Administrator and the Director of Nursing (DON) the IJ Template and informed the LNHA that an acceptable Removal Plan must be submitted to the Department of Health on [DATE] by 10:00 AM. On [DATE] the facility submitted a Removal Plan by e-mail. The Removal Plan was reviewed and accepted by the New Jersey Department of Health (NJDOH) on [DATE]. The survey team conducted an onsite visit on [DATE] for the verification of the removal plan. The survey team could not verify the facility's removal plan for the following reasons: The facility was unable to provide the following information that had been included in their Removal Plan: 1. Policy and procedure for methadone receipt from a clinic that prohibits the facility to acquire the drug and receipt, storage, and administration of methadone. 2. A copy of the Root Cause Analysis (RCA) that was completed 3. Policy regarding resident's escort to and from the methadone clinic 4. Documented evidence that the administrator spoke with the methadone clinic on [DATE] and scheduled a weekly conference with the case management of the clinic to discuss the compliance of the resident 5. A contract from the administrator and the transport service regarding transport and monitoring to the clinic. On [DATE] at 10:37 AM the the surveyors interviewed a staff member who identified herself as being part of the Quality Assurance (QA) team. She told the surveyors that she was not involved in the development of the Root Cause Analysis. This was done by the Department Heads and Regional Corporate person and she would get a copy when it was completed, she continued that otherwise she was not involved. At 10:46 AM the surveyor interviewed the Receptionist who stated she did not receive any inservice during the survey relating to Resident #101's transportation to and from the methadone clinic. She did receive some training relating to transport about a month and a half ago. Surveyors interviewed 5 Certified Nursing Assistants (CNAs) and only one CNA had received an in-service education regarding the 1:1 monitoring of Resident #101. The facility administrator was unavailable, either in person or by phone. On [DATE] the surveyors made a second onsite visit to determine if the removal plan for F684 had been implemented. Based on interview with administrative staff and review of records, On [DATE] AT 10:51 AM the survey team determined the Removal Plan had been implemented by the facility. The IJ was removed. The facility currently has no residents on Methadone treatment. The deficient practice is evidenced by the following: The surveyor reviewed the clinical record of Resident #101 on [DATE] at 01:57 PM. The admission Face Sheet revealed that Resident #101 was admitted to the facility on [DATE]. There was a readmission on [DATE] with diagnoses that included bipolar disorder, anxiety, hypertension, alcohol intoxication, asthma and ankle surgery for repair of right ankle. Physician's orders dated [DATE](a Readmission) contained an order for Methadone HCL 120 mg/12 ml by mouth daily for a diagnosis of drug abuse. Methadone is a Schedule II narcotic and has strict regulations for the ordering, dispensing, and accountability of the narcotic. It is the facility's responsibility to appropriately receive, store, dispense and account for this medication. The facility was unable to provide a Policy and Procedure for the receipt, transportation from the Methadone clinic, storage, dispensing and accountability of the Methadone It was not noted on the Medication Administration Records reviewed until April. The Annual Minimum Data Set (MDS) assessment tool dated [DATE] and the Quarterly MDS dated [DATE] revealed that Resident #101 was awake, alert and oriented. Resident #101 scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Further review of the clinical record on [DATE] revealed a form titled: New Jersey Universal Transfer Form (NJUTF). This form is used to document pertinent medical information about a resident for the receiving health care facility when a resident is sent out for an acute care treatment or when returning from treatment. The surveyor noted the following NJUTFs for Resident #101: Feb. 12, 2020 PM (no specific time) the NJUTF from the acute care hospital (MC #1 to the facility noted the reason for transfer as alcohol intoxication with delirium, altered mental status. Allergies listed were Latex and Methadone. NJUTF dated [DATE] and timed 12:50 PM from the facility to MC #1. This form noted Resident #101 was sent to MC #1 for opioid OD (overdose). The form listed the resident was allergic only to Latex. NJUTF dated Dec. 8, 2020 timed 2:45 PM from the facility to MC #1 noted that Resident #101 was found on the floor and was difficult to rouse. The form failed to include the information that the resident had returned earlier that day from the methadone clinic. The Interdisciplinary Progress Notes concerning this incident documented that the resident returned from the methadone clinic at 10:45 AM. At 12:45 PM the resident had been found stuporus in the bathroom with water running and flooding his/her room. At 2:00 PM the resident was found collapsed on the floor by his/her wheelchair and was described as difficult to rouse with several attempts and had been incontinent. The facility called 911 and when the ambulance arrived at 2:15 PM the resident refused to go to the hospital. That same day at 10:00 PM after returning from the outside smoking area the resident requested to go to the hospital for a sore throat and pain in leg. MD was called and ordered transport to MC #1 which the resident refused, insisting on going to MC #2. The resident packed belongings and went to his/her friend's room and then to outside smoking area. The transport company arrived, refused to take him/her to MC #2. Resident insisted Emergency 911 be called because they would take him/her to their choice of MC #2. Resident left the facility at 12:30 AM on Dec. 9, 2020 via the 911 Emergency ambulance service. There is no NJUTF from MC #2 to Amboy Care. According to the IDCP notes, the resident returned on [DATE] at 5:30 PM and told the staff he/she had COVID. The transport service employee said she did not have COVID, paperwork from sending hospital did not note COVID, and a rapid test at the facility was negative for COVID. The resident then proceeded to the outdoor smoking area. On [DATE] at 9:30 AM, the surveyor requested the investigative reports and any hospital records for the above dates but the facility did not provide any of this information. The surveyor also requested the police reports from the two dates the police were called for Resident #10. The facility could not provide these reports. On [DATE] the surveyor requested a copy of the Interdisciplinary Progress Notes concerning the above incidents from the DON and the Regional Licensed Practical Nurse (R-LPN). The IDCP note dated [DATE] at 10:30 AM, indicated that Resident #101 was picked up by the ambulance for a post-operative appointment. The note reflected that Resident #101 returned to the facility and was wheeled to the nursing unit by his/her roommate at 2:30 PM and that the resident appeared lethargic and had slurred speech. A nurse followed the resident into their room, the resident verbalized that he/she was tired and wanted to go to sleep and did not want to eat. The nurse documented that they would continue to monitor the resident every 15 minutes and that they notified the physician who ordered a urinalysis with a culture and sensitivity and a drug panel screen. It was documented the urine specimen was collected on [DATE]. On [DATE] at 11:55 AM, the LNHA provided the surveyor a copy of the urine lab result. The lab result showed that Resident #101 tested positive for cocaine and barbiturates. The barbiturates were part of a prescribed medication, the cocaine was not. Review of an IDCP note dated [DATE], revealed that the physician was made aware of the laboratory result on [DATE] and that no new order was received. The note also indicated that the physician asked the nurse to inform the DON of the cocaine positive lab result. An attached note dated [DATE] (the date of collection of the specimen) and signed by the LNHA, acknowledged that LNHA was aware of the urine specimen positivity for cocaine and barbiturates. On [DATE] at 3:35 PM, the DON provided the surveyor with the investigation of the [DATE] incident. The investigation revealed that the facility team met with Resident #101 to discuss the positive cocaine lab result. The investigation indicated that the police were called to the facility to speak with Resident #101. The facility further documented on the investigation that Resident #101 would be escorted to the Methadone clinic by staff to monitor the resident. The plan was written up and presented to the resident to sign but Resident #101 refused. The IDCP note dated [DATE] and timed 4:00 PM, indicated that Resident #101's room had a strong odor of cigarettes smoke, and that the LNHA and Director of Nursing were notified. The IDCP note indicated that the facility installed a smoke detector in the resident's room that same day at 4:30 PM. The facility was unable to provide the surveyors with an investigation into why the resident's room smelled of cigarette smoke. Smoking is prohibited in the facility. The resident is familiar with the facility smoking area as evidenced by numerous IDCP notes reflecting the resident is out in smoking area. The IDCP note dated [DATE] and timed 6:00 PM, reflected that Resident #101 was observed in their room seated in the wheelchair, slumped over onto the bed, and was difficult to rouse. There was no further information provided by the facility regarding this change in mental status, and no evidence of an assessment into the reason for the lethargy. The resident stated she was tired. The IDCP note dated [DATE] and timed 12:30 PM documented that staff looked through the window and observed Resident #101 in the courtyard slumped over in the wheelchair. The IDCP noted that the night shift reported the resident had left for the clinic. The return time was not noted. Resident #101 had returned from the Methadone clinic but did not report to the nursing unit until 11:30 AM. An IDCP note timed 12:15 PM indicated that the resident still appeared lethargic and slumped over when staff observed the resident in the doorway to his/her room after returning to the nursing unit. The staff notified the MD and DON. The MD ordered the administration of Narcan (an opioid antagonist which will reverse the effects of narcotics) 0.4 milligrams x 1 dose and to send Resident #101 to the Emergency Department for evaluation. The Resident refused to go to the hospital and refused to take Narcan. The facility could not produce an investigation of the incident in order to determine the cause of the extreme lethargy. There was no communication with the Methadone clinic concerning dosage given at the clinic and the Methadone sent back to the facility with the resident. That same day at 8:45 PM nursing staff documented that a resident reported Resident #101 asked for his/here Percocet, an opioid combination medication. The resident refused to give Resident #101 any Percocet. A [DATE] note at 11:00 PM reported resident was off the floor outside most of the shift and 30 min checks ongoing. An IDCP note dated [DATE], indicated that Resident #101 left for the Methadone clinic at 9:45 AM with one transport escort. The staff were unable to determine the resident's return time. A 12:00 PM IDCP note documented that at 11:45 AM, they saw the resident outside with other residents. A [DATE] IDCP note timed 12:15 PM noted the resident was in his/her room slumped in wheelchair, rousable, with slurred speech/ The physician was in the facility, was notified and ordered a urinalysis and a drug screen and it was noted the resident was compliant with the order. At 1:30 PM the resident was observed by staff to be still asleep in the wheelchair. At 2:30 PM the resident was found in a stuporus condition kneeling on the floor with a reddened left knee. Resident denied pain except for the post surgical pain. The DON and Supervisor were notified and ordered transport to MC #1 for evaluation. At 4:00 PM the transport service arrived and the resident refused hospitalization. The facility called the police who did arrive and interview the resident . The police told the facility that they cannot force her to go to hospital. There was no documentation of Narcan being ordered, there was no documentation of the Methadone clinic being contacted about the resident's condition. There was no information provided regarding who accompanied the resident to and from the methadone clinic, what time the resident returned, how the Methadone for the next days' doses was transported to the facility and how that Methadone is held once in the facility. A Licensed Practical Nurse (LPN # 5) documented in an IDCP Note dated [DATE] 4:45 PM, that Urine specimen obtained and lab collected. A report from the laboratory dated [DATE] provided to the surveyors on [DATE] at 2:45 PM, revealed that the request for Multi Class drugs urine test was not performed because no specimen was received and that the test should be rescheduled. There was no evidence that the test was completed as ordered. There was no documentation that the MD was made aware. An IDCP note dated [DATE] timed 9:00 AM, indicated that the resident returned from the Methadone clinic. The methadone bottle was checked by staff who noted the seal had been opened and there was a little bit of liquid in it. When staff questioned the resident about the open methadone bottle seal the resident stated, That is what I received. There was no evidence the facility contacted the Methadone clinic to confirm the dosage give to the resident and the condition of the bottle and seal. At 9:45 the staff documented in an IDCP note that Resident #101 was observed in his/her room, was lethargic and had dropped her cell phone to the floor. When staff approached the resident he/she told them to leave him/her alone. At 10:45 AM the resident went outside, and at 11:10 AM was asleep in front of the nurses station. IDCP note from [DATE] timed 8:38 AM documented methadone given resident has the key to the box. At this same time staff documented there was some drainage from the surgical site, resident advised to elevate foot but refused. On [DATE] at 6:00 PM staff documented that the resident was lethargic seated in wheelchair with head slumped over onto bed sleeping. Was rousable. An IDCP note date [DATE] time 7 AM to 3 PM noted resident looks sleepy, took all meds, but was sleeping when taking meds, only woke when name called, drooling from mouth while sleeping in wheelchair and leaning over bed On [DATE] the IDCP note documented the resident went out to the methadone clinic at 9:00 AM and returned at 10:45 AM stating I'm so tired. At 12:45 AM the resident was found seated in wheelchair by bathroom sink with the water running and flooding the entire room. Resident stated I'm tired. At 2:00 PM staff documented resident found on floor by wheelchair, difficult to rouse and incontinent. No injuries noted, Emergency 911 called, DON and Supervisor notified. When Emergency ambulance arrived the resident once again refused to go to hospital. Review of an investigation dated [DATE], revealed that a Certified Nursing Assistant (CNA ) found Resident #101 on the bedroom floor. LPN #2 documented that she assessed Resident #101 and noted the resident's left knee with redness. Resident #101 reported feeling tired and was transferred from the floor to the wheelchair and assessed further by nursing staff, who found no other apparent injury. Staff called 911 to transfer the resident to the emergency room for further assessed since the fall was unwitnessed, but the resident refused to go. On this same day at 10:00 PM after smoking outside with close friend, the resident came to the nurse and stated he/she wanted to go to hospital, after calling the MD the transport service arrived. While awaiting transport service resident returned with friend to smoking area. The resident refused transport service and demanded Emergency 911 be called because they would take him/her where he/she wanted to go, MC #2. Resident returned to facility on [DATE] at 5:30 PM. IDCP note dated [DATE] timed 2:00 PM notes resident seen putting pills in pocket, resident did comply with showing meds to nurse. Nurse was shown 1 Klonopin tablet, .5 mg. The medication taken from the resident. The LNHA, physician and DON were notified. The Physician ordered all meds to be crushed going forward. Klonopin is used to treat seizures and panic attacks, it is included in the class of drugs known as Benzodiazepines. Among other disorders is used to treat panic attacks. It can cause severe drowsiness, breathing problems (respiratory depression), coma, and death when taken with opioid medicines. Klonopin can cause sleepiness or dizziness and can depress thinking and motor skills. On [DATE] at 11:28 AM, the surveyor interviewed Resident #101 regarding holding onto the Klonopin pills. Resident #101 informed the surveyor that sometimes he/she would save the physician prescribed Klonopin and used the Klonopin dose with half of his/her Neurontin (an anti-convulsant and nerve pain medication) dose and would take them together at night to get a good night sleep. The surveyor informed the Registered Nurse (RN #1) of the above statement. RN#1 did not indicate that she was aware that Resident #101 was accumulating or saving the medication instead of taking it. An IDCP Note dated [DATE] at 2:00 PM, indicated that RN #1 observed Resident #101 putting a Klonopin dose in the coat pocket. RN #1 asked Resident #101 to search the coat. Resident #101 removed the Klonopin tablet and gave it to RN #1. On [DATE], the surveyor interviewed RN #1 who wrote the [DATE] IDCP note. RN#1 confirmed the [DATE] event. RN #1 stated that she informed the MD who is also the Medical Director and that MD suggested that the Klonopin be crushed to promote resident's compliance. Review of medical record showed that the facility did not follow through with the MD's order of crushing the Klonopin. Review of the Medication Administration Record (MAR) showed that the Klonopin dose had not been crushed to promote compliance. RN #1 documented that the LNHA and the DON were made aware that Resident #101 saved his/her medication without taking it as prescribed. The facility was unable to provide any investigation into this behavior. When interviewed on [DATE] at 4:00 PM, the LNHA stated that he could not recall if he was made aware of the above incident. An interview with RN #1 on [DATE] at 11:40 AM, revealed that Resident #101 would bring the Methadone box and it's key to the facility and would give the key to the nurse. After the incident the nurse kept the Methadone box on the medication cart, and the resident had the key. There was no Policy and Procedure or consistent process regarding the management and storage of Methadone being brought by the resident from the Methadone clinic. During interview with the facility administration on [DATE] at 4:00 PM, the LNHA denied that Resident #101 currently brought Methadone to the facility and stated that was in the past. The LNHA did not provide a policy and did not seem to be aware that Resident #101 brought Methadone to the facility. At the first revisit on [DATE] at 10:46 AM the surveyor interviewed the Receptionist about Resident #101 and the Methadone Clinic. The Receptionist told the survey that she accompanied the resident to the Methadone Clinic in [DATE]. She would wait in the transport van unless she had permission from the resident to enter the building. She never entered the building, the resident entered alone. After being seen the resident walked directly from the clinic to the van. She stated in the past this had been a problem and that is why she was assigned to accompany the resident. The resident would return to the van with the box. The receptionist did no know if the box was locked. At the facility the resident would give the box to the Lead Receptionist. The Receptionist told the surveyor that sometimes Resident #101 was drowsy and sometimes normal. Review of the plan of care dated [DATE] included focus areas for drug abuse and potential for complications such as recurrence of substance use, mood, and behavior disturbance. Interventions included to discuss issues which may lead to substance abuse/ misuse. Explore alternative methods of coping. Notify MD when observed to be intoxicated. Send Resident to hospital. Obtain consent of resident for personal items to be reviewed. Obtain urine specimen to test for drug use. Educate on risk of drug abuse and to inform the resident that continued drug use may result in 30 days discharge notice. The resident had episodes of sudden change in condition on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The surveyor noted that these days corresponded to the days the resident went to Methadone clinic for treatment. There was no evidence that the facility contacted the Methadone clinic to inform them of the resident's condition upon return from the clinic, implemented the plan of care or put a system in place to address the risk factors in order to protect Resident #101 and other residents. An observation of Resident #101 was made during the initial tour of the facility on [DATE] 11:25 AM, as the resident was seated in the wheelchair in their room. The surveyor interviewed Resident #101 and noted that the resident was alert and oriented, answered all questions appropriately. Resident #101 expressed concerns over his/her pain and stated that the pain was not being addressed by the facility. On [DATE] 12:27 PM, the surveyor went to see the resident, but staff informed the surveyor that the resident was not in the facility because he/she went to the Methadone clinic. On [DATE] at 10:03 AM, the surveyor was informed that the resident was admitted to the hospital. On [DATE] at 10:56 AM, the surveyor observed the resident in the room eating breakfast, awake and alert and reported no pain. On [DATE] at 11:28 AM, the surveyor interviewed Resident #101 regarding the change in condition that occurred on [DATE]. Resident #101 stated that he/she could not recall the event. On [DATE], the surveyor interviewed LPN #8 who completed the NJUTF dated [DATE]. LPN #8 informed the survey team that the DON assessed Resident #101 on [DATE] and notified the MD and that it was the MD who dictated the opioid overdose information that the DON entered on the NJUTF. On [DATE] at 11:20 AM, the surveyor interviewed LPN #2 who wrote the IDCP Notes dated [DATE] and [DATE]. LPN #2 stated that she noted that Resident #101 was disoriented and lethargic and that she obtained the resident's vital signs which included: Blood Pressure (BP) 99/69, Heart Rate 70. Oxygen saturation 86%. LPN #2 further stated that she notified the Physician and the DON and that when the ambulance arrived, the resident's B/P was 81/52, Heart rate 61, oxygen saturation was 91%. LPN #2 commented that Resident #101 had a history of drug abuse. [DATE] at 2:02 PM, the surveyor interviewed the DON who confirmed that Resident #101 had a change in condition on [DATE]. The DON informed the surveyor that she assessed Resident #101 and that Resident #101 was lethargic and difficult to arouse, with low blood pressure and shallow respiration. The DON stated that Resident #101 had a history of drug abuse and that the MD had ordered Narcan which Resident #101 refused. The DON did not provide further information as to how they ensured that the resident did not experience repeated episodes of negative health symptoms on the days he/she went to the Methadone clinic. On [DATE] at 10:30 AM, the surveyor conducted an interview with the Attending Physician for Resident #101 who was also the Medical Director (MD.) The MD indicated that he was familiar with Resident #101 and was aware of the change in condition that occurred on [DATE] and other subsequent episodes. The MD stated that Resident #101 almost died twice at the facility from overdose and that Narcan was administered. He added that investigations were completed, and that the police was called. When asked about the evidence of investigation, the MD told the team that he does not have time to document and that Resident #101 was non- compliant. The MD did not provide any information regarding how the facility addressed the problem to prevent it from continuing to happen. The surveyor asked for the police reports but the facility was unable to produce them. On [DATE], the surveyor reviewed the Physician's Progress Notes which did not reflect the incident of [DATE] nor the other incidents. On [DATE] at 11:30 AM, the surveyor asked the DON for the investigations and the Hospital record for Resident #101 for the episodes of change in condition on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The surveyor noted that investigations were completed for the following dates: [DATE], [DATE] and [DATE]. There was no evidence that the facility implemented interventions to address the root causes of these incidents. On [DATE] at 4:41 PM two surveyor interviewed the LNHA and the DON. The DON stated that at some point the facility asked the Methadone Clinic if a staff member could go to the clinic and pick up the resident's prescribed dose. The DON told the surveyors the clinic said only the resident could pick up the Methadone. The DON also stated that the resident would bring the Methadone back to the facility and the nurses would put it in the narcotic box. The DON also said that at times the dosage appeared to be off and the facility was not sure if the resident took any of it before handing the Methadone over to the nurse. The DON stated there was documentation in her office that a staff member had called the clinic to check on the resident. The surveyors asked for this but it was not provided. The Management Team Note dated [DATE] included the following: On [DATE], the resident was seen by the management staff and presented with a copy of her urine screen that was positive for cocaine. The resident denied any use of recreational or illegal substances. The Management Team asked the resident for permission to check his/her belongings for substances or drug paraphernalia. The police were notified and came to the facility to speak with the management team as well as the resident. The resident was informed that an escort from the transport company would follow him/her to the Methadone clinic and would stay with the resident until the resident was brought back to the facility. The Team Note also reflected that the resident was educated on the interactions of drugs and medications, and informed that items brought to the facility from others will be reviewed by management and that continued use of drugs may result in a 30-day notice of discharge but the resident refused to sign this plan. The facility did not provide any information as to what they did after Resident #101 refused to follow the above plan, and continued to experience episodes of extreme lethargy after returning from Methadone clinic. There was no evidence that the facility had contact with the clinic concerning the resident's frequent medical issues after returning from the clinic or how the methadone should be handled. After the [DATE] incident the facility had the nurse store the box in the medication cart and the resident will keep the key. LNHA stated on [DATE] at 4:00 PM that he reached out to the transportation provider and arranged for the company escort to stay with Resident #101 at all times. The administrator was asked to provide the accountability log from the transport provider to show that the monitoring arrangement was being followed by the escort but the LNHA did not provide evidence of how the facility accounted for the escort monitoring of Resident #101. An interview with the unit staff revealed that nursing staff could not account for when Resident #101 left and returned to the facility from the Methadone clinic. There was no follow up done and no laboratory tests completed when Resident #101 exhibited sudden change in conditions on [DATE], [DATE], [DATE] and [DATE]. The facility did not conduct root cause analysis in regard to Resident #101's pattern of sudden change in condition upon return from the Methadone clinic and other medical appointments. Review of an undated policy titled: Suspected and Drug or alcohol Use Policy indicated the following: In an effort to provide a continuous safe environment for all residents and staff, if resident is suspected to be under the influence of drugs or alcohol the following is to occur, The resident will be assessed by the assigned nurse or supervisor (vital signs, physical assessment, etc) The assigned physician's will be called to hold all narcotics for 24 hours period. Wi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and review of other facility documentation during a Recertification survey ending on 4/6/21, it was determined that the facility failed to: a.) follow isolation precaution protocols for residents on Transmission-Based Precautions (TBP) on the unit for Persons under observation (PUI) and b.) properly isolate PUI residents from well, non Covid-19 exposed residents as a preventative measure to prevent the transmission of COVID-19. Residents and Health Care Personnel who have been exposed to Covid-19 have the potential to be Covid-19 positive and show no symptoms, thereby spreading this deadly virus. The facility's failure to isolate Resident #4, #45, #104, and #321 from the well, non-exposed residents posed a serious and immediate threat to the safety and wellbeing of the well, non-exposed residents. This resulted in an Immediate Jeopardy (IJ) situation that began on 3/14/2021, when it was determined that the the facility failed to follow Transmission Based Precautions of 14 -day quarantine for Residents #4, #45, #104 and #321. The facility's Administration was notified of the IJ on 3/22/2021 at 3:15 PM after the surveyors consultation with the New Jersey Department of Health. On 3/23/2021 while the Recertification survey was still in progress the surveyors received an acceptable Removal Plan. On 3/24/21 the immediacy was removed after verification that the Removal Plan was implemented. This deficient practice was identified for 4 of 4 residents reviewed for infection control precautions; (Residents #4, #45, #104, and #321) and was evidenced by the following: 1. During the initial tour of the third-floor nursing unit on 3/15/21 at 12:08 PM, the surveyor observed that the third floor was divided into two wings, with a nurse's station in between the two wings. The surveyor noted that the negative, well residents resided on one wing while the opposite wing housed residents under a 14-day observation for potential exposure to Covid-19 / Persons Under Investigation (PUI) side. The surveyor observed Resident #4 as he/she walked down the hallway, dressed in a coat and carrying a plastic bag. The resident was not wearing a mask as he/she entered the of room of Resident #104. At 12:30 PM, the surveyor observed Resident #4 exit Resident #104's room, walk down the hall and into his/her own room. The surveyor was not aware of either resident's isolation status at the time of this observation. The surveyor observed a sign on Resident #4's door warning Stop - please see nurse before entering room. There was also a 3- drawer plastic cart filled with Personal Protective Equipment (PPE) which was outside the room. The surveyor noted that there was no signage on the door of Resident #104's room and no isolation cart with PPE outside the room. On 3/15/21 at 12:32 PM, the surveyor interviewed Resident #4's assigned Certified Nursing Assistant (CNA #1). CNA #1 informed the surveyor that Resident #4 was supposed to be in isolation but refuses. CNA #1 stated that Resident #4 wanders everywhere and did not follow rules. CNA #1 stated that Resident #104 was not on isolation. On 3/15/21 at 12:38 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who was caring for Resident #4. LPN #1 told the surveyor Resident #4 was in the hospital on 3/14/21 and that he/she was on PUI precautions. LPN #1 stated that Resident #4 was supposed to be on quarantine, but that Resident #4 refused to stay in the PUI designated section of the 3rd floor and was given a private room to quarantine in place. LPN #1 further stated that Resident #4 often left their room and refused to remain in the room. LPN #1 stated that Resident #104 was not on isolation or any precautions. The surveyor observed that Resident #4's private room was located at the end of the well residents' wing of the third floor. On 3/15/21 at 12:40 PM, the surveyor spoke with Resident #22 who resided on the Well side of the third floor unit. Resident #22 told the surveyor that Resident #4 was supposed to be on quarantine, but usually left their room and walked everywhere in the facility. Resident #22 remarked that Resident #4 walked around the facility like he/she owns the place. Resident #22 further stated that he/she was concerned for his/her own health because Resident #4 was supposed to be on isolation. Resident #22 stated that he/she had reported these concerns and observations to the Licensed Nursing Home Administrator (LNHA) more than once. Resident #22 did not explain how he/she learned of Resident #4's isolation status. A review of the Quarterly MDS (Minimum Data Set) assessment tool dated 3/14/21, indicated that Resident #22 had BIMS (Brief Interview for Mental Status) of 15, which indicated the resident had fully intact cognition. On 3/15/21 at 12:46 PM, the surveyor interviewed LPN #2 who stated that new and readmission residents were supposed to quarantine as PUI for 14 days. LPN #2 stated that Resident #4 was non-compliant, refused to follow PUI protocols and that the supervisor was aware of the resident's behavior. LPN #2 further stated that Resident #4 was educated numerous times about infection control protocols, but the resident refused to follow the rules and that the facility Administration was aware. On 3/15/21 at 3:00 PM, the surveyor observed Resident #4, wearing a surgical mask standing in the lobby of the facility talking to the receptionist who was seated behind the front desk. On 3/16/21 at 10:33 AM, the surveyor observed Resident #104 was not wearing a mask as he/she exited Resident #4's room. The surveyor interviewed Resident #104 who told the surveyor he/she was visiting with Resident #4. Resident #104 further stated that Resident #4 was not on isolation precautions and added: that sign on the door means nothing. At that time, Resident # 104 walked down the hall and entered his/her own room. On 3/16/21 at 10:35 AM, the surveyor interviewed Resident #4 who stated that he/she did not have to be quarantined because he/she was only at the hospital for a few hours. Resident #4 stated that he/she had lung disease and had breathing problems and so, had to go to the hospital on 3/14/21. Resident #4 stated that there was no reason to have a sign on his/her door for isolation and added: I came right back. On 3/16/21 at 12:20 PM, the surveyor interviewed the facility Infection Preventionist (IP), who stated that residents who were newly admitted and readmitted were supposed to be placed on the PUI unit for a 14- day quarantine. The IP stated that Resident #4 refused to stay on the PUI unit. Because of this refusal he/she was given a private room to quarantine in place. The IP stated that Resident #4 was non-compliant and that the resident was difficult to manage. At that time, the surveyor requested a copy of the facility's policy on PUI and TBP. The IP stated that she would provide the policy. The surveyors never received the facility's policy on PUI/TBP. On 03/17/21 at 11:30 AM, another member of the survey team observed Resident #4 wearing a surgical mask as he/she walked out of the smoking area located on the first-floor courtyard and onto the elevator. There was no one else in the elevator at the time. The smoking area is for all residents. On 03/17/21 at 1:33 PM, a second member of the survey team observed Resident #4 wearing a surgical mask and ambulating in the third floor hallway to their room. The surveyor walked up to Resident #4's room and observed a bin containing PPE outside the resident's room but did not observe any signage indicating isolation precautions. The surveyor donned full PPE which included an N-95 mask with surgical mask over it, face shield, isolation gown and gloves and entered Resident #4's room to interview the resident. Resident #4 claimed he/she was not informed that he/she needed to be on isolation. The resident stated, I went to the hospital and was only there for 4 hours and I was not admitted so I don't need to be on isolation. Resident #4 further stated, I went out before and they did not quarantine me. On 03/18/21 at 11:07 AM, the surveyor interviewed RN #2 regarding the facility's protocol for TBP/PUI. RN#2 stated that residents who were readmissions or new admissions to the facility were placed on quarantine on droplet precautions on the PUI Unit for 14 days. RN#2 further stated that Resident #4 went to the emergency room and was supposed to be on quarantine. RN#2 also stated that they frequently encouraged Resident #4 to wear a surgical mask when out of the room. On 03/18/21 at 12:16 PM, the surveyor interviewed the Director of Social Services (DSS) who stated that the LNHA was very involved with Resident #4 and the resident's daughter. The DSS told the surveyor no other staff or residents had complained to him directly regarding any concerns with Resident #4. On 3/19/21 at 10:00 AM, the surveyor interviewed LPN #3 about PUI protocol. LPN #3 stated that all admissions and readmissions must be quarantined for 14 days on the PUI unit. LPN #3 stated that Resident #4 was noncompliant with infection control protocols and walked out of his/her room all the time and needed constant encouragement and reminders to wear a mask when going to the smoking area. LPN #3 stated that Resident #4 did not follow any rules of the facility. On 3/19/21 at 10:05 AM, the surveyor interviewed LPN #4 about the facility's TBP protocol. She stated that admissions and readmissions were to be put on the PUI unit and quarantined for 14 days. LPN #4 stated that Resident #4 refused to go on the PUI unit when he/she returned from the hospital, and was given a private room instead. LPN #4 stated that Resident #4 was non-compliant and did not follow any PUI protocols or rules of the facility. LPN #4 further stated that Resident #4 was frequently encouraged by staff to maintain PUI protocol, but the resident refused to follow infection control protocols and would verbally abuse staff when asked to do so. On 3/19/21 at 10:15 AM, the surveyor interviewed the IP again. The IP stated that residents who were out of the facility for 4 hours or less on appointments did not have to be quarantined. The IP stated that if a resident was out of facility for more than 4 hours, the resident would have to be on the PUI unit and quarantined for 14 days. At this time, the surveyor requested from the IP again, a copy of the facility policy for PUI/TBP but the IP still did not provide the facility's policy. On 3/22/21 at 9:57 AM, the surveyor interviewed Resident #82 who resides on the third floor. Resident #82 stated that Resident #4 was supposed to be on quarantine but walked all over the unit and frequently left their room without wearing a mask. Resident #82 also stated that Resident #104 went in and out of Resident #4's room all day and neither Resident #4 nor Resident #104 wore masks. Resident #82 also stated that Resident #4 was usually out of the room without a mask while speaking with nurses in the hall. Resident #82 told the surveyor that nursing staff encouraged Resident #4 to wear mask only when other residents complained about Resident #4. Resident #82 further stated that on 3/17/21, he/she observed Resident #4 coughing and touching the food on the meal cart while standing and looking for his/her tray. Resident #82 added that he/she had to order another meal after seeing Resident #4 touch all the meal trays on the cart. Resident #82 stated that he/she was concerned for their own health because Resident #4 was supposed to be quarantined and not walking around without a mask. Resident #82 stated that he/she had reported these concerns to the LNHA more than once. Resident #82 stated that the LNHA usually stated that he would talk to Resident #4. Resident #82 stated that he/she had observed no changes in Resident #4 behavior related to quarantine and that it is extremely frustrating. A review of the Quarterly MDS dated [DATE], showed that Resident #82 had BIMS of 15, which indicated Resident #82 had intact cognition. On 03/22/21 at 10:03 AM, the surveyor interviewed Resident #35 another resident residing on the third-floor who stated that he/she had observed Resident #4 walking in the hallways and into Resident # 104's room. Resident #35 further stated that Resident #4 was argumentative and added: I feel he/she is out of control. A review of Resident #35's medical record revealed that Resident #35 was cognitively intact. On 3/22/21 at 10:14 AM, the surveyor interviewed Resident #22 who also resided on the third floor. Resident #22 stated that he/she saw Resident #4 last Wednesday (3/17/21) rummaging through the lunch truck and coughing. Resident #22 further stated that he/she ordered another tray because he/she was scared for their health. A review of the Quarterly MDS dated [DATE], indicated that Resident #22 had a BIMS of 15, which indicated intact cognition. Review of medical record and Quarterly MDS dated [DATE], showed that Resident #4 had BIMS of 15, which indicated intact cognition. The MDS also indicated that Resident #4 had diagnosis that included depression. Review of Resident #4's care plan indicated that the facility would evaluate and treat, order psychiatric consultation. There was no care plan intervention regarding the resident's non-compliance with infection control/PUI protocol. Further review of the medical record showed that Resident #4 had Covid-19 test was on 3/14/21 and 3/17/21, 3/22/21 which were negative for Covid-19. On 3/22/21 at 11:51 AM, during an interview with the administrative team, the LNHA and the Regional MDS Coordinator (MDS) both stated that Resident #4 and his/her daughter were given verbal notification regarding Resident #4's pending discharge to another facility due to Resident #4's continued non-compliance with the facility's policies. The LNHA and MDS also indicated that both Resident #4 and his/her daughter would be issued the discharge notification in writing today being 3/22/21 and that Resident #4 had agreed to be discharged to another facility. There was no intervention in place to protect other residents in the facility given Resident #4's noncompliance with infection control protocols. 2. On 3/23/21 at 9:34 AM., the surveyor observed a resident (Resident #321), in the elevator with another resident. Resident #321 informed the surveyor that he/she was newly admitted to the facility on [DATE] from the hospital. The surveyor noted that both residents wore surgical masks. The surveyor observed the other resident got off on the second floor. Resident #321 rode in the elevator with the surveyor and got off the elevator on the third- floor. The surveyor observed Resident #321 walk past the nurses' station and onto the PUI area, then went into his/her room on the PUI wing of the unit. Review of Resident #321's medical records revealed that Resident #321 was newly admitted to the facility on [DATE]. There was no MDS completed at this time. On 3/23/21 at 9:40 AM, during interview, LPN #3 stated that residents on PUI could leave the PUI unit to go to the smoking area independently but needed to wear an N95 mask. Staff did not provide information on who or how oversight was provided for residents on PUI unit who went outside to smoke. 3. On 3/23/21 at 9:50 AM, the surveyor observed that Resident #104 had a sign on his/her room door warning, Stop see nurse before entering. There was a cart filled with PPE outside the resident's room but there was no description of the type of precautions to be followed for Resident #104. Further investigation on 3/23/21 at 9:52 AM, revealed that Resident #104 was on PUI precautions. LPN #3 stated that Resident #104 went to the emergency room on 3/20/21 at 10:30 AM, and returned to the facility the same day (3/20/21) at 7:30 PM. LPN #3 also stated that Resident #104 refused to stay on the PUI wing of the unit and therefore was given a private room. On 3/23/21 at 9:55 AM, the surveyor interviewed CNA #1 who stated that Resident #104 was on PUI/TBP precautions. On 3/23/21 at 10:10 AM, the surveyor interviewed Resident #104 who stated that he/she went to the hospital on 3/20/21 for leg pain and returned to the facility on the same day. Resident #104 stated that he/she was on quarantine upon return and was asked to wear an N95 mask when leaving his/her room. When asked about the meaning of Quarantine, Resident #104 stated that Quarantine meant staying 6 feet away from other people. The resident then added: No one here explained anything to me. Resident #104 stated that when he/she returned to the facility, he/she had a rapid Covid-19 test done and that it was negative. On 3/23/21 at 10:20 AM, the surveyor observed Resident #104 walk out of his/her room without a mask to the nurses' desk and asked for a towel. At that time, the LPN at the nurses' desk escorted Resident #104 to his/her room. A review of the admission assessment dated [DATE], showed that Resident #104 had a BIMS of 15, which indicated intact cognition. A review of Resident #104's medical records indicated the resident had diagnoses that included Bacterium (presence of bacteria in the bloodstream), Diacritics (inflammation of Lumbar region), Bipolar disorder, and Heroine abuse. Further review of the medical record showed that Resident #104 had a physician's order dated 3/20/21 for Transmission Based Precautions (TBP) for 14 days for Covid-19 precautions. There was no documented evidence that the facility informed Resident #104's physician regarding the resident's noncompliance with TBP/PUI precautions. On 3/23/21 at 10:46 AM, the surveyor requested from the IP, a copy of the facility's PUI/Quarantine policy, and smoking policy for PUI/Quarantine residents. On 3/23/21 at 10:53 AM, the LNHA provided a one - paragraph untitled statement dated May 11, 2021, which indicated: It is the Policy of Amoy Care Center that when a resident is seen outside the facility for a medical appointment or has been seen at the emergency room for less than twenty-four (24) hours, upon return the resident will receive a rapid Covid-19 test and a repeat of this test in 72 hours. This written statement from the LNHA was different from the information provided to the survey team by the IP. The LNHA provided another one paragraph statement titled: Out on Pass Policy during Covid-19 Pandemic/Amoy Care Center, and dated 9/1/2020 with review date of 1/24/21. The document reflected the following: It is the policy of Amoy Care Center that residents may go out on Pass but upon return each resident will be placed on Transmission based precautions/PUI for a duration of no less than 14 days. The documented also indicated that upon return each resident would be administered a rapid Covid-19 test and that residents were educated on risks of exposure to Covid-19 virus including risk of exposure to other residents and staff members. There was no evidence that this statement was communicated to the facility staff and that the facility implemented the instructions on the document. On 3/23/21 at 10:58 AM, during an interview with the LNHA, IP and DON, in the presence of the survey team, the LNHA stated that it was his decision regarding whether a resident was placed on the PUI unit upon returning from the hospital or not, and that the facility was following CDC guidelines. The LNHA further stated that it was their facility's policy that only residents who were out of the facility for over 24 hours needed to be placed on PUI/TBP upon return. The LNHA did not provide the CDC guidance he followed to make his determination for TBP/PUI quarantine. Also, none of the staff members interviewed was aware of this 24 -hour policy. The IP stated that the facility encouraged residents to wear an N-95 mask when they left their rooms. The IP further stated that when a resident was on PUI precautions, the residents could leave their rooms to go to the designated smoking area and were to wear an N-95 mask. The IP stated that their practice for non-compliant residents was for staff to continue to encourage the residents to cooperate with infection control protocols. The IP did not provide information on how they supervised the noncompliant residents on TBP precautions, to ensure the protection of other residents from potential exposure to Covid-19. 4. On 3/23/21 at 01:00 PM, the surveyor reviewed Resident #45's chart. The chart contained an ICP note written by LPN #5 dated 02/13/21 at 11:00 AM, which reflected that Resident #45 signed a Against Medical Advice (AMA ) form to leave the facility and discharged him/herself from the facility. The resident was noted to use a motorized wheelchair. The nurse's note dated 02/13/21 at 02:35 PM revealed that Resident #45 returned to the facility after being away from the facility for several hours. There was no documentation as to where Resident #45 had gone and no documented evidence that the resident was placed on quarantine after the resident returned to the facility. Review of the Annual Comprehensive MDS dated [DATE], Resident #45 was cognitively intact and independent for mobility at a wheelchair level. On 03/23/21 at 2:55 PM, the surveyor interviewed LPN #5 who confirmed that Resident #45 had left the facility AMA on 2/13/21 and returned at 2:35 PM on the same day. LPN #5 stated that Resident #45 returned to his/her room which he/she shared with another resident. Resident #45 was not placed on PUI precautions. LPN #5 did not stated how many hours Resident #45 was out of the facility or where the resident went. On 03/24/21 at 10:30 AM, the surveyor interviewed Resident #70, (the roommate of Resident #45), who stated that Resident #45 left the faciity on AMA and returned to the facility about two hours later and came back into their room. The surveyor asked Resident #70 if he knew about Resident #45 leaving the building. Resident # 70 told the surveyor that Resident #45 went to visit his kids and went to Wendy's fast food restaurant. Resident #45 brought Resident back a sandwich. A review of Resident #70's medical record revealed that Resident #70 was cognitively intact. The surveyor was unable to interview Resident #45 as the resident had expired. On 03/24/21 at 02:12 PM, the surveyor interviewed the IP who stated that the facility's AMA policy was that if a resident left the facility AMA, the resident should not return to the facility. The facility was unable to provide a policy and procedures for residents that left the facility against medical advice (AMA), and there was no process for readmitting residents that left the facility AMA. A review of the facility's Outbreak Plan revised on 08/2020, defined Isolation as a separation of an individual or group who is reasonably suspected to be infected with a communicable disease from those who are not infected to prevent the spread of the disease. Quarantine was defined as a separation of an individual or group reasonably suspected to have been exposed to a communicable disease but who is not yet ill (displaying signs and symptoms) from those who have not been so exposed to prevent the spread of the disease. According to the facility's Outbreak Plan, the facility will cohort residents as follows: A. COHORT A- INFECTED RESIDENTS: This cohort consists of both symptomatic and asymptomatic residents who test positive for the infectious virus, including any new or re-admissions known to be positive, who have not met the discontinuation of Transmission-Based Precautions criteria. B. COHORT B- NEGATIVE, (EXPOSED): This cohort consists of symptomatic and asymptomatic residents who tested negative for the virus with an identified exposure to someone who was positive. C. COHORT C- NEGATIVE, (NOT EXPOSED): Facility will dedicate a separate unit/wing with residents who test negative for the virus with no symptoms and are thought to have no known exposure. D. COHORT D- NEW OR RE-ADMISSIONS: This cohort consists of all persons from the community or other healthcare facilities who are newly or readmitted . This cohort serves as an observation area when persons remain for 14 days to be monitored for symptoms that may be compatible with the infectious virus, including Covid-19. Review of the U.S. Center for Disease Control and prevention (CDC) guidelines, Clinical Questions about Covid-19: Questions and Answers, updated 1/7/21, reflected to, Place potentially exposed patients who are currently admitted to the healthcare facility in appropriate Transmission Based Precautions and monitor them for the onset of Covid-19 until 14 days after their last possible exposure. Review of the facility's Infection Prevention and Control Program updated on 10/2020, indicated that the facility will implement appropriate isolation precautions when necessary; and follow established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). There was no evidence that the facility ensured that new/readmission residents were properly isolated and monitored to prevent potential cross-contamination with infectious agents. A review of the facility's smoking policy dated 10/19/2020 revealed that during the Covid-19 pandemic, all residents that were positive for Covid-19, PUI, or on Transmission based precautions will be seated away from other smokers on the patio to achieve proper social distancing. The facility had no process in place to separate TBP/PUI residents away from well residents. N.J.A.C. 8:39-19.4 (a)(b)(c)(d); 27.1 (a)