**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part B On 1/23/25 at 10:31 AM, the surveyor observed Resident #73 dressed and groomed seated in a wheelchair in the doorway of their room. The resident stated they used continuous oxygen, which was observed by the surveyor. At that time, the resident had not expressed any concerns related to abuse. The surveyor observed an oxygen concentrator (a medical device that delivers oxygen to those with breathing related disorders) in the room set at 2 liters per minute (lpm), and an oxygen tank secured to the back of the resident's wheelchair. On 1/24/25 at 10:30 AM, the surveyor conducted a Resident Council Meeting where Resident #73 was in attendance. At that time, Resident #73 stated that one night they had difficulty breathing around 4:00 AM, and requested a nebulizer (a device used to administer medication in a form of a mist inhaled into the lungs) treatment to the Certified Nurse Aide (CNA #1). The resident stated they waited two hours until the nurse came in. At that time, the nurse stated she did not know anything about the resident's above mentioned request. The resident stated the nurse left the room, and it took another 45 minutes to receive the treatment. The resident further stated that they reported this to the Activities Director (AD); however, they (the AD) did not acknowledge the issue, and no one came back to follow up. A review of the Resident Council Minutes which was conducted on 1/14/25 at 2:00 PM, reflected that Resident #73 and the AD were in attendance. The minutes included that Resident #73 stated they were in respiratory distress at approximately 3:00 AM and told CNA #1. The resident further stated that they did not receive a nebulizer treatment until 7:15 AM. The resident also stated they spoke with the Licensed Practical Nurse/Unit Manager (LPN/UM #1) about the issue and the staff member (CNA#1). The resident further stated that CNA #1 stood in front of the resident in an intimidating manner because the resident told on her. On 1/24/25 at 2:02 PM, the surveyor requested any accidents, incidents, grievances, or investigations for Resident #73, and the DON stated she did not have anything for that resident. The surveyor reviewed the EMR for Resident #73. A review of the admission Record face sheet revealed the resident had diagnoses which included but were not limited to; asthma, acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in the body tissues), alcohol abuse and depression (a mental illness that can cause severe symptoms that affect a person's mood, thoughts, and daily activities). A review of the comprehensive MDS, dated [DATE], reflected the resident had a BIMS score of 15 out of 15, which indicated an intact cognition. It also reflected the above diagnoses and was coded for oxygen therapy. A review of the ICCP reflected a focus dated 11/29/23, that the resident had noncompliance with respiratory therapy. In addition, there was a care plan dated 10/30/23, with a focus that the resident had oxygen therapy due to respiratory illness. The goal was that the resident would not have poor oxygen absorption and interventions included but were not limited to; oxygen settings at 2 lpm, administer medications as ordered by the physician and monitor/document side effects and effectiveness. A review of the Order Summary Report reflected a physician's order (PO) dated 3/20/24, for oxygen set at 2 lpm; a PO dated 4/3/24, to check oxygen level every shift for shortness of breath (SOB); and a PO dated 1/5/24, for a nebulizer treatment every six hours as needed for SOB. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2024 and January 2025, revealed the resident's oxygen levels were 90% or above from 12/1/24 through 12/31/24, for all three shifts and 95% or above from 1/1/25 through 1/29/25, for all three shifts. A further review revealed the resident had not used a nebulizer treatment for either month. A review of the Progress Notes from 12/2/24 through 1/30/25, revealed no documented evidence that the resident had SOB, was in respiratory distress, or received a nebulizer treatment. In addition, there was no documented evidence of the resident's alleged incident prior to surveyor inquiry. On 1/24/25 at 2:04 PM, the surveyor interviewed the DON, who stated that she was unaware of the resident's alleged incident on 1/14/25, until now. The DON stated Resident #73 had not approached her with this concern, which she was surprised since she felt they had a good rapport and saw the resident often. The DON stated that now that she was aware, she would initiate an immediate investigation. She acknowledged that she had no formal way to follow up Resident Council Minutes content. On 1/24/25 at 2:48 PM, the surveyor interviewed the AD, who stated if there were nursing concerns brought up during Resident Council, he sent the DON an email and waited for a response. The AD stated that he could not remember concerns that were brought up at the last Resident Council Meeting, and at that time, he reviewed the minutes from the meeting on 1/14/25. The AD stated that if a resident expressed a concern at council, he spoke to them on the side and encouraged the resident to speak to the department head and could not recall if he did that with Resident #73. The AD stated the resident was very cognitively intact and could express themselves, but he still sent an email to the DON. He acknowledged he did not send the email to the LNHA as well. The AD stated he was taught to communicate via email and could not speak to why he did not report the resident's concern/allegation verbally as well. The AD stated he did not recall a response from the DON and stated he knew she was very busy. The AD stated if he had not received a response, he would reapproach the email recipient and acknowledged he did not do that and that 10 days was too long to wait. The AD stated, I should have followed up. The AD provided a copy of the email he sent to the survey team. On 1/24/25 at 3:56 PM, the surveyor interviewed the DON, who acknowledged that the AD sent an email but used the previous director's email account. The DON acknowledged the subject indicated 1/14 Resident Council, and stated, I just didn't get a chance to see that. The DON also stated LPN/UM #1 denied awareness of the incident, and the DON was able to identify the CNA and LPN that were allegedly involved and relayed that information to the survey team. The DON could not speak to why Resident #73 had not reported this to her and that the resident stated the incident occurred a few weeks before that Resident Council Meeting on the overnight shift. The DON stated that the resident had no history of making accusatory or inaccurate statements. The DON stated the AD should have brought this to her attention immediately, and further stated that the AD attended morning meeting daily as well. On 1/28/25 at 2:00 PM, the surveyor conducted a follow up interview with the resident in their room. The resident stated that they spoke to the AD the morning of the Resident Council Meeting on 1/14/25, about their concerns. The resident stated the AD stated to hold off and to mention the incident without details during the Resident Council Meeting so he can include it in an official report. The resident further described the incident to the surveyor. The resident stated that morning, while trying to sleep they felt they needed a nebulizer treatment. The resident stated they rang the call bell around 4:00 AM, and CNA #1 responded, Don't be like your friend [name redacted], which the resident stated was a resident who complained often. The resident acknowledged that they had not used the call bell again after. The resident stated at 6:30 AM, LPN #2 came to the room to administer medications. At that time, the resident asked if CNA #1 told her about the request for a nebulizer treatment. LPN #2 stated no and the resident stated that LPN #2 administered a nebulizer treatment at 7:15 AM. During that same interview, the resident stated they felt fine and that there was no negative outcome. The resident then stated that at approximately 9:30 AM, they went outside to the smoking area to speak with LPN/UM #1 (who they knew smoked after morning meeting) about the incident. The resident further stated the IPN was also present. The resident also stated later that morning, CNA #1 approached the resident in an intimidating manner, and stated the resident never told her about needing a nebulizer treatment and that the resident reported her and got her in trouble. The resident stated that later that morning they reported the incident to the AD, who told the resident to hold off and bring it up at the Resident Council Meeting so he could put it in an official report. The resident stated they did speak of the incident at the 2:00 PM Resident Council Meeting that day. The resident stated that they were disappointed this was not addressed in a timely manner since they went through the chain of command. The resident stated that on Friday (1/24/25) as soon as the DON was aware of the incident, she took care of it right away. The resident further stated that if the DON had known sooner, she would have acted rapidly. The resident stated that at no time did they feel unsafe or threatened to live on the 3rd floor. On 1/28/25 at 2:19 PM, the surveyor interviewed the IPN, who stated if he was made aware a resident reported they did not receive a requested treatment or care, he went straight to the unit manager and then reported it to the DON and LNHA. The IPN stated an investigation should have been done. The IPN stated that if he became aware that a resident reported that they were spoken to inappropriately by staff, he would go straight to the DON and LNHA, that's a serious situation, and it's a dignity issue. The IPN further stated it would have to be reported to the state and an official investigation should then be started. He did not recall being in the presence of the resident and LPN/UM #1 outside in the smoking area during a conversation regarding the resident's allegation. The IPN also stated that the resident had not reported anything to him. On 1/28/25 at 2:39 PM, the surveyor interviewed the AD, who stated he could not recall if the resident reported the allegation to him prior to the Resident Council Meeting. The AD stated, I think I would have remembered that. The AD stated that he did not think the resident was an accurate historian and was an emotional person who used extreme words. The AD stated he reported what the resident stated via an email sent rapidly. He did acknowledge and stated, I should have acted sooner. The AD stated, I don't want to diminish what [gender redacted] says but I know [gender redacted] does exaggerate. He further stated, I should have followed up sooner. He also stated I don't remember if the email or concern was discussed in morning meeting or if he checked with the DON to ensure she received the email and had followed up. He stated he assumed the DON read the email and followed up. The AD stated he received abuse education and named emotional abuse. The AD stated if a resident reported any type of abuse to him, he would have reported this to the DON. The AD stated, like I said, I should have possibly followed through a little more maybe I dropped the ball a little. On 1/28/25 at 3:32 PM, the surveyor interviewed LPN/UM #1, who stated that if a resident stated they rang the call bell for help and did not receive it, that she would interview the staff identified and report this to the DON and LNHA. LPN/UM #1 stated that if staff denied the allegation, she reassured the resident and still reported it to the LNHA. LPN/UM #1 stated, she reported all incidents to the DON, and the DON asked her for a statement related to an allegation by Resident #73. LPN/UM #1 stated she had no recollection of such incident, and had not been outside in the smoking area at the same time as the resident since the summer. LPN/UM #1 had no recollection of Resident #73 alleging any complaints about staff. UM/LPN #1 stated that had she been aware, she would have reported it to the DON. The LPN/UM #1 further stated the resident requested nebulizer treatments very infrequently. On 1/28/25 at 3:50 PM, the surveyor interviewed CNA #1, who stated that if a resident rang the call bell and needed treatment from a nurse, she reported this to the nurse immediately, especially if the resident was having trouble breathing. CNA #1 stated she had not experienced any incidents with a resident on the 3rd floor since she has worked there full time since 2020. CNA #1 stated that she answered call bells even if they were not on her assignment, and if a nurse did not do their job, she would have reported it to the unit manager, especially if it had to do with difficulty breathing. CNA #1 stated that Resident #73 was not on her assignment, but recalled that she answered her call bell one night or early morning. CNA #1 stated the resident stated they could not sleep, and that the resident was watching a scary movie at a loud volume. CNA #1 stated that it was sometime after 3:00 AM, and she encouraged the resident to turn off the television, that it may help them sleep. The CNA stated that the resident did not ring the call bell again, I guess [they] slept. CNA #1 stated she could not recall the exact date and stated it was sometime last year. On 1/29/25 at 10:33 AM, the surveyor conducted a phone interview with LPN #2, who stated that she was the resident's regular nurse and could not recall any incident with the resident. LPN #2 stated she could not recall the last time she provided the resident with a nebulizer treatment; that it was infrequent. LPN #2 stated that if she had, it would have been accounted for in the MAR/TAR. LPN #2 further stated the resident received continuous oxygen on 2 lpm and the resident's oxygen level was typically 95% or above. On 1/30/25 at 12:22 PM, the surveyor interviewed the Director of Social Work (DSW), who stated the LNHA was the abuse officer. The DSW further stated that if she was aware of any type of abuse allegation, she would have addressed it in morning meeting and that the DON and LNHA would follow up immediately. On 1/30/25 at 3:49 PM, the surveyor interviewed the DON and LNHA, in the presence of the survey team. The LNHA stated he would have expected the AD to go directly (physically) to the DON with Resident #73's allegation brought up at Resident Council and that email communication was not the typical procedure. The LNHA stated that he addressed this with the AD. The LNHA stated the AD did not feel it was abuse. The DON stated that in the past, the AD reported concerns to her verbally. In addition, she stated she was the only department the AD emailed, and not the LNHA as well. The LNHA stated that he was shocked. On 1/31/25 at 10:31 AM, the surveyor interviewed the LNHA, in the presence of the survey team. The LNHA acknowledged he was the abuse officer and was responsible to ensure allegations of abuse were reported and fully investigated. The LNHA stated he was responsible to oversee this process and that it was done in accordance to their facility abuse policy. A review of the facility's Resident Right's policy dated 6/2024, included employees should treat all residents with kindness, respect and dignity .resident rights included being able to voice grievances and have the facility respond to those grievances .the facility would make every effort to assist each resident to exercise their rights to assure that the resident was always treated with respect, kindness and dignity . A review of an undated unsigned facility job description for Director of Activities, included the directors Main Duties: included Support the facility's philosophy of care and strive to achieve its goals and objectives. A review of the AD's employee file reflected the resident had training on Abuse and Neglect of 1/10/24. He answered 10 of 10 questions correctly, which included Speaking to a resident in a disrespectful or intimidating manner is not considered verbal abuse; he correctly answered False, and Abuse of any resident may occur emotionally, verbally or physically; he correctly answered True, and If you suspect that a resident has been abused or neglected, it is your duty to report it to your supervisor; he correctly answered True. NJAC 8:39-4.1(a)(5); 33.2(c)(12) Complaint #: NJ 168006 Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) implement their abuse policy and ensure residents were protected from sexual abuse after a cognitively intact resident (Resident #155) made an allegation of rape on 9/30/23, and was sent to the hospital for evaluation. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #155). A review of a Nursing Note dated 9/30/23, revealed that Resident #155 was in bed with their Resident Representative (RR #1) at bedside, when the resident reported to the Registered Nurse (RN #1) that they were raped. The note further indicated that the resident, without RR #1 or RN #1's knowledge, had called the local police to report the rape. RN #1 documented that they spoke to the physician who ordered the resident to be transferred to the hospital for evaluation. Interviews on 1/24/25, with the Director of Nursing (DON) and on 1/28/25, with RN #1 confirmed the allegation of rape was made. The DON acknowledged that all allegations of abuse were to be immediately investigated and reported to the New Jersey Department of Health (NJDOH), and the DON confirmed Resident #155's allegation of sexual abuse was not investigated or reported to the NJDOH. The facility's failure to implement their abuse policy including investigating and reporting all allegations of abuse including sexual abuse placed all residents at risk for abuse which posed the likelihood of serious physical and emotional harm, or impairment resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 9/30/23, after Resident #155 made an allegation of rape to RN #1. The facility was notified of the IJ on 1/28/25 at 5:59 PM. The facility submitted an acceptable Removal Plan (RP) on 1/29/25 at 2:56 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 1/29/25. The facility further failed to ensure b.) an allegation of neglect and intimidation was investigated and reported in a timely manner when a cognitively intact resident made an allegation of not receiving a respiratory treatment as it was requested and was spoken to by staff in an intimidating manner. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #73). The evidence was as follows: Part A A review of the facility's Abuse, Neglect, Misappropriation Prevention Policy and Procedure dated reviewed 6/2024, included: Policy: Every resident as the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary isolation .Purpose: To ensure timely and thorough investigation of abuse, neglect and/or mistreatment of residents .Sexual abuse: Includes but is not limited to humiliation, harassment, sexual coercion, unwanted sexual touching, or sexual assault Investigation & Protection: Procedure: 1. When an incident or suspected incident of abuse is reported, the Administrator will appoint a facility representative to initiate an investigation and follow through to completion. 2. The investigation will proceed as follows: a. Interview/obtain statement of person(s) reporting incident, b. Interview/obtain statement from involved resident, c. Interview/obtain statement of any witnesses to incident, d. As necessary interview/obtain statements from staff members having contact with the resident during the previous shift prior to the shift of the alleged incident, e. If relevant, interview/obtain statements from resident's roommate, family, and visitors, f. Review the medical record .5. The Administrator or investigative designee will provide the resident or responsible party with timely progress reports in addition to all corrective actions taken. 6. All investigative information will be documented on the Resident Abuse Investigation form 7. In the event of allegation of abuse or neglect of any kind, the Administrator or designee will report the findings immediately to the Office of Ombudsman and the New Jersey Department of Health and Senior Services. Additional notification to the [name redacted] Police Department as circumstances warrant, 8. Inquiries concerning abuse reporting and investigation should be referred to the Administrator of designee .Abuse, Neglect, Exploitation Incident Investigation Checklist .Checklist to be initiated by Administrator, Assistant Administrator, Director of Nursing or Director of Social Services .Obtain Incident report. Be thorough. Obtain verbal or written statement form Resident, if possible. A verbal statement may be transcribed and signed by the resident .Obtain written statements from all staff involved in Resident's care .Place information in investigative file that is available for survey process. The Director of Nursing/designee is designated as the individual who conducts the investigation. 3. The DON/Designee: a. Reviews the accident/incident report. b. Obtains written statements of staff assigned to the Resident for: i. the shift during the allegation is noted; ii. A minimum of 16 hours prior to the incident if indicated or appropriate, c. interviews witnesses, if any, d. Reviews the Resident's record. E. Reviews staff assignments and staff performance .h. Reports finding to the Administrator. The surveyor reviewed the electronic medical record (EMR) for Resident #155. A review of the admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; acute posthemorrhagic anemia (low blood count), heart failure (a condition in which the hear does not pump blood as well as it should), hypertension (high blood pressure), and depression (a mental illness that can cause severe symptoms that affect a person's mood, thoughts, and daily activities.) A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 9/16/23, revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating the resident was cognitively intact. Further review of the MDS, revealed the resident required extensive assistance with activities of daily living and mobility. A review of the Progress Notes included a Nursing Note written by the RN #1 dated 9/30/23 at 9:58 PM, which revealed that the resident was received in their room with RR #1 by their bedside. The resident was alert, awake, and oriented to person and place, but not time. The resident reported, I was raped by some people; some people spoke to me but in real sense they did not, I want to talk to the [doctor], when is the doctor coming? RR #1 at the bedside reported that the resident's mental status was never like that before the resident was taken to the hospital and brought to the facility for rehabilitation. The resident, without RR #1's and RN #1's knowledge, used their landline phone and called the police who then showed up at the facility and conversed with the resident. RN #1 assured RR #1 that the change would be communicated to the resident's physician. The physician was notified who then recommended that the resident be sent to [hospital name redacted] for evaluation. The resident was picked up at around 7:15 PM. A review of the individual comprehensive care plan (ICCP) included a focus of area for the use antidepressant medication related to depression, dated 9/10/23. The goals included; will show decreased episodes of the behaviors of depression through the review date, revised on 9/21/23. Interventions included to monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal, dated initiated 9/10/23. On 1/24/25 at 9:28 AM, the surveyor requested any accidents, incidents, grievances, or reportable events for Resident #155. On 1/24/25 at 10:04 AM, the DON informed the surveyor that she did not have any reports for Resident #155. On 1/24/25 at 2:44 PM, the surveyor interviewed the DON in the presence of the survey team, regarding an allegation of rape. At that time, the DON stated the Licensed Nursing Home Administrator (LNHA) had already left for the day. The DON stated if this is [name redacted-Resident #155], I had spoken with the Social Worker (HSW) from the hospital who stated they (the hospital) would work [Resident #155] up (tests and assessments conducted to collect evidence of sexual assault). The DON stated she spoke with the facility's nursing staff who stated RR #1 was in the room that whole day with the resident. The DON stated the police were called to the facility by the resident, and she notified the LNHA the police were here. At that time, the DON stated she was not sure it (the allegation of rape) was a reportable event (to the NJDOH) as the resident did not return to the facility. The DON stated the allegation happened on a Saturday, and on Monday when she came in, the resident was not back. I spoke to the HSW who said Resident #155 was not sexually assaulted. The DON stated the HSW gave no timeframe or no specifics to the allegation, at that time. The DON stated the resident said the rape occurred while they were still here (in the facility.) The DON stated the resident was sent to the hospital due to saying they were raped and had a change in their mental status. On 1/28/25 at 12:34 PM, the surveyor conducted a telephone interview with RN #1, who documented the resident's allegation of rape on 9/30/23. RN #1 did not remember the incident at first, but when the surveyor read RN #1's note from 9/30/23, RN #1 stated, Now I remember, that evening I was the RN working. RN #1 further explained that the resident stated they were raped by some people, only RR #1 was in room with the resident. RN #1 stated the police just showed up and said the resident called and said they were raped. RN #1 confirmed the supervisor was aware and was on the floor. RN#1 was unsure if the DON was notified, and she was unsure if she should have been. RN #1 remembered talking to the police, but was not sure if Resident #155 remained in the facility or went to the hospital. On 1/28/25 at 1:16 PM, the surveyor conducted a telephone interview with the RN Nursing Supervisor (RNS #1), who verified they were the supervisor on 9/30/23. RNS #1 stated he thought he vaguely remembered that case, but he could not recall the nurse on the unit. RNS #1 stated that the nurse called me that the resident was confused; RR #1 was always at the bedside; and I don't think that anyone would do that while [RR #1] was there. RNS #1 stated he and RN #1 called the physician, who ordered to send the resident to the emergency room. He further stated that we (the facility) called the police because of the allegation of rape. RNS #1 stated the resident told the police they were being raped or something like that. RNS #1 stated the DON was notified. The surveyor asked RNS #1 what should be done if a resident made an allegation of rape, he stated, let the doctor know, call the police, let the family know and notify the DON. On 1/28/25 at 2:19 PM, the surveyor interviewed the Infection Prevention Nurse (IPN), who stated if a resident told you a concern, you told the Unit Manager and informed the DON or LNHA and an investigation would occur. The IPN stated a grievance should be made available to the resident. The IPN stated it (the concern) would follow the chain of events, and then I would give a statement, and all parties involved would also need to give one, including the resident. The IPN added that he would go straight to the DON or LNHA, if the concern was mistreatment, he stated that was a serious situation because I believe they would have to report it to the state and start an official investigation. On 1/28/25 at 2:39 PM, the survey team interviewed the Activities Director (AD), who stated examples of abuse were physical, sexual, financial, emotional, restraining, withholding things and should be reported to the DON. On 1/28/25 at 5:55 PM, the survey team met with the DON and LNHA. The LNHA stated the types of abuse were physical, sexual, and verbal. The LNHA stated that an allegation of sexual abuse was a reason to suspect something happened, and he should be notified as soon as possible. The LNHA stated it would be reported, then investigated. The LNHA stated that typically an allegation of rape was reported to the NJDOH unless the staff was 100% certain it did not happen. The LNHA further stated that if a resident was cognitively impaired, it was sometimes their behavior so determination to report was made on a case-by-case basis. The LNHA stated that the DON had a soft file for Resident #155's allegation. The survey team informed him the soft file was not provided to the survey team on 1/24/25, when the accidents, incidents, grievances, or reportable events were requested for Resident #155. The survey team also stated that a soft file was not mentioned during the interview with the DON on 1/24/25. On 1/30/25 at 9:07 AM, the surveyor interviewed the Assistant Administrator (AA), who stated any type of abuse: verbal, physical, or sexual should be discussed with the LNHA and the DON. The AA stated an investigation included: checking on the resident; interviewing the resident and staff; reaching out to the family; doing a body assessment; and calling the police if warranted. The AA stated that the facility reported any allegation of abuse to the NJDOH as soon as we found out an incident occurred. The AA stated, if a resident made a statement of rape, they should be assessed; the LNHA should be called; and an investigation started. The AA stated she could not recall Resident #155's allegation of sexual abuse. On 1/30/25 at 9:37 AM, the surveyor interviewed the Medical Director (MD), who stated if staff called him regarding an allegation of abuse with a resident, he would have the resident sent to the hospital for evaluation and tell the staff to follow the facility's protocol for investigation. On 1/30/25 at 9:58 AM, the surveyor interviewed the LNHA and asked who was ultimately responsible for the building, and he stated, I am as the administrator. I am expected to be notified everyday of anything going on in the building. My staff are instructed to make me aware of everything. I understand it to be my responsibility. The LNHA stated typically we would be notified right away but if he was unavailable, the AA should field that call. The LNHA stated if staff left him a voicemail, it went to his email. The LNHA stated ultimately the DON knew what to do when he was not at the facility, and she knew what should be reported. The LNHA stated, Monday morning anything that happened over the weekend, I expect my staff to tell me and make me aware. The LNHA

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part B On 1/23/25 at 10:31 AM, the surveyor observed Resident #73 dressed and groomed seated in a wheelchair in the doorway of their room. The resident stated they used continuous oxygen, which was observed by the surveyor. At this time, the resident had not expressed any concerns related to abuse. The surveyor observed an oxygen concentrator (a medical device that delivers oxygen to those with breathing related disorders) in the room set at 2 liters per minute (lpm), and an oxygen tank secured to the back of the resident's wheelchair. On 1/24/25 at 10:30 AM, the surveyor conducted a Resident Council Meeting where Resident #73 was in attendance. At that time, Resident #73 stated that one night they had difficulty breathing around 4:00 AM, and requested a nebulizer (a device used to administer medication in a form of a mist inhaled into the lungs) treatment to Certified Nurse Aide (CNA #1). The resident stated they waited two hours until the nurse came in. At that time, the nurse stated she did not know anything about the resident's above mentioned request. The resident stated the nurse left the room, and it took another 45 minutes to receive the treatment. The resident further stated that they reported this to the Activities Director (AD); however, they (the AD) did not acknowledge the issue, and no one came back to follow up. A review of the Resident Council Minutes which was conducted on 1/14/25 at 2:00 PM, reflected that Resident #73 and the AD were in attendance. The minutes included that Resident #73 stated they were in respiratory distress at approximately 3:00 AM and told CNA #1. The resident further stated that they did not receive a nebulizer treatment until 7:15 AM. The resident also stated they spoke with the Licensed Practical Nurse/Unit Manager (LPN/UM #1) about the issue and the staff member (CNA#1). The resident further stated that CNA #1 stood in front of the resident in an intimidating manner because the resident told on her. On 1/24/25 at 2:02 PM, the surveyor requested any accidents/incidents/grievances or investigations for Resident #73, and the DON stated she did not have anything for that resident. On 1/28/25 at 11:10 AM, the DON provided the survey team with a copy of an email which verified she reported the allegation of abuse for Resident #73 to the NJDOH on 1/24/25 at 4:41 PM. The surveyor reviewed the EMR for Resident #73. A review of the admission Record face sheet revealed the resident had diagnoses which included but were not limited to; asthma, acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in the body tissues), alcohol abuse and depression. A review of the annual MDS dated [DATE], reflected the resident had a BIMS score of 15 out of 15 which indicated an intact cognition. It also reflected the above diagnoses and was coded for oxygen therapy. On 1/24/25 at 2:04 PM, the surveyor interviewed the DON in the presence of the survey team. The DON stated that she was unaware of the resident's alleged incident on 1/14/25 until now. On 1/24/25 at 2:48 PM, the surveyor interviewed the AD in the presence of the survey team. At that time, he reviewed the minutes from the last resident council meeting dated 1/14/25. He stated he sent an email to the DON regarding Resident #73's allegation during the resident council meeting. He acknowledged he did not send the email to the LNHA as well. He stated he could not speak to why he did not report the resident's concern/allegation verbally. He did not recall a response from the DON and stated he knew she was very busy. The AD stated, I should have followed up and that 10 days was too long to wait. He provided a copy of the email he sent to the survey team. On 1/24/25 at 3:56 PM, the surveyor interviewed the DON in the presence of the survey team. The DON stated the AD should have brought this to her attention immediately. On 1/28/25 at 3:32 PM, the surveyor interviewed LPN/UM #1, in the presence of a second surveyor. LPN/UM #1 stated, she reported all incidents to the DON. She stated that Resident #73 did not report any allegations of neglect or intimidation to her. She stated had she been aware, she would have reported it to the DON. On 1/28/25 at 3:50 PM, the surveyor interviewed CNA #1, in the presence of a second surveyor. She stated that if a resident rang the call bell and needed treatment from a nurse, she would report this to the nurse immediately, especially if the resident was having trouble breathing. CNA #1 stated that if a nurse did not do their job, she would have reported it to the unit manager, especially if it had to do with difficulty breathing. On 1/30/25 at 3:49 PM, the surveyor interviewed the DON and LNHA, in the presence of the survey team. The LNHA stated he would have expected the AD to go directly (physically) to the DON with Resident #73's allegation brought up at resident council and that email communication was not the typical procedure. He stated that he addressed this with the AD. The LNHA stated the AD did not feel it was abuse. The DON stated that in the past, the AD reported concerns to her verbally. In addition, she stated she was the only department the AD emailed, and not the LNHA as well. The LNHA stated that he was shocked. On 1/31/25 at 10:31 AM, the surveyor interviewed the LNHA, in the presence of the survey team. He acknowledged he was the abuse officer and was responsible to ensure allegations of abuse were reported and fully investigated. The LNHA stated he was responsible to oversee this process and that it was done in accordance to their facility abuse policy. A review of the AD's employee file reflected the resident had training on Abuse and Neglect of 1/10/24. He answered 10 of 10 questions correctly, which included If you suspect that a resident has been abused or neglected, it is your duty to report it to your supervisor; he correctly answered True. NJAC 8:39-9.4(f) Complaint #: NJ 168006 Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) a.) an allegation of sexual abuse for a cognitively intact resident (Resident #155) who reported being raped. This deficient practice was identified for 1 of 2 residents reviewed for abuse. A review of a Nursing Note dated 9/30/23, revealed that Resident #155 was in bed with their Resident Representative (RR #1) at bedside, when the resident reported to the Registered Nurse (RN #1) that they were raped. The note further indicated that the resident, without RR #1 or RN #1's knowledge, had called the local police to report the rape. RN #1 documented that they spoke to the physician who ordered the resident to be transferred to the hospital for evaluation. Interviews on 1/24/25, with the Director of Nursing (DON) and on 1/28/25, with RN #1 confirmed the allegation of rape was made. The DON acknowledged that all allegations of abuse were to be reported immediately to the NJDOH, and the DON confirmed Resident #155's allegation of sexual abuse was not reported to the NJDOH. The facility's failure to implement their abuse policy including investigating and reporting all allegations of abuse including sexual abuse placed all residents at risk for abuse which posed the likelihood of serious physical and emotional harm, or impairment resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 9/30/23, after Resident #155 made an allegation of rape to RN #1. The facility was notified of the IJ on 1/28/25 at 5:59 PM. The facility submitted an acceptable Removal Plan (RP) on 1/29/25 at 2:56 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 1/29/25. The facility further failed to ensure b.) an allegation of neglect and intimidation was reported to the NJDOH in a timely manner when a cognitively intact resident made an allegation of not receiving a respiratory treatment as it was requested and was spoken to by staff in an intimidating manner. This deficient practice was identified for 1 of 2 residents (Resident #73) reviewed for abuse. The evidence was as follows: Refer F 600 Part A A review of the facility's Abuse, Neglect, Misappropriation Prevention Policy and Procedure dated reviewed 6/2024, included: Policy: Every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary isolation .Sexual abuse: Includes but is not limited to humiliation, harassment, sexual coercion, unwanted sexual touching, or sexual assault .Investigation & Protection: Procedure: 1. When an incident or suspected incident of abuse is reported, the Administrator will appoint a facility representative to initiate an investigation and follow through to completion .7. In the event of allegation of abuse or neglect of any kind, the Administrator or designee will report the findings immediately to the Office of Ombudsman and the New Jersey Department of Health and Senior Services. Additional notification to the [name redacted] Police Department as circumstances warrant .Reporting, 1. The Director of Nursing/Administrator/designee will report the incident to the Department of Health and Ombudsman program according to regulatory requirements if there is reason to suspect abuse, neglect or mistreatment .7. All appropriate regulatory agencies will be notified of any allegations of abuse or neglect according to required timeframe's. The surveyor reviewed the electronic medical record (EMR) for Resident #155. A review of the admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; acute posthemorrhagic anemia (low blood count), heart failure (a condition in which the hear does not pump blood as well as it should), hypertension (high blood pressure), and depression (a mental illness that can cause severe symptoms that affect a person's mood, thoughts, and daily activities.) A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 9/16/23, revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating the resident was cognitively intact. Further review of the MDS, revealed the resident required extensive assistance with activities of daily living (ADLs) and mobility. A review of the Progress Notes included a Nursing Note written by the RN #1 dated 9/30/23 at 9:58 PM, which revealed that the resident was received in their room with RR #1 by their bedside. The resident was alert, awake, and oriented to person and place, but not time. The resident reported, I was raped by some people; some people spoke to me but in real sense they did not, I want to talk to the [doctor], when is the doctor coming? RR #1 at the bedside reported that the resident's mental status was never like that before the resident was taken to the hospital and brought to the facility for rehabilitation. The resident, without RR #1's and RN #1's knowledge, used their landline phone and called the police who then showed up at the facility and conversed with the resident. RN #1 assured RR #1 that the change would be communicated to the resident's physician. The physician was notified who then recommended that the resident be sent to [hospital name redacted] for evaluation. The resident was picked up at around 7:15 PM. On 1/24/25 at 9:28 AM, the surveyor requested any accidents, incidents, grievances, or reportable events for Resident #155. On 1/24/25 at 10:04 AM, the DON informed the surveyor that she did not have any reports for Resident #155. On 1/24/25 at 2:44 PM, the survey team interviewed the DON, who stated that she and the Licensed Nursing Home Administrator (LNHA) were responsible for reportable events (reporting to the NJDOH) and that they should be reported as soon as possible. In Resident #155's case, the DON stated that she had spoken with the staff, and they informed her that RR #1 had been in the room with Resident #155 that whole day. The police were called to the facility by the resident, and the DON notified the LNHA that the police were at the facility. The DON further stated that at that time she was not sure it (the allegation of rape) was reportable event as the resident did not return to the facility. The DON stated the allegation was made on a Saturday, and when she came in on Monday, the hospital's Social Worker (HSW) called her. The DON reported that the HSW stated the hospital would work [Resident #155] up. (Tests and assessments conducted to collect evidence of sexual assault) The surveyor was unable to interview the LNHA as the DON stated he had left the facility already. On 1/28/25 at 12:34 PM, the surveyor conducted a telephone interview with RN #1, who documented the resident's allegation of rape on 9/30/23. RN #1 did not remember the incident at first, but when the surveyor read RN #1's note from 9/30/23, RN #1 stated, Now I remember, that evening I was the RN working. RN #1 further explained that the resident stated they were raped by some people, only RR #1 was in room with the resident. RN #1 stated the police just showed up and said the resident called and said they were raped. RN #1 confirmed the supervisor was aware and was on the floor. RN#1 was unsure if the DON was notified, and she was unsure if she should have been. On 1/28/25 at 1:16 PM, the surveyor conducted a telephone interview with the RN Nursing Supervisor (RNS #1), who verified they were the supervisor on 9/30/23. RNS #1 stated he thought he vaguely remembered that case, but he could not recall the nurse on the unit. RNS #1 stated that the nurse called me that the resident was confused; RR #1 was always at the bedside; and I don't think that anyone would do that while [RR #1] was there. RNS #1 stated he and RN #1 called the physician, who ordered to send the resident to the emergency room. He further stated that we (the facility) called the police because of the allegation of rape. RNS #1 stated the resident told the police they were being raped or something like that. RNS #1 stated the DON was notified. The surveyor asked RNS #1 what should be done if a resident made an allegation of rape, he stated, let the doctor know, call the police, let the family know and notify the DON. On 1/28/25 at 5:55 PM, the survey team met with the DON and LNHA. The LNHA stated the types of abuse were physical, sexual, and verbal. The LNHA stated that an allegation of sexual abuse was a reason to suspect something happened, and he should be notified as soon as possible. The LNHA stated it would be reported, then investigated. The LNHA stated that typically an allegation of rape was reported to the NJDOH unless the staff was 100% certain it did not happen. The LNHA further stated that if a resident was cognitively impaired, it was sometimes their behavior so determination to report was made on a case-by-case basis. The LNHA stated that the DON had a soft file for Resident #155's allegation. The survey team informed him the soft file was not provided to the survey team on 1/24/25, when the accidents/incidents, grievances, or reportable events were requested for Resident #155. The survey team also stated that a soft file was not mentioned during the interview with the DON on 1/24/25. On 1/30/25 at 9:07 AM, the surveyor interviewed the Assistant Administrator (AA), who stated any type of abuse: verbal, physical, or sexual should be discussed with the LNHA and the DON. The AA stated that the facility reported any allegation of abuse to the NJDOH as soon as we found out an incident occurred. The AA stated, if a resident made a statement of rape, they should be assessed; the LNHA should be called; and an investigation started. The AA stated she could not recall Resident #155's allegation of sexual abuse. On 1/30/25 at 9:58 AM, the surveyor interviewed the LNHA, who stated ultimately the DON knew what should be reported to the NJDOH when there was an allegation of abuse. On 1/30/25 at 10:15 AM, the surveyor interviewed the DON, who stated that she normally discussed any significant events that happened over the weekend at the Monday morning meeting, which included all the Department Heads: the DON, the Assistant Director of Nursing (ADON), the LNHA, and the AA. When asked if an allegation of rape or if the police came to the building was a significant event, she stated yes. The DON stated, I cannot remember if I discussed it (the allegation of abuse and the police coming to the building) in morning meeting. An acceptable removal plan was received on 1/29/25 at 2:56 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: the allegation was reported to the NJDOH on 1/28/25, and the Ombudsman on 1/29/25; an investigation and conclusion was completed immediately for Resident #155 on 1/28/25; as of 1/28/25, the LNHA ensures that within two hours, all allegations will be reported to the appropriate authorities (NJDOH, Ombudsman, and local police department); the DON was re-educated by the LNHA regarding the requirement to report any allegation of abuse or neglect immediately to the LNHA, NJDOH. Ombudsman, and local police department; the DON or designee has inserviced all staff currently available in the building regarding reporting allegations of abuse and completion of incident report and investigations within two hours; and any staff member who has not received the inservice in person or over the phone on 1/29/25, will not be allowed to work their next scheduled shift until receiving re-education regarding reporting of abuse allegations. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 1/29/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part B On 1/23/25 at 10:31 AM, the surveyor observed Resident #73 dressed and groomed seated in a wheelchair in the doorway of their room. The resident stated they used continuous oxygen, which was observed by the surveyor. At that time, the resident had not expressed any concerns related to abuse. The surveyor observed an oxygen concentrator (a medical device that delivers oxygen to those with breathing related disorders) in the room set at 2 liters per minute, and an oxygen tank secured to the back of the resident's wheelchair. On 1/24/25 at 10:30 AM, the surveyor conducted a Resident Council Meeting where Resident #73 was in attendance. At that time, Resident #73 stated that one night they had difficulty breathing around 4:00 AM, and they requested a nebulizer (a device used to administer medication in a form of a mist inhaled into the lungs) treatment to the Certified Nurse Aide (CNA #1). The resident stated they waited two hours until the nurse came in. At that time, the nurse stated she did not know anything about the resident's above mentioned request. The resident stated the nurse left the room, and it took another 45 minutes to receive the treatment. The resident further stated that they reported this to the Activities Director (AD); however, they (the AD) did not acknowledge the issue, and no one came back to follow up. A review of the Resident Council Minutes which was conducted on 1/14/25 at 2:00 PM, reflected that Resident #73 and the AD were in attendance. The minutes included that Resident #73 stated they were in respiratory distress at approximately 3:00 AM and told CNA #1. The resident further stated that they did not receive a nebulizer treatment until 7:15 AM. The resident also stated they spoke with the Licensed Practical Nurse/Unit Manager (LPN/UM #1) about the issue and the staff member (CNA #1). The resident further stated that CNA #1 stood in front of the resident in an intimidating manner because the resident told on her. On 1/24/25 at 2:02 PM, the surveyor requested any accidents/incidents/grievances or investigations for Resident #73, and the DON stated she did not have anything for that resident. On 1/24/25 at 2:04 PM, the surveyor interviewed the DON, who stated that she was unaware of the resident's alleged incident on 1/14/25, until now. She stated Resident #73 had not approached her with this concern, which she was surprised since she felt they had a good rapport and saw the resident often. The DON stated that now that she was aware, she would initiate an immediate investigation. She acknowledged that she had no formal way to follow up resident council minutes content. The surveyor reviewed the EMR for Resident #73. A review of the admission Record face sheet revealed the resident had diagnoses which included but were not limited to; asthma, acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in the body tissues), alcohol abuse and depression (a mental illness that can cause severe symptoms that affect a person's mood, thoughts, and daily activities). A review of the comprehensive MDS, dated [DATE], reflected the resident had a BIMS score of 15 out of 15 which indicated an intact cognition. It also reflected the above diagnoses and was coded for oxygen therapy. On 1/24/25 at 2:48 PM, the surveyor interviewed the AD in the presence of the survey team. At that time, he reviewed the minutes from the last Resident Council Meeting dated 1/14/25. The AD stated he sent an email to the DON regarding Resident #73's allegation during the Resident Council Meeting, and he acknowledged that he did not send the email to the LNHA as well. The AD stated he could not speak to why he did not report the resident's concern/allegation verbally, and he did not recall a response from the DON, but he stated he knew the DON was very busy. The AD stated, I should have followed up and that 10 days was too long to wait. The AD provided a copy of the email he sent to the survey team. On 1/24/25 at 3:56 PM, the surveyor interviewed the DON, in the presence of the survey team. The DON stated the AD should have brought this to her attention immediately. On 1/30/25 at 3:49 PM, the surveyor interviewed the DON and LNHA, in the presence of the survey team. The LNHA stated he would have expected the AD to go directly (physically) to the DON with Resident #73's allegation brought up at Resident Council and that email communication was not the typical procedure. The LNHA stated that he addressed this with the AD. The LNHA stated the AD did not feel it was abuse. The DON stated that in the past, the AD reported concerns to her verbally. In addition, she stated she was the only department the AD emailed, and not the LNHA as well. The LNHA stated that he was shocked. On 1/31/25 at 10:31 AM, the surveyor interviewed the LNHA in the presence of the survey team. He acknowledged he was the abuse officer and was responsible to ensure allegations of abuse were reported and fully investigated. The LNHA stated he was responsible to oversee this process and that it was done in accordance to their facility abuse policy. NJAC 8:39-4.1 (a) (5); 8:39-33.2 (c) (12) Complaint #: NJ 168006 Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) implement their abuse policy and investigate an allegation of sexual abuse for a cognitively intact resident (Resident #155) who reported being raped. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #155). A review of a Nursing Note dated 9/30/23, revealed that Resident #155 was in bed with their Resident Representative (RR #1) at bedside, when the resident reported to the Registered Nurse (RN #1) that they were raped. The note further indicated that the resident, without RR #1 or RN #1's knowledge, had called the local police to report the rape. RN #1 documented that they spoke to the physician who ordered the resident to be transferred to the hospital for evaluation. Interviews on 1/24/25, with the Director of Nursing (DON) and on 1/28/25, with RN #1 confirmed the allegation of rape was made. The DON acknowledged that all allegations of abuse were investigated, and the DON confirmed Resident #155's allegation of sexual abuse was not investigated. The facility's failure to implement their abuse policy including investigating all allegations of abuse including sexual abuse placed all residents at risk for abuse which posed the likelihood of serious physical and emotional harm, or impairment resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 9/30/23, after Resident #155 made an allegation of rape to RN #1. The facility was notified of the IJ on 1/28/25 at 5:59 PM. The facility submitted an acceptable Removal Plan (RP) on 1/29/25 at 2:56 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 1/29/25. The facility further failed to ensure b.) an allegation of neglect and intimidation was investigated when a cognitively intact resident made an allegation of not receiving a respiratory treatment as it was requested and was spoken to by staff in an intimidating manner. This deficient practice was identified for 1 of 2 residents (Resident #73) reviewed for abuse. The evidence was as follows: Refer to F 600 Part A A review of the facility's Abuse, Neglect, Misappropriation Prevention Policy and Procedure dated reviewed 6/2024, included: Policy: Every resident as the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary isolation .Purpose: To ensure timely and thorough investigation of abuse, neglect and/or mistreatment of residents .Sexual abuse: Includes but is not limited to humiliation, harassment, sexual coercion, unwanted sexual touching, or sexual assault Investigation & Protection: Procedure: 1. When an incident or suspected incident of abuse is reported, the Administrator will appoint a facility representative to initiate an investigation and follow through to completion. 2. The investigation will proceed as follows: a. Interview/obtain statement of person(s) reporting incident, b. Interview/obtain statement from involved resident, c. Interview/obtain statement of any witnesses to incident, d. As necessary interview/obtain statements from staff members having contact with the resident during the previous shift prior to the shift of the alleged incident, e. If relevant interview/obtain statements from resident's roommate, family, and visitors, f. Review the medical record .5. The Administrator or investigative designee will provide the resident or responsible party with timely progress reports in addition to all corrective actions taken. 6. All investigative information will be documented on the Resident Abuse Investigation form .8. Inquiries concerning abuse reporting and investigation should be referred to the Administrator of designee .Abuse, Neglect, Exploitation Incident Investigation Checklist .Checklist to be initiated by Administrator, Assistant Administrator, Director of Nursing or Director of Social Services .Obtain Incident report. Be thorough. Obtain verbal or written statement form Resident, if possible. A verbal statement may be transcribed and signed by the resident .Obtain written statements from all staff involved in Resident's care .Place information in investigative file that is available for survey process. The Director of Nursing/designee is designated as the individual who conducts the investigation. 3. The DON/Designee: a. Reviews the accident/incident report. b. Obtains written statements of staff assigned to the Resident for: i. the shift during the allegation is noted; ii. A minimum of 16 hours prior to the incident if indicated or appropriate, c. interviews witnesses, if any, d. Reviews the Resident's record. E. Reviews staff assignments and staff performance .h. Reports finding to the Administrator. The surveyor reviewed Resident #155's electronic medical record (EMR). A review of the admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; depression (a mental illness that can cause severe symptoms that affect a person's mood, thoughts, and daily activities) and heart failure (a condition in which the hear does not pump blood as well as it should). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 9/16/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Further review of the MDS, revealed the resident required extensive assistance with activities of daily living and mobility. A review of the Progress Notes included a Nursing Note written by the RN #1 dated 9/30/23 at 9:58 PM, which revealed that the resident was received in their room with RR #1 by their bedside. The resident was alert, awake, and oriented to person and place, but not time. The resident reported, I was raped by some people; some people spoke to me but in real sense they did not, I want to talk to the [doctor], when is the doctor coming? RR #1 at the bedside reported that the resident's mental status was never like that before the resident was taken to the hospital and brought to the facility for rehabilitation. The resident, without RR #1's and RN #1's knowledge, used their landline phone and called the police who then showed up at the facility and conversed with the resident. RN #1 assured RR #1 that the change would be communicated to the resident's physician. The physician was notified who then recommended that the resident be sent to [hospital name redacted] for evaluation. The resident was picked up at around 7:15 PM. A review of the individual comprehensive care plan (ICCP) included a focus of area for the use antidepressant medication related to depression, dated 9/10/23. The goals included; will show decreased episodes of the behaviors of depression through the review date, revised on 9/21/23. Interventions included to monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal, dated initiated 9/10/23. On 1/24/25 at 9:28 AM, the surveyor requested any accidents, incidents, grievances, or reportable events for Resident #155. On 1/24/25 at 10:04 AM, the DON informed the surveyor that she did not have any reports for Resident #155. On 1/24/25 at 2:44 PM, the surveyor interviewed the DON in the presence of the survey team, regarding an allegation of rape. At that time, the DON stated the Licensed Nursing Home Administrator (LNHA) had already left for the day. The DON stated if this is [name redacted-Resident #155], I had spoken with the Social Worker (HSW) from the hospital who stated they (the hospital) would work [Resident #155] up (tests and assessments conducted to collect evidence of sexual assault). The DON stated she spoke with the facility's nursing staff who stated RR #1 was in the room that whole day with the resident. The DON stated the police were called to the facility by the resident, and she notified the LNHA the police were here. At that time, the DON stated she was not sure it (the allegation of rape) was a reportable event (to the New Jersey Department of Health (NJDOH)) as the resident did not return to the facility. The DON stated the allegation happened on a Saturday, and on Monday when she came in, the resident was not back. I spoke to the HSW who said Resident #155 was not sexually assaulted. The DON stated the HSW gave no timeframe or no specifics to the allegation, at that time. The DON stated the resident said the rape occurred while they were still here (in the facility.) The DON stated the resident was sent to the hospital due to saying they were raped and had a change in their mental status. On 1/28/25 at 12:34 PM, the surveyor conducted a telephone interview with RN #1, who did not remember the incident at first. When the surveyor read RN #1's note from 9/30/23, she stated, Now I remember that evening, I was the RN working, I think the [resident] had just come from the hospital, [RR #1] was at the bedside. RN #1 stated that the resident was oriented to maybe only person and place, not time, and the resident stated raped by some people, only their [RR #1] was in room with [resident]. RN #1 stated the police just showed up and said the resident called and said they were raped, and RR #1 was in the room; there were no other people around. RN #1 stated she notified the supervisor who was on the floor, and she was not sure if the DON or the physician were notified. RN #1 remembered talking to the police, but she was not sure if the resident went to the hospital or remained in facility. She stated, the police told her the [resident] told them they were raped. On 1/28/25 at 1:16 PM, the surveyor conducted a telephone interview with the RN Nursing Supervisor (RNS #1), who verified he was the supervisor on 9/30/23. RNS #1 stated he thought he vaguely remembered that case; that he was the supervisor, but he was unsure of the nurse on the unit. RNS #1 stated that the nurse called him that the resident was confused, and RR #1 was always at the bedside and I don't think that anyone would do that while [RR #1] was there. RNS #1 stated that he and RN #1 called the physician, who ordered to send the resident to the emergency room. He further stated that we (the facility) called the police because of the allegation of rape; that the resident told the police they were being raped or something like that. RNS #1 stated that the DON was notified as we notified the DON, whenever we sent a resident out regardless of the reason being sent out. The surveyor asked RNS #1 what should be done if a resident made an allegation of rape, he stated, let the doctor know, call the police, let the family know and notify the DON. On 1/28/25 at 2:19 PM, the surveyor interviewed the Infection Prevention Nurse (IPN), who stated if a resident told you a concern, you tell the Unit Manager and inform the DON or LNHA and an investigation would occur. The IPN stated a grievance should be made available to the resident. The IPN stated it (the concern) would follow the chain of events, and then I would give a statement, and all parties involved would also need to give one, including the resident. The IPN added that he would go straight to the DON or LNHA, if the concern was mistreatment, he stated that was a serious situation because I believe they would have to report it to the state and start an official investigation. On 1/28/25 at 5:55 PM, the survey team met with the LNHA and the DON. The LNHA stated types of abuse were physical, sexual, and verbal. The LNHA stated an allegation of sexual abuse was a reason to suspect something happened, and he should be notified as soon as possible. The LNHA stated, I would typically report before and do an investigation after. The LNHA added the DON had a soft file for the above mentioned event, and he could not speak to why the facility did not follow their policy and use the forms in their policy. No evidence of an investigation was provided to the surveyors regarding the allegation of rape. The soft file was not provided to surveyors when previously asked for any investigation, grievance, or reportable events. On 1/30/25 at 9:07 AM, the surveyor interviewed the Assistant Administrator (AA), who stated any type of abuse: verbal, physical, or sexual should be discussed with the LNHA and the DON, and it was discussed as a team. The AA stated an investigation included to check on the resident, interview them and staff, reach out to the families, do a body assessment and call the police if warranted. The AA stated, if a resident made a statement of rape, they should be assessed. The LNHA should be called and an investigation started. The AA stated she could not recall Resident #155's allegation of rape. On 1/30/25 at 9:37 AM, the surveyor interviewed the Medical Director (MD), who stated if staff called him regarding an allegation of abuse with a resident, he would have the resident sent to the hospital for evaluation and tell the staff to follow the facility's protocol for investigation. On 1/30/25 at 10:15 AM, the surveyor interviewed the DON, who stated she kept a soft file on the event in case there was a question, she added it was not part of the medical record. The surveyor asked was that not the purpose of an investigation, she stated yes. The DON could not explain why she did not offer the soft file to the survey team. An acceptable Removal Plan was received on 1/29/25 at 2:56 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: the LNHA or designee initiated immediately an investigation and conclusion was completed; the allegation was reported to the NJDOH; the DON was reeducated on Investigations/Prevention/Correct Alleged Violations; and all staff were educated on the facility's abuse policies and procedures. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 1/29/25.

Complaint #: NJ 168006 Based on observations, interviews, record review 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 ensuring a.) an allegation of rape was thoroughly investigated and reported to the New Jersey Department of Health (NJDOH) for Resident #155. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #155). 1. Resident #155, who was cognitively intact with diagnoses which included but not limited to; depression (a mental illness that can cause severe symptoms that affect a person's mood, thoughts, and daily activities) and heart failure (a condition in which the hear does not pump blood as well as it should). Resident #155 reported on 9/30/23, to the Registered Nurse (RN #1) an allegation of rape. RN #1 documented the allegation in the electronic medical record and reported the incident to the Registered Nurse Supervisor #1 and the Director of Nursing (DON) on 9/30/23. The facility did not implement their abuse policy to investigate and report the allegation. The facility's failure to ensure all staff, including the LNHA, implemented their facility policies to ensure all residents were free from abuse by not investigating and reporting an allegation of rape (Resident #155) posed a serious and immediate threat for abuse that can cause serious physical and emotional harm or impairment. This resulted in an Immediate Jeopardy (IJ) situation which the facility became aware of on 1/28/25 at 4:59 PM. Refer to F 600, F 609, F 610. This resulted in an IJ situation that began on 9/30/23, after Resident #155 reported to RN #1 an allegation of sexual abuse that they were raped, and the facility was aware of the allegation and did not report the incident to the NJDOH or investigate the allegation. The facility Administration was notified of the IJ on 1/30/25 at 4:59 PM. The facility submitted an acceptable Removal Plan (RP) on 1/31/25 at 10:32 AM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 1/31/25. The facility further failed to ensure b.) an allegation of neglect and intimidation was investigated and reported to the NJDOH in a timely manner when a cognitively intact resident made an allegation of not receiving a respiratory treatment as it was requested and was spoken to by staff in an intimidating manner. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #73). The evidence was as follows: Part A A review of the Administrator-Job Description provided by the facility revealed the following: Position Summary: this position is responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meet resident's needs in accordance with federal, state and local regulation. Also, develop and maintain systems that are effective and efficient to operate the facility in a financially sound manner. Essential Requirements, Duties, and Responsibilities: -Develop, maintain and implement operation policies and procedures to meet resident's need compliance with federal, state and local requirements. -Develop and enforce a monitoring program to assure compliance with federal, state, and local requirements. -Serve as a representative of the facility to residents, family and the general public. -Establish systems to enforce the facility policies and procedures. -Serve as an active member of all committees as appropriate. -Arbitrate complaints and disputes concerning residents, families or personnel. -Interpret all federal, state and local regulations for the facility staff. -Establish systems to ensure compliance with all federal, state, and local regulations. -Observe all facility policies and procedures. On 1/24/25 at 2:44 PM, the surveyor interviewed the DON in the presence of the survey team, regarding the allegation of rape by Resident #155. At that time, the DON stated the LNHA had already left for the day. The DON stated the police were called to the facility by the resident. The DON further stated she notified the LNHA the police were here. At that time, the DON stated she was not sure it (the allegation of rape) was a reportable event (to the NJDOH) as the resident did not return to the facility. The DON stated the allegation was made on a Saturday, and when she came in on Monday, the hospital's Social Worker (HSW) called her. The DON reported that the HSW stated the resident was not sexually assaulted. On 1/28/25 at 2:19 PM, the surveyor interviewed the Infection Prevention Nurse (IPN), who stated if a resident told you a concern, you told the Unit Manager and informed the DON or LNHA, and an investigation would occur. The IPN stated a grievance should be made available to the resident. The IPN stated it (the concern) would follow the chain of events, and then I would give a statement, and all parties involved would also need to give one, including the resident. The IPN added, he would go straight to the DON or LNHA, if the concern was mistreatment, he stated that was a serious situation because I believe they would have to report it to the state and start an official investigation. On 1/28/25 at 2:39 PM, the survey team interviewed the Activities Director (AD), who stated examples of abuse were physical, sexual, financial, emotional, restraining, withholding things and it should be reported to the DON. On 1/28/25 at 5:55 PM, the survey team met with the LNHA and the DON. The LNHA stated types of abuse were physical, sexual, verbal. The LNHA stated an allegation of sexual abuse was reason to suspect something happened and he should be notified as soon as possible. The LNHA stated, I would typically report before and do an investigation after. The LNHA added the DON had a soft file for Resident #155's allegation of abuse. The LNHA could not speak to why the facility did not follow their policy and use the forms in their policy. No evidence of an investigation was provided to the surveyors regarding the allegation of rape. The soft file was not provided to surveyors when previously asked for any investigation, grievance, reportable events. On 1/30/25 at 9:07 AM, the surveyor interviewed the Assistant Administrator (AA), who stated any type of abuse: verbal, physical, or sexual should be discussed with the LNHA and the DON, and it would be discussed as a team. The AA stated an investigation included to check on the resident, interview them and staff, reach out to the families, do a body assessment and call the police if warranted. The AA stated report any allegation of abuse to the NJDOH as soon as we find out an incident occurred. The AA stated, if a resident made a statement of rape, they should be assessed. The LNHA should be called and an investigation started. The AA stated she could not recall the above mentioned event. On 1/30/25 at 9:37 AM, the surveyor interviewed the Medical Director (MD), who stated he was not aware of the reason for the Immediate Jeopardy situation during the current survey. The MD stated he recently reviewed the abuse policy because he was asked to but he went through it quickly, because I thought it was routine. The MD added if staff called him regarding an allegation of abuse with a resident, he would have the resident sent to the hospital for evaluation and tell the staff to follow the facility's protocol for investigation. On 1/30/25 at 9:58 AM, the surveyor interviewed the LNHA and asked who was ultimately responsible for the building, he stated, I am as the administrator. I am expected to be notified everyday of anything going on in the building. My staff are instructed to make me aware of everything. I understand it to be my responsibility. The LNHA stated typically he would be notified right away, but if he was unavailable, the AA should field that call. The LNHA stated if staff left him a voicemail, it will also went to his email. The LNHA stated ultimately the DON knew what to do when he was not there and knew what should be reported. The LNHA stated, Monday morning anything that happened over the weekend, I expect my staff to tell me and make me aware. The LNHA stated he instructed his staff to keep soft files in case there was ever a question about an event, but he could not explain the purpose of keeping a soft file. On 1/30/25 at 10:15 AM, the surveyor interviewed the DON, regarding Resident #155's allegation. The DON stated, I knew right away who (which resident) they (the survey team) were asking about. The DON stated she received a phone call from RNS #1 to say the police came to the building and he notified the doctor. The DON stated she informed the LNHA or the AA. She could not recall if she reported the event to the LNHA. The DON stated she kept a soft file on the event in case there was a question, she added it was not part of the medical record. The surveyor asked was that not the purpose of an investigation, and the DON stated yes. The DON could not explain why she did not offer the soft file to the survey team during the interview on 1/24/25. The DON stated she normally discussed any significant events that happened over the weekend at the Monday morning meeting, which included all the department heads: the DON, the Assistant Director of Nursing (ADON), the LNHA, and the AA. When asked if an allegation of rape or if the police came to the building was a significant event, she stated yes. The DON stated, I cannot remember if I discussed it (the allegation of abuse and the police coming to the building) in morning meeting. On 1/30/25 at 12:22 PM, the surveyor interviewed the Director of Social Work (DSW), who stated the LNHA was the abuse officer. The DSW further stated that if she was aware of any type of abuse allegation, she would have addressed it in morning meeting and that the DON and LNHA would follow up immediately. On 1/31/25 at 10:31 AM, the surveyor interviewed the LNHA in the presence of the survey team. The LNHA acknowledged he was the abuse officer and it was his responsibility to ensure allegations of abuse were reported and fully investigated. The LNHA stated he was responsible to oversee this process and that it was done in accordance to the facility's abuse policy. An acceptable removal plan was received on 1/31/25 at 10:32 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: the Clinical Consultant and Governing Body educated the Administrator regarding Administration, and the abuse policy including; reporting abuse and conducting a thorough investigation to ensure resident's safety. The survey team verified the implementation of the removal plan during the continuation of the on-site survey and determined the IJ for F 835 was removed on 1/31/25. Part B Refer F 600, F 609, F 610 On 1/24/25 at 3:56 PM, the surveyor interviewed the Director of Nursing (DON) regarding an allegation of neglect and intimidation for Resident #73, the DON acknowledged that the Activities Director (AD) sent her an email regarding the allegation. The DON stated that the AD used the previous director's email, and she acknowledged that the subject indicated 1/14 Resident Council. The DON stated, I just didn't get a chance to see that. The DON also stated that the Licensed Practical Nurse/Unit Manager (LPN/UM #1) denied awareness of the incident, and that the resident had no history of making accusatory or inaccurate statements. The DON stated the AD should have brought this to her attention immediately. On 1/28/25 at 2:39 PM, the survey team interviewed the AD, who stated examples of abuse were physical, sexual, financial, emotional, restraining, withholding things and it should be reported to the DON. On 1/28/25 at 3:32 PM, the surveyor interviewed LPN/UM #1, who stated that if a resident stated they rang the call bell for help and did not receive it, she would interview the staff identified and report this to the DON and LNHA. LPN/UM #1 stated that if staff denied the allegation, she reassured the resident and still reported it to the LNHA. LPN/UM #1 stated, she reported all incidents to the DON. On 1/28/25 at 5:55 PM, the survey team met with the LNHA and the DON. The LNHA stated types of abuse were physical, sexual, verbal. The LNHA stated an allegation of sexual abuse was reason to suspect something happened and he should be notified as soon as possible. The LNHA stated, I would typically report before and do an investigation after. On 1/30/25 at 9:07 AM, the surveyor interviewed the Assistant Administrator (AA), who stated any type of abuse: verbal, physical, or sexual should be discussed with the LNHA and the DON, and it would be discussed as a team. The AA stated an investigation included to check on the resident, interview them and staff, reach out to the families, do a body assessment and call the police if warranted. The AA stated report any allegation of abuse to the NJDOH as soon as we find out an incident occurred. On 1/30/25 at 9:58 AM, the surveyor interviewed the LNHA and asked who was ultimately responsible for the building, he stated, I am as the administrator. I am expected to be notified everyday of anything going on in the building. My staff are instructed to make me aware of everything. I understand it to be my responsibility. The LNHA stated typically he would be notified right away, but if he was unavailable, the AA should field that call. The LNHA stated if staff left him a voicemail, it will also went to his email. The LNHA stated ultimately the DON knew what to do when he was not there and knew what should be reported. On 1/30/25 at 12:22 PM, the surveyor interviewed the Director of Social Work (DSW), who stated the LNHA was the abuse officer. The DSW further stated that if she was aware of any type of abuse allegation, she would have addressed it in morning meeting and that the DON and LNHA would follow up immediately. On 1/30/25 3:49 PM, the surveyor interviewed the DON and LNHA in the presence of the survey team. The LNHA stated he would have expected the AD to go directly (physically) to the DON with Resident #73's allegation brought up at Resident Council and that email communication was not typical procedure. The LNHA stated that he addressed this with the AD and the AD stated he did not feel it was abuse. The DON stated that in the past, the AD reported concerns to her verbally. In addition, she stated she was the only department the AD emailed, and not the LNHA as well. The LNHA stated that he was shocked. On 1/30/25 at 4:19 PM, in the presence of the survey team, the LNHA stated that the AD did not feel like the resident was intimidated. On 1/31/25 at 10:31 AM, the surveyor interviewed the LNHA in the presence of the survey team. The LNHA acknowledged he was the abuse officer and it was his responsibility to ensure allegations of abuse were reported and fully investigated. The LNHA stated he was responsible to oversee this process and that it was done in accordance to the facility's abuse policy. NJAC 8:39-9.2(a) NJAC 8:39-9.3(a) NJAC 8:39-27.1(a)