**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ #: 174364 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow their abuse policies and procedures by ensuring residents were free from verbal abuse. This deficient practice was identified for 2 of 3 residents reviewed for abuse, Resident #60 and #79, and was evidenced by the following: 1. Resident #79, who had diagnoses which included post-traumatic stress disorder (PTSD), anxiety, and depression reported to the Social Worker (SW) on 5/16/24, that Certified Nursing Aide (CNA #1) made sexual comments towards Resident #79 which included CNA #1 stating, bend over; you will like it, and that the resident's messy hair made the resident look sexy. This was witnessed by the nursing aide (NA) and Rehabilitation Director (Rehab Director). Resident #79 reported that the comments by CNA #1 made them feel uncomfortable. The SW handled the incident as a grievance, which was reported as Resident #79 having a poor service interaction with CNA #1 and was not investigated as an abuse allegation. This situation resulted in the resident, who had PTSD from a history of sexual abuse, to have increased anxiety with their PTSD exacerbated post incident with CNA #1. 2. A second resident, Resident #60, who had diagnoses which included depression, anxiety, ankylosing spondylitis (an autoimmune disease), had a verbal altercation with Unit Manager/Licensed Practical Nurse (UM/LPN) on 5/23/24, when the UM/LPN scolded and yelled at Resident #60 for requesting assistance with activities of daily living (ADLs) from staff which caused the resident to become afraid and fearful of the nurse which resulted in increased anxiety of who was going to help the resident. The incident was reported to the Business Office Manager (BOM) who immediately reported the incident to the Licensed Nursing Home Administrator (LNHA). The investigation was not started until 6/6/24, 2 weeks after the incident. The facility's failure to ensure all residents were free from abuse, by not investigating the witnessed actions of CNA #1, and the actions of the UM/LPN posed a likelihood of serious harm to Residents #60 and #79. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 5/16/24 after CNA #1 verbally sexually abused Resident #79 and continued to work twelve additional shifts. A second IJ began on 5/23/24 when the UM/LPN verbally abused Resident #60. The facility Administration was notified of the first IJ on 6/5/24 at 2:27 PM and the second IJ on 6/7/24 at 12:40 PM. The facility submitted an acceptable Removal Plan (RP) on 6/8/24 at 8:01 AM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 6/6/24 and 6/10/24. The evidence was as follows: A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy dated revised September 2022, included if resident abuse [ .] is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law; the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility .immediate is defined as within two hours of an allegation of abuse .upon receiving any allegation of abuse [ .] the administrator is responsible for determining what actions (if any) are needed for the protection of the residents; all allegations are thoroughly investigated. The administrator initiates investigation .the administrator provides supporting documents and evidence related to alleged incident to the individual in charge of investigation .any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete; the individual conducting the investigation at minimum: a. reviews the documentation and evidence; .d. interviews the person (s) reporting the incident; e. interviews any witnesses to the incident; interviews the resident [ .]; j. interviews other residents to whom the accused employee provides care or services; .l. documents the investigation completely and thoroughly. The following guidelines are used when conducting interviews: .witness statements are obtained in writing, signed and dated . A review of the facility's undated Abuse Prevention Program policy included the administration would implement the following protocols: 1. protect our residents from abuse by anyone including, but not necessarily limited to: facility staff .investigate and report any allegation of abuse within timeframe as required by federal requirements; protect residents during abuse investigations . A review of the facility's undated Grievances/Complaints, Recording and Investigating policy included the administrator had been assigned the responsibility of investigating grievances and complaints to the grievance officer; upon reviewing grievance and complaint report, the grievance officer would begin an investigation into the allegation .the investigation and report would include, as applicable: the date and time of alleged incident; circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts; the resident's alleged account; accounts of any other individuals involved .the grievance officer would coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse [ ] would be reported and investigated under guidelines for reporting abuse . 1. On 6/3/24 at 10:58 AM, Resident #79 reported to the surveyor that CNA #1, a male aide, had made sexual comments towards Resident #79. Resident #79 stated that they had refused to have male aides. The resident stated CNA #1 told the resident to bend over, the resident replied, no thank you and CNA #1 stated you will like it. The resident stated that on another the day CNA #1 stated, Don't take this the wrong way but your hair looks sexy that way. The resident stated that an NA and Rehab Director were both present and the comments, as well as CNA #1, made the resident feel uncomfortable. The resident stated that they had complained to administration regarding the comments made by CNA #1, however the LNHA, Director of Nursing (DON), and/or Assistant Director of Nursing (ADON) did not address the incident. The surveyor reviewed the medical record for Resident #79. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included PTSD and major depressive disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/29/24, the resident had a brief interview for mental status (BIMS) score of 15 out of 15; which indicated that the resident's cognition was intact. A review Resident #79's individualized comprehensive care plan (ICCP) included a focus area dated and initiated on 11/26/22, revealed that the resident had a history of PTSD with interventions that included to avoid situations that may cause flashbacks, to ask the resident about triggers and incorporate them into the resident's plan of care, consult psychiatry/psychology as needed, and that the resident preferred female aides when possible. A review of the Psychologist Only Initial evaluation dated 11/29/22, included an Emotional Summary that the resident had a history of PTSD symptoms after being sexually assaulted while a patient in a hospital. The resident had flashbacks, nightmares, high startle response, hypervigilance, intrusive thoughts, and mistrust. The resident was aware of their triggers, and the resident's mood was anxious and depressed. A review of a grievance dated 5/16/24 and resolved on 5/17/24, completed by the SW, indicated that Resident #79 reported the resident had a poor service interaction with Aid on the unit. The summary of the grievance included that the SW completed a follow-up which revealed that Resident #79 used profanity towards CNA #1 as they were joking and CNA #1 walked away. The SW asked Resident #79 if the resident would prefer not to have interaction with CNA #1, and the resident was satisfied. The Unit Manager was made aware, CNA #1 was not assigned to the resident and would have no contact. Further review of the grievance did not include statements from the resident, witnesses, CNA #1, any residents CNA #1 may have come in contact, or education. On 6/5/24 at 8:26 AM, the surveyor interviewed the NA who stated there was an incident between Resident #79 and CNA #1 about a month ago where she had gotten the resident ready for physical therapy and they were waiting in the dining room with CNA #1. The NA stated that CNA #1 and herself were joking with the resident, and she was unsure who initiated the interaction, but the resident stated to CNA #1 bite me and CNA #1 stated bend over and the NA left because the Rehab Director came in. The NA reported that the Rehab Director told her that after that interaction, the resident used profanity in a non-joking way, and CNA #1 stated are you sure about that and the resident responded ew. The NA stated she did not report the incident at first because she thought everyone was joking, but when the resident reported to her that it made [Resident #79] feel a certain way, she asked if they wanted to speak to the SW to report it, and the resident stated yes. The NA stated, now they are just investigating it. On 6/5/24 at 9:00 AM, the surveyor asked the DON if CNA #1 was working that day, and the DON stated CNA #1 was suspended pending investigation for an allegation of abuse from a resident as of 6/3/24 (first day of survey). On 6/5/24 at 9:08 AM, the surveyor interviewed the Rehab Director who stated about a month ago, the resident was waiting for therapy in the dining room with the NA and CNA #1. The Rehab Director informed the resident therapy was ready, and in a joking way CNA #1 stated ya go do something and the resident laughed and stated, bite me and CNA #1 said bend over and the resident responded with profanity. The Rehab Director stated while on their way to therapy, the resident saw the SW and immediately reported the incident to them. On 6/5/24 at 10:00 AM, the surveyor conducted a telephone interview with CNA #1 who stated there was an incident with the resident two or three weeks ago but was unable to recall the details. CNA #1 stated he was told there was another altercation where he told the resident that their hair looked nice, but they took it the wrong way. CNA #1 stated he spoke with the SW about the incident maybe two or three weeks ago but was never asked for a statement or instructed not to interact with the resident. CNA #1 stated after the incident, he took it upon himself to not interact with the resident. On 6/5/24 at 10:09 AM, the surveyor re-interviewed Resident #79 who stated after speaking to the surveyor about their concern with CNA #1 on Monday (6/3/24), the LNHA and DON came to speak to the resident about the incident. On 6/5/24 at 10:28 AM, the surveyor interviewed the SW who stated she started the grievance process, but the LNHA was the Grievance Officer who completed the grievance. The SW stated Resident #79 had an interaction with CNA #1, and she spoke to CNA #1, but she did not obtain a statement. The SW continued that the nursing department would obtain statements from the nursing staff, but she could not speak to why one was not obtained. The SW stated that the LNHA had access to that grievance. On 6/5/24 at 10:39 AM, the surveyor interviewed the DON who stated the facility investigated all allegations of abuse which included asking the resident what happened and obtain a statement, obtain statements from staff and witnesses, suspend staff that the allegation was made against pending investigation, notify the New Jersey Department of Health (NJDOH), Ombudsman, LNHA, and Corporate. The DON stated she was informed by the LNHA on Monday (6/3/24) that they needed to speak to Resident #79 but was given no additional information. The DON stated the resident reported to them that the SW was aware of the situation. The DON confirmed the allegation should have been investigated at the time, statements should have been gathered, and CNA #1 should have been suspended at the time pending investigation. The DON stated staff was suspended during the investigation because if the allegation was substantiated, you do not want to put others at risk or the same resident at risk. The surveyor requested CNA #1's timecard from May to present. On 6/5/24 at 10:55 AM, the surveyor interviewed the LNHA who confirmed he was the Grievance Officer with the assistance of the SW. The LNHA stated he sometimes gathered statements or sometimes the SW did, but the facility investigated all grievances. The LNHA stated the facility obtained statements, but they were not always written, and any allegation of abuse was reported to the NJDOH, Ombudsman, Medical Director, police, and family. The LNHA further stated the staff member who the allegation was made against was suspended pending investigation to determine if they were safe to be around someone. The LNHA stated he typically reviewed all grievances to ensure everything was taken care of and usually grievances were reviewed weekly at a meeting, but sooner if needed. The LNHA stated he spoke to the SW about this incident, and the SW spoke to the parties involved at the time. At that time, the surveyor reviewed the grievance dated 5/16/24, with the LNHA and asked where on the grievance did it indicate what poor experience meant, and the LNHA confirmed it did not and should be looked at to rule out abuse. The LNHA stated he did remember a conversation with the SW, but it was not documented, and there could have been a more written clarification or explanation of the poor experience. The surveyor asked why the LNHA spoke to Resident #79 on Monday (6/3/24) regarding the concern, and the LNHA stated it was mentioned in a meeting that day that he should speak to Resident #79. The surveyor asked the LNHA what the facility's policy indicated for investigating abuse, and the LNHA stated he was unsure. A review of CNA #1's timecard revealed the CNA worked twelve shifts after the allegation of abuse was made on 5/16/24, prior to being suspended on 6/3/24, after working from 6:69 AM until 3:05 PM. The surveyor continued to review the resident's medical record. A review of the Individual Psychotherapy Progress Note dated 6/4/24, indicated that the reason for the visit was for Resident #79's allegation of sexual harassment by a staff member. Further review of the progress notes included that a male staff member had made sexually inappropriate comments to Resident #79 which Resident #79 initially ignored but told him to stop. The progress note indicated that Resident #79 felt uncomfortable and was worried about the aftermath due to past sexual trauma. In addition, the resident's anxiety has increased and PTSD has exacerbated. An acceptable Removal Plan (RP) on 6/6/24 at 1:05 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including staff education on the facility abuse policy, and suspension of CNA #1, the SW, the NA, Director of therapy, and the certified occupational therapy assistant. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 6/6/24. 2. On 6/7/24 at 9:09 AM, the Regional LNHA in the presence of the LNHA, and DON informed the survey team that upon in-servicing staff on abuse, it was brought to their attention by the Business Office Manager (BOM) that the facility should speak to Resident #60 regarding an incident that should be investigated. The BOM stated the Resident's Representative (RR) reported to them the incident involving Resident #60; that after being discharged from Medicaid services, the Unit Manager/Licensed Practical Nurse (UM/LPN) informed a CNA (unknown) not to help a resident pick up a sock. The incident occurred maybe a week ago, but no one had a definite date. The Regional LNHA continued the BOM indicated in her written statement that the LNHA was aware of the concern and was placed on administrative leave yesterday (6/6/24), re-educated on abuse training, and the DON was now the Grievance Officer. At that time, the surveyor asked the LNHA if he was made aware, the LNHA stated he was made aware that Resident #60 had concerns with their activities of daily living (ADL) care and wanted additional help with ADLs, so he asked the UM/LPN to speak to the resident to see if additional help was needed. On 6/7/24 at 9:25 AM, the surveyor interviewed Resident #60 who stated they needed help with ADLs such as putting their sock on since they cannot reach their feet, and yesterday the facility provided them with an assistive device to put on socks on that they could not use. The resident stated that the facility just wanted to supplement with equipment when they asked for help; it makes me feel like they care more about not taking care of me than helping me. The resident continued that they felt bad asking staff for help and ringing the call bell because people abuse the call bell and take up too much of the staff's time. The resident stated they tried to be more independent which resulted in increased physical pain, so the facility increased their pain medication. The resident stated since they did not use the call bell and tried to do tasks on their own, they were discontinued from Medicaid, and after that, when I asked for help, the [UM/LPN] came to my room angry and scolded me for asking for help and was really mad when I explained my side. Then one day, [CNA #1] helped me, and the [UM/LPN] was really mad and told me I knew I was not supposed to ask for help. Then I went out of my room and the [UM/LPN] at the nurse's station in front of people, yelled at me saying I lied to her and she was committing perjury if she allowed anyone to help me. Resident #60 stated this made the resident feel embarrassed and afraid, and fearful of her acting on her anger which caused me emotional harm and fear of what am I going to do; no one is going to help. The resident stated the BOM was aware of this, and the UM/LPN would walk passed the resident's room staring which made them uncomfortable because the look was not welcoming to want to help and she told me I did not need help. The resident stated they were unable to remember the date, but to call their RR who was aware of the whole situation and knew the dates. On 6/7/24 at 9:50 AM, the surveyor conducted a telephone interview with CNA #1 who stated the UM/LPN informed him if the resident needed help, to help them, but the resident did not need much help. CNA #1 recalled an incident at the nurse's station, but the resident was yelling at the UM/LPN and the UM/LPN was not yelling but was sternly telling the resident what was to be done. On 6/7/24 at 10:29 AM, the surveyor interviewed the BOM who stated sometime towards the end of May after the resident was denied from Medicaid the resident informed the Rehab Director, UM/LPN, and an unknown CNA was very rude to [Resident #60] because [Resident #60] started asking for help. Upon hearing that, the BOM reported that she immediately informed the LNHA that the resident reported the Rehab Director, UM/LPN, and a CNA were very rude because [Resident #60] didn't need help, but after [Resident #60] was denied Medicaid [Resident #60] started asking for help and [Resident #60] said that staff feel [Resident #60] is faking it. The BOM confirmed she had followed-up with the LNHA after a meeting, and he reported that he had already spoken to staff and not the resident about it. The BOM stated yesterday after she was in-serviced on abuse, she reminded the LNHA of the incident in front of the Regional LNHA, DON, and Regional Nurse. The BOM stated when she first informed the LNHA, she was never asked to provide a statement. On 6/7/24 at 11:00 AM, the surveyor interviewed the RR via telephone who stated the incident occurred two weeks ago yesterday (5/23/24), after the RR encouraged the resident to start asking for help from facility staff. The RR stated the resident was removed from assisted living because the resident could no longer walk and required twenty-four-hour nursing assistance. The RR stated the resident began asking for help, and the UM/LPN went to the resident and started yelling at them and the resident called and informed the RR. The RR stated the resident was now calling the RR multiple times a day; that their anxiety had increased. The RR reported that the UM/LPN brought the resident in front of all the nurses and told them not to help the resident. The RR stated they spoke with the Director of Rehab who would not let them speak and spoke over them. The RR stated they spoke to the UM/LPN to explain the resident's medical diagnosis of ankylosing spondylitis (AS) which was an autoimmune that caused systemic inflammation similar to MS (multiple sclerosis) in which the resident's spine was fusing and they could have good days or bad days. The RR stated the UM/LPN was aloof and asked what do you want me to do. The RR stated they reported this to the BOM who notified the SW. The SW called back a few days later and the RR reported that the nurses will not help the resident. The RR reported that the SW informed them the facility was aware and they spoke with staff. The RR stated staff was questioning why the resident needed help that only increased the resident's anxiety, in addition to the UM/LPN walking by the resident's room not speaking to them. The UM/LPN was also identifying the resident as an alcoholic and will be kicked out (recovering alcoholic for years) and they were committing fraud if they helped. Review of the BOM's undated statement included that during the meeting with [Resident #60], [Resident #60] told me that the Director of Rehab, the nurse (UM/LPN) and the CNAs in the unit were rude to [Resident #60]. [Resident #60] was told that they would not help, and they would not document any assistance they were providing [Resident #60]. I reported this to the LNHA right away, asked him if he could talk to the Rehab Director and staff on the unit which he told me he already did. On 6/3/24, I received a call from the [RR] and the [RR] voiced their concern of how staff treated the resident, and the [RR] wants to call the Ombudsman's office. After I spoke to the [RR], I spoke to the SW to give the [RR] a call, and she did. The surveyor reviewed the medical record for Resident #60. A review of the admission Record face sheet indicated the resident was admitted to the facility with diagnoses which included muscle wasting and atrophy; generalized muscle weakness; depression, and anxiety. A review of the most recent comprehensive MDS dated [DATE], reflected the resident had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. Further review indicated the resident required supervision or touching assistance with lower body dressing and personal hygiene. A review of the ICCP included a focused area dated 4/22/24, which included that the resident was ADL self-care deficient with interventions included to encourage the resident to use call bell for assistance and that the resident required assistance of one person for ambulation and bathing. A review of a Social Services Note dated 6/3/24, did not include the resident or RR's concern about staff. An acceptable Removal Plan (RP) on 6/8/24 at 8:01 AM 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 staff education on the facility abuse policy, and suspension of UM/LPN, and the Rehab Director. The survey team verified the implementation of the RP during the continuation of the on-site survey on 6/8/24. NJAC 8:39-4.1(a)5

Complaint # NJ 173248; 174364 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 himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) ensuring Resident #79 was free from verbal sexual abuse and b.) ensure Resident #60 was free from verbal abuse. This deficient practice was identified for 2 of 3 residents reviewed for abuse (Resident #60 and #79). Resident #79, who had diagnoses which included post-traumatic stress disorder (PTSD), anxiety, and depression reported to the Social Worker (SW) on 5/16/24, that Certified Nursing Aide (CNA #1) made sexual comments which included bend over; you will like it; and the resident's messy hair made them look sexy. This was witnessed by the nursing aide (NA), Rehabilitation Director (Rehab Director). Resident #79 reported that the comments by CNA #1 made them feel uncomfortable. The SW handled the incident as a grievance, which was reported as Resident #79 having poor service interaction with CNA #1 and was not investigated as an abuse allegation. The SW stated that the LNHA was the Grievance Officer and was aware of the incident. This situation resulted in the resident, who had PTSD from a past history of sexual abuse, to have increased anxiety with their PTSD exacerbated post incident with CNA #1 and resulted in an Immediate Jeopardy (IJ) situation. A second resident, Resident #60, who had diagnoses which included depression, anxiety, ankylosing spondylitis (an autoimmune disease), who had a verbal altercation with the Unit Manger/Licensed Practical Nurse (UM/LPN) on 5/23/24, when the UM/LPN scolded and yelled at Resident # 60 for requesting assistance with activities of daily living (ADLs) from staff which caused the resident to become afraid and fearful of the nurse causing increased anxiety of who was going to help the resident. The incident was reported to the Business Office Manager (BOM) who immediately reported the incident to the LNHA, but did not start the investigation until 6/6/24, 2 weeks after the incident. The UM/LPN continued to work ten shifts with residents including Resident #60. This resulted in a second IJ situation. The facility's failure to ensure all staff, including the LNHA, implemented their facility policies to guarantee all residents were free from abuse by not investigating the actions of CNA #1 after witnessed by staff, that the SW and LNHA were aware of; as well as the actions of the UM/LPN, which the BOM made the LNHA aware of, posed a serious and immediate threat for abuse that can cause serious physical and emotional harm or impairment, resulted in two IJ situations which the facility became aware of on 6/5/24 at 2:27 PM and 6/7/24 at 12:40 PM. Refer to F 600. This resulted in an IJ situation that began on 5/16/24 after CNA #1 verbally sexually abused Resident #79 and continued to work twelve additional shifts after staff was aware of the situation. The facility Administration was notified of the IJ on 6/7/24 at 12:42 PM. The facility submitted an acceptable Removal Plan (RP) on 6/8/24 at 8:01 AM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 6/10/24. The evidence was as follows: A review of the Administrator's job description provided by the facility revealed the following: The primary purpose of the job position is to direct the day-to-day functions of the Center in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing Centers to assure that the highest degree or quality care can be provided to residents at all times. Administrative Functions included but not limited to: develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Center; review the Center's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations; interpret the Center's policies and procedures to employees, residents, family members, visitors, government agencies, [etcetera] as necessary; ensure all employees, residents, visitors, and general public follow the Center's established policies and procedures; assume the administrative authority, responsibility and accountability of directing the activities and programs of the Center. Safety and Sanitation included but not limited to: review accident/incident reports (falls, injuries of unknown source, abuse [etcetera]. Monitor to determine the effectiveness of the Center's risk management. Resident Rights included but not limited to: review resident complaints and grievances and make written reports of action taken. Discuss such actions with residents and family as appropriate; review complaints and grievances made by the resident and make a written/oral report to Nurse Supervisor/Charge Nurse. Follow Center's established procedures; maintain a written record of resident's complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint; report all allegations of resident abuse and/or misappropriation of resident property. On 6/3/24 at 10:58 AM, the surveyor interviewed Resident #79 who stated CNA #1 made sexual comments towards them that made them feel uncomfortable; that staff including a Nursing Aide (NA) who witnessed the interaction. The resident stated the facility was aware of the incident, and the LNHA had not spoken to them. On 6/5/24 at 8:26 AM, the surveyor interviewed the NA who confirmed she had witnessed the incident between Resident #79 and CNA #1, that she initially thought they were joking until the resident reported it made them feel a certain way. The NA stated it was reported to the SW who spoke to the resident. The NA stated the incident happened maybe one month ago, but the facility had just asked for a statement. On 6/5/24 at 10:28 AM, the surveyor interviewed the SW who stated the LNHA was the Grievance Officer, and confirmed Resident #79's concern regarding sexual abuse was handled as a grievance and not an investigation. The SW reported the LNHA was aware of the situation. On 6/5/24 at 10:55 AM, the surveyor interviewed the LNHA who stated their role was to oversee all department heads as well as the facility in general. The LNHA confirmed he was the Grievance Officer with the assistance of the SW, and grievances were reviewed weekly at a meeting or sooner if needed. The LNHA confirmed he recalled the situation with Resident #79, and the SW spoke to both parties. The surveyor reviewed the grievance dated 5/16/24 with the LNHA who acknowledged poor service interaction with CNA #1 was not sufficient information. The surveyor asked the LNHA why he spoke to the resident on 6/3/24, regarding the incident that was previously reported on 5/16/24, and the LNHA stated during a meeting, staff informed him to speak to the resident. The LNHA stated that all allegations of abuse were investigated and reported to the New Jersey Department of Health (NJDOH), but the LNHA could not speak to the specifics of how the facility investigated abuse and stated he needed to review the policy. On 6/5/24 at 2:27 PM, the facility was made aware of an IJ situation which resulted from Resident #79's allegation of verbal sexual abuse when the facility was aware of the incident between CNA #1 and the resident, and CNA #1 continued to work twelve shifts having contact with other residents with no investigation. On 6/6/24 at 8:23 AM, the LNHA in the presence of the Director of Nursing (DON) stated he was not aware of the incident with Resident #79 and CNA #1 until 6/3/24, which contradicted the LNHA's previous interview. The LNHA again confirmed he was the Grievance Officer and could not recall exactly when he reviewed the grievance. On 6/6/24 at 10:02 AM, the LNHA informed the survey team again he was unaware of the resident's grievance until 6/3/24. The LNHA confirmed again his role was to oversee the operations of the facility, and his role as the Grievance Officer was to review all grievances, but the incident was never brought to his attention. The LNHA confirmed all grievances were typically reviewed on Wednesdays. On 6/7/24 at 9:09 AM, the Regional LNHA, in the presence of the LNHA, DON, and survey team stated while inserviced staff on abuse yesterday, it was brought to their attention from the Business Office Manager (BOM), that the facility should speak to Resident #60 regarding a complaint about Unit Manager/Licensed Practical Nurse (UM/LPN) and that the LNHA was made aware at the time. The Regional LNHA stated the LNHA placed himself on administrative leave until he was trained on abuse, and then returned to the facility as the administrator. At that time, the surveyor asked the LNHA if he was aware of the situation, and he responded that he never spoke to the resident, but he was aware the resident wanted more help with activities of daily living. The LNHA then asked the UM/LPN to speak to the resident. The LNHA confirmed the incident was not investigated and the Regional LNHA confirmed the UM/LPN was not in the facility. On 6/7/24 at 9:25 AM, the surveyor interviewed Resident #60 who confirmed the UM/LPN had scolded and yelled at the resident for asking staff for help. The resident stated this caused increased anxiety as well as fear for who was going to help them. On 6/7/24 at 12:40 PM, the facility was made aware of a second IJ situation which resulted from Resident #60's concern regarding verbal abuse which the BOM made the LNHA immediately aware of, and the UM/LPN continued to work in the facility until 6/6/24, when the incident was brought to the Regional LNHA and DON's attention. This resulted in an second concern for the IJ situation that began on 5/16/24 after CNA #1 made sexually inappropriate comments to Resident #79 which was reported to the SW, and continued to work twelve additional shifts. The facility Administration was notified of the additional IJ concern on 6/7/24 at 12:42 PM. The facility submitted an acceptable Removal Plan (RP) on 6/8/24 at 8:01 AM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 6/10/24. On 6/10/24 at 9:15 AM, the Regional LNHA in the presence of the DON informed the survey team that the governing body removed the immediate threat by suspending the LNHA, and now the Regional LNHA was the facility's administrator and was inserviced by the Chief Nursing Officer on the facility's policies. The Regional LNHA stated the LNHA provided commentary on his suspension notice, which the LNHA denied knowledge of the situations. A review of the facility's undated Abuse Prevention Program policy included the administration will implement the following protocols: 1. protect our residents from abuse by anyone including, but not necessarily limited to: facility staff .investigate and report any allegation of abuse within timeframe as required by federal requirements; protect residents during abuse investigations . A review of the facility's undated Grievances/Complaints, Recording and Investigating policy included the administrator has been assigned the responsibility of investigating grievances and complaints to the grievance officer; upon reviewing grievance and complaint report, the grievance officer will begin an investigation into the allegation .the investigation and report will include, as applicable: the date and time of alleged incident; circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts; the resident's alleged account; accounts of any other individuals involved .the grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse will be reported and investigated under guidelines for reporting abuse . A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy dated revised September 2022, included if resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law; the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility .immediate is defined as within two hours of an allegation of abuse .upon receiving any allegation of abuse [ .] the administrator is responsible for determining what actions (if any) are needed for the protection of the residents; all allegations are thoroughly investigated. The administrator initiates investigation .the administrator provides supporting documents and evidence related to alleged incident to the individual in charge of investigation .any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete; the individual conducting the investigation at minimum: a. reviews the documentation and evidence; .d. interviews the person (s) reporting the incident; e. interviews any witnesses to the incident; interviews the resident [ .]; j. interviews other residents to whom the accused employee provides care or services; .l. documents the investigation completely and thoroughly. The following guidelines are used when conducting interviews: .witness statements are obtained in writing, signed and dated . NJAC 8:39-9.2(a) NJAC 8:39-9.3(a) NJAC 8:39-27.1(a)